Outlive, by Peter Attia MD. Book review.

Outlive aims to teach us how to live a longer healthy life.  I like the book because it fits my goals.  I am not afraid of death, but for as long as possible I wish to remain active. To achieve this goal, I need to be strong both mentally and physically.  I have been listening to Peter Attia for several years. He is an MD (and engineer,) smart, charismatic, and his explanations fit my way of thinking  (1).  The book is well organized, although, to my taste, it could be shorter by reducing the number of anecdotes.

As I was reading, I realized that the correct audience are my three middle-aged children.  They are old enough to be aware of aging, yet still have enough time to implement the advice in the book.  Perhaps this review will motivate them to read it.

The book is organized around Objective, Information, Strategy, and Tactics. 

Objective

Delay death, and get the most out of our extra years. The rest of our lives becomes a time to relish rather than to dread.

Information 

Aging is a process of deterioration of both mind and body. Eventually, the deterioration leads to illness and death.  The four main causes of death in western society are heart diseases , cancer, neurodegenerative disease (Alzheimer),  and Type 2 diabetes.  Attia named them the four horsemen [of the apocalypse.]  The book dedicates at least one chapter to each horseman, describing its causes and treatments.  The common thread in these chronic illnesses is that they are a result of a mismatch between the modern environment and our genetic makeup. 

Strategy

Today's medical practice does a good job of tackling acute disease, yet it is not equipped to handle chronic diseases.  To increase our healthspan, we need to develop a new style of medicine, which Attia names Medicine 3.0.   Since chronic illness starts to develop many years before it is recognized and treated, Version 3.0 focuses on early detection and early prevention.  It uses data to provide individuals with advice which minimizes the risk of intervention, while maximizing the reward (years of health).

Tactics

If we want to outlive our life expectancy and live it better, we will have to work.

The tactics entail five tools:  Exercise, nutrition, sleep, emotional health, and exogenous molecules (a fancy name for drugs and supplements).  Attia aims to provide general principles for these tools, rather than exact recipes, though in many cases he does provide detailed advice.

Exercise

Exercise is, by far, our most effective tool.  It is more potent than any known medication.  It can offset many adverse lifestyle factors.  Exercise reduces our risk of illness and death from any of the horsemen.  In addition, to be able to execute the activities we wish to do in our last years, we need to build some reserve now.  That includes both aerobic fitness and strength. 

We want to be able to walk uphill with our grand (or grand-grand) children, as well as pick them up when we desire.  Strong muscles also help avoid accidental falls, and the resulting bone fractures.  Interestingly, grip strength has a very high correlation to reduced mortality risk.  

          Attia provides some advice on how, how much, and how often to exercise.

Nutrition

Nutrition is a fuzzy science.  The experiments are not clear, and the effects are not large.  Bad nutrition habits can make us ill, but as long as we avoid the Standard American Diet (SAD), all other diet religions provide about the same benefit.  Instead of a diet, Attia recommends these simple rules:   "Don’t eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens and toxins" 

All macronutrients and their qualities are discussed.  Special attention is placed on consuming sufficient protein.  For active people, sufficient daily quantity is 2.2 grams per Kg of body weight.  That's nearly three times the medical advice. 

Sleep

High quality sleep is essential to our health.  Attia provides advice on how to achieve it. 

Emotional health

“Why would you want to live longer if you’re so unhappy?”

A lot of this chapter is devoted to Attia's long road from child abuse to therapy, but the lesson may apply to any of us.  Emotional health will affect our physical health and longevity.

[In a separate but related reference, I learned that chronic stress causes a faster rate of telomere shortening, and therefor accelerates aging.  Stress relief methods such as meditation, are highly recommended (2)]  

Medication and supplementation

The book does not dedicate a chapter to this tool.  Attia prescribes medication to patients who do not respond to the other tools.

Notes:

1.  The theory behind this book seems solid to me.  However, over the years I realized that Attia is a bit fanatic about ideas he believes are true, and more than a bit obsessive in his activities.   In the book he claims that he has reformed these tendencies.  Nonetheless, if any of the ideas or suggestions in the book seem wrong to you, feel free to further investigate and or reject them. 

2.  The Stress Prescription, by Elissa Epel, Penguin books 2022.

Time to Eat

Recently, Doron published a photo of himself and the almost-finished guitar he is building.  Both looked good.  When questioned, he told me that his slim appearance is due to better nutrition habits.  Congratulations.  For various reasons, the subject of nutrition has been occupying my thoughts, and Doron's reply prompted me to share them in this post.

Michael Pollan, in his book In defense of food: An eater's manifesto, provides three rules for good nutrition:

Eat Food, not too much, mainly from plants.

These  concise and elegant rules describe my convictions, and I follow them, without being too religious about it.   In recent years, I found an additional rule that may not have been available to Pollan at the time of his writing.  I am convinced that the practice of Time Restricted Eating (TRE) contributes greatly to a healthy body.  Many of you already heard me say it, but on this subject, I don't mind being a nag.  So I hope Pollan won't mind if I modify his rules to read:

Eat Food, not too much and not at night, mainly from plants. 

Food

Pollan is contrasting food as obtained from nature, to processed food.  For example: steak is Food, hot-dog is not.  Obviously, there are different levels of processing, and it is up to us to define the level we are willing to tolerate.  Processed meat seems to be the worst of the lot, but anything that comes in a package is suspect.

Not too much

That's a hard one.  Some pretty solid research (See my post) shows that lack of protein forces us to overeat.  Eating enough protein reduces hunger before we gobble too many calories.  There is probably enough protein even in a plant-based diet, but just to make sure, I consume a daily (plant-based) protein supplement.  Another effective way to constrain our eating is through the practice of TRE.

Not at night

Based on his research on the Circadian rhythm, Dr. Satchin Panda is one of the early proponents of TRE.  In his papers, lectures, and books, he advocates the health benefits of such a regime.  He proposes a schedule which he calls the  "12/3", which means 12 hours without eating, including the three hours before going to sleep.  Longer TRE periods, such as the popular 16-hour TRE, provide additional benefits through the biological process of autophagy.

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Catering to my affection for organization charts (and the number Three) I expand a section of my post Searching for Happiness.   No new information.  Feel free to skip this part.

Comfort    To me, this is the basic level (See note) of contentment.  It is supported by three pillars: 

      Healthy Body    Active Mind    Love and Friendship
     

      Healthy body is achieved by:

            Good Nutrition    Vigorous Exercise    Deep Sleep

            The three rules for good nutrition:

                   Eat Food    Not too much and not at night    Mainly from plants

Note:  I realize that first, we must have a shelter to sleep, enough money for food, and spare time for exercise.  

To Health. Part 1: Vigorous Exercise

Yael wrote, asking for details of my health habits.  I made the assumption that others may be interested too, and I am responding here, and possibly some following, posts.

Exercise, is first on my "To Health" list, not because it is easy (although I do enjoy it), but because it is so effective.  Several studies have shown that exercise mitigates the damage of many lifestyle errors.  People who smoke, or are overweight, or ... pick-your-sin, AND exercise, are at the same risk for disease and death, as the rest of the population.  Exercise achieves this by reducing inflammation, reducing insulin resistance, slowing down several markers of aging, and rejuvenating muscles.  As an extra benefit, it also makes you look good.   

However, an occasional stroll around the park will not do.  To achieve these benefits, we have to stress our muscles to the point in which their energy stores are fully depleted.  To get there, we can choose between two, equally effective, exercise modalities.  The first, usually known as Aerobic Exercise, entails a moderate level of intensity, extended over four to five hours a week.  The second is High Intensity Interval Training (HIIT), which depending on our choices, could last less than an hour a week.  I chose the latter because I don't mind the pain (yes there is), and I can use the extra time.  A good reference for this method and the science behind it, can be found in The One Minute Workout, by Dr. Martin Gibala.

I aim to train five times a week, alternating between three exercise modalities, all three following HIIT principles.

1. Resistance training (Once or twice a week).  I consider RT as my primary exercise.  The HIIT version is described in Body by Science , by Doug McGuff M.D.   He claims that one, fifteen-minute, session per week, is all you need to be fit and healthy.  Adi, after a short adjustment period, now loves the challenge, and is proud of her improving body shape.
2. Other (Once or twice a week).  I do a variety of exercises.  Stationary bike, burpees, situps etc.  These supplement RT, just in case McGuff is not totally correct.  BTW, a Tabata routine takes four! minutes.
3. Swimming (Once to three times a week).  A few years ago, due to deteriorating knees, I substituted running with swimming.  Now, I eliminated the endurance sessions and incorporated HIIT.  I continue to swim because I am challenged to improve my technique, and I love open-water swims.

This plan could result in overtraining, but when I feel tired, I take an extra rest day.

Final observation.  A HIIT session can produce anxiety and discomfort, especially in a beginner, but it lasts only a short time, and delivers a lot of satisfaction.

Labriut

To Health: Introduction

It's been a year since Adi discovered, fought, and probably won her battle against cancer.  During this year, I spent countless hours looking for weapons to assist in the fight.  I concluded that technology is not yet ready, and the answer has to come from lifestyle modifications.  I researched, and sometimes tried, several methods recommended by science, and over time, we distilled those into our pareto-few.  These are the ones that have the highest result-to-effort ratio.  Our goal is not just to beat cancer, but to avoid other chronic or age-related diseases.  Therefore, I believe that these recommendations would be beneficial to anyone.

So here is our list in priority order:

1. Exercise vigorously.  (Exercise can erase any sin)
2. Don't eat at night (Twelve hour fast)
3. Avoid processed food (Anything that comes in a can, bottle, or plastic bag)
4. Avoid added sugar
5. Sleep enough (Eight hours), and well
6. Eat plenty of vegetables (especially green), and sufficient protein.(Your body is a good judge of "sufficient").  Sate hunger, by eating fat (Avocado, walnuts, butter, etc.)
7. Practice time-restricted eating (Daily sixteen-hour fast, or more.)
8. Learn a new skill

Labriut

P.S.  All of these recommendations are backed-up by peer-reviewed scientific research.