Outlive: The Science & Art of Longevity

Outlive: The Science & Art of Longevity: Rethinking Medicine to Live Better Longer is a long (400 pages) and comprehensive treatise on the systems to be considered and the diseases people often succumb to.

The author Peter Attia is a physician specializing in cancer surgery. However through the book he regularly refers to his varied and eclectic background, which lends additional credibility to his recommendations.

In my haste to finish, I nearly abandoned my reading at page 375 when he began his chapter 'Work in Progress' where he details his own highly personal battle with emotional health manifest through anger issues, mostly turned inward.. The reveal, to me, added further credibility to the book as a whole. It pointed out how integral this component is to relevance of all his physical health prescriptions.

One revelation he comes to through this struggle is the need to work on his “eulogy virtues” (what those around you think of you) versus “resume virtues” or “accomplishments”.

The author also regularly refers to his disagreement with the current, although maybe changing medical philosophy. He calls it “medicine 2.0” and essentially it is when science, about the time of the industrial revolution, became the primary foundation for the medical treatment. Belief in exercise and diet as medicine may have had its start with the Greeks, but in the intervening more than two millennia even this gave way to a lot of mysticism, guessing and other motivations and treatments.

But in the author's mind medicine 2.0 continues to focus too much on diseases only when they are readily apparent and well established. Then treatments (waiting for diagnosis before intervening) are more desperate and often painful to meet the primary goal of prolonging life. He does not fault physicians for their efforts, but the philosophy of medical practice, especially that relating to “late” intervention, instead of prevention.

What he is advocating, and calls “medicine 3.0”, is looking for signs (genetic, chemical) of potential problems before they manifest into full blown disease. And in the case of this book, they are mostly the diseases of civilization (last 200 years) He characterizes them as the “four horsemen”. Simply put they are heart disease, diabetes, cancer and dementia.

And while the title “Outlive” suggests lifespan as the goal, for the author, it must be seen along with “health-span” or how well one maintains capabilities to enjoy life.

He is described as a Canadian/America physician, although the book is aimed at the U.S. market where he lives and has studied and works, there are little hints of his Canadian experience such as boxing training in Scarborough.

He has an elite medical resume with Stanford University medical and a Johns Hopkins residency. He had started in applied math and engineering. And for a time abandoned medicine to pursue his interest in mathematics in the financial field, before resuming medicine.

While he doesn't refer to his personal physical regime and specialization over the years as ideal fitness, it is varied and intense including long distance open water swimming and bicycle time trials, along with boxing. Now his favourite sports are archery and race car driving, but even here he questions his own driven-for-excellence motivation.

Now back to the “secrets” of living a long healthful and happy life. He confesses to having thought for a time that nutrition was the most important factor, but now ranks activity and exercise, and by a wide margin, the most important.

On diets, he says, “some work, but most don't”. However, that has not prevented him from trying some and retaining parts of others. Fasting may have a place, but it can be tricky to implement and follow.

But his recipe has two other legs and they are sleep and socialization, a growing recognition in the field of gerontology. Contributing may be drugs, hormones and supplements, where warranted. And all four are important in precluding, delaying and managing the entropy of aging and its looming diseases.

Traditionally, little if any medical education, was devoted to these factors. Now physicians have a growing awareness of their importance but few have much knowledge to help their patients. Medical education, he says, has focussed on drugs and or surgery as the treatment. Hence we may see what is promoted as “health care” more accurately is “sickness care”.

Family history and genetic makeup may increase the likelihood of being victims of certain diseases. But they can be ameliorated, much more than has traditionally been believed, by a more healthful lifestyle and measures specifically to forestall potential vulnerabilities.

While the medical schooling may not yet be much changing, the awareness of these health components is growing. I know of three recent McMaster University medical graduates who exercise strenuously and eat accordingly.

This book could have a wide and varied readership because it is presented in a language and knowledge base allowing for many from lay to physician to find it relevant. Some complex chemical and genetic elements may appeal to physicians, but can be glossed over by other readers.

An interesting and useful writing technique is the interjection of anecdotes, which serve to illustrate, but also entertain and provide a break from assimilating the tougher material.

Precis

While lifespans have dramatically increased, possibly mostly due to sanitation, antibiotics and vaccination, there has been comparatively little improvement in countering death tolls from cancer (with the exception of lung cancer and smoking), diabetes and dementia. Medical science's best progress has been made against heart disease. Attia is optimistic that better antivirals will come out of the Covid research.

The author is critical of the binary (you have it or you don't) way of looking at and treating disease when a cumulative continuum is the way most diseases evolve, inviting earlier intervention for better results. Often that intervention is modifying and incentivizing a more healthful lifestyle, which is not integral to medicine 2.0. Also there are no billing codes for “prescriptions” to improve health, only to treat sick.

He points out that “normal” or “average” is not “optimal” for many test results.

While popular press and diets have focussed on fat and carbohydrates as they may relate to excess weight, as people age protein becomes the more important macronutrient. It is especially important in maintaining muscle. crucial to quality of life.

Attia says “exercise is by far the most important longevity “drug”. No other intervention does nearly as much to prolong our lifespan and preserve our cognitive and physical function.” And most people don't do enough exercise and many do it “the wrong way”.

Changing and pursuing a healthy lifestyle requires a strategy involving more motivation, work and discipline on the part of the patient, than just showing up for the practitioner to prescribe a drug.

And while the strategy at 70 might be to be able to walk the dog around the block, when 90 that may require more than just keep on doing one lap all the time. Again building reserve against future decline is important. That may mean keeping the muscle and increasing oxygen uptake now.

Improved strength and cardio respiratory reduces risk of death from all causes, he adds.

Sleep is critical to the physiological repair process especially in the brain, says Attia.

Now, despite the call to healthful behaviour in this book, Attia points out that centenarians by and large don't seem to have a healthier lifestyle than other people and maybe worse. It seems that genes matter more the older one gets and centenarians develop the same diseases, but later..

However, says Attia, it doesn't mean one can't outlive their “expectancy” with a smart deliberate strategy. The health-span may be more within one's control.

While more females reach 100, the men who do are usually in better condition. He speculated that might be because of more muscle mass retained.

He doesn't believe that extreme age is related to one or a few 'silver bullet' genes. Activation of relevant genes may be a product of lifestyle.

Attia is critical of medicine 2.0's focus on single diseases in isolation rather that treating them with the relationship to each other, that appears to be the case.

After saying no single genes is responsible he alludes to a “drug” rapamycin discovered in earth on Easter Island as the only substance that appears to extend lifespan in mammals. It seems to slow cellular growth and division. Eating less may be related to this phenomenon. It may increase cells resistance to stress and increase metabolic efficiency.

However, the abundance of rich foods in modern society works against the eating less and promotes metabolic disorder such as diabetes. Obesity may be more a symptom than a cause, he adds. Metabolism is the process whereby nutrients are broken down for use by the body. And storage of excess can lead to problems.

The subcutaneous fat, society demands be eliminated, is not so much the problem as the 'visceral' fat stored around organs. And fat storage may have a genetic component.

Too much fructose, available in fruit and especially its juices, sets up for metabolic failure, if the person is not physically active.

Moving on, heart disease, of the four, it is the most easily treatable and possibly preventable. Cholesterol and the battle about 'good' and 'bad', Attia regards as inappropriate since both are needed. The concentration of each is the question. It is not directly a problem of diet since the relevant substance is produced in the body.

“Heart disease” starts many decades, maybe as early as 15, long before it is recognized in a patient.

Despite long distance swimming Attia ('not thin Peter') became aware of his own potential heart disease before he was 40. For those interested, and with the aptitude, his chapter 'The Ticker' details much of the chemistry and biology of heart disease.

Attia says that reduced smoking removed one important health hazard, but it has been replaced by obesity.

Metabolic struggle, especially with insulin resistance. may raise the susceptibility to cancer. As Attis puts it the “low hanging fruit of cancer prevention after smoking”.

Early detection (fewer cancer cells) remains the best hope against cancer. And the best hope on the horizon for this are liquid biopsies that could determine if cancer is present and what its biology is. In any event, strategies against cancer remain less effective than those for cardiac and metabolic. Gene scanning for susceptibility is also useful.

Dementia is among the most feared by many, ahead of death. Little is known about prevention. There is no cure or ready reversibility and little treatment when symptoms begin. Susceptibility can be revealed by genetic testing.

There has been some success with interventions around nutrition, physical activity and cognitive training, he says. Efforts at prevention hold the most hope so far.

Women are more susceptible and progression is faster giving some suggestion that hormone change may be a factor. It can be progressing for years before symptoms are noticeable.

Olfactory neurons related to smell seem to be among the first signs.

Resistance is increased by maintaining and increasing skills such as a foreign language or playing a musical instrument. Building up “cognitive reserve” helps.

Along with this is “movement reserve” which is the only intervention that slows Parkinson's. Again complexity of movement seems a further factor.

Robust blood flow seems a factor in reducing dementia progress, hence the exercise (especially endurance) prescription. And curiously, increased grip strength seems correlated with lower risk of dementia.

Both cardiac and metabolic (with insulin resistance) issues contribute to the manifestation of Alzheimer's. Poor sleep patterns also seem to contribute and there is a correlation with hearing loss.

Attia calls Alzheimer's the last of the Horseman to bypass on the way to 100.

The diseases of civilization represent an evolution in genes that no longer matches our environment, he says. Hence new tactics are required.

They are several types of exercise, nutrition, sleep, emotional health and the category of drugs, supplements and hormones. None of the first four “were covered or even mentioned in medical school”. Those physicians with knowledge have usually picked it up on their own, he adds.

Poor metabolic health, he says, goes along with being under-muscled which can relate to exercise and lack of protein.

Strong on the exercise component, Attia concurs that the smallest increase from no exercise brings the highest proportional benefit, but if varied, there is no limit to the amount of activity that gives benefit.

He says exercise is not part of the life of 77 per cent of Americans. Ninety minutes a week may reduce chances of dying from all causes by 14 per cent. And regular exercisers live as much as a decade longer than sedentary.

Cardiorespiratory exercise is the single most related to longevity. Lack of this fitness “carries a greater relative risk of death than smoking”.

On the issue of muscle mass, it seems that muscle strength, rather than size, is the more important component. And while cardiovascular and oxygen usage capacity appears to be the primary, at least one study, he says had strength trumping it.

Muscle strength helps protect and support the body and improve metabolic health through consuming energy efficiently.

Exercise produces “endogenous drug-like chemicals” helping to strengthen the immune system and stimulate growth of muscles and bones.

Muscle mass loss occurs steeply after 65 and even more dramatically after 75.

He doubts your physician knows your VO2 max or has ever tested your grip strength. Attia criticizes his activity of the past when he was training only for a cycling time trial and was doing nothing for other components of fitness. He thinks of fitness now as though a decathlon with several fitness skills. They would be related to desirable activities of life. It would help people define what is possible and raise expectations.

Along with cardio fitness and strength, stability is the other major component which includes balance and can prevent injury.

Endurance level cardio, where one can still talk, but with effort (70 to 85 per cent of heart rate maximum), is ideal for combatting aging and an additional factor is that it promotes using fat as an energy source. It is the most efficient and abundant source. Three hours per week of this is regarded by experts as the minimum needed. Many gym machines have gauges that help the exerciser find the optimum level.

Without fitness people will rely only on glucose as fuel. It is unfortunately ironic that the people who most need to burn fat are metabolically unable to.

An interesting revelation is that we lose muscle strength two to three times as fast as we lose muscle mass. With aging, muscle atrophy occurs first in quick twitch muscle fibres. To rehabilitate that muscle heavy weights must be lifted. Slow twitch muscles can be maintained with less resistance.

And for bone density, it is advisable to incorporate strength training before the problem manifests. Estrogen is essential for bone density in both genders. And bone density is important to better protect against fractures and disabling.

One of the main applications of strength training is be able to carry things., he adds. Humans evolved with this capacity more than any other animal. Since carrying begins with the grip, that is an important strength, along with being an indicator of potential longevity. It may be because decline is an indicator of increasing sarcopenia.

Practicing balance leads to better stability and less likelihood of falling, a key danger as people age.

An important aspect in nutrition is finding a way to consume fewer calories while increasing protein intake.

In nutrition, too many are focussing on small issues and not enough on the big ones. Small variations in what people eat probably matters a lot less than people think.

Nutritional biochemistry (nutrition) involves the interaction of so many chemicals and different needs it is largely impossible to untangle what any one food means in the big picture. And what people imagine is a food influence may actually be just a baseline health issue of the person.

Attia believes poor journalism contributes to misinformation about the effect of individual foods.

Studies with people (they don't eat what they claim) are hard to manage and control, unlike that with contained animals, such that the validity of conclusions may not represent what it is hoped they would represent.

However “among the best, or least bad, clinical trials show a clear advantage for the Mediterranean diet or at least for nuts and olive oil”. (It seems however, that the Mediterraneans have largely abandoned that diet in favour of less optimal foods others are eating.)

Evolution has “optimized us to be highly efficient fat storage vehicles” an unfortunate predisposition in modern society, however useful it might have been in the past. Humans store fat when they should be using it, which has been made impossible for many because of changes in metabolism from low activity.

“Dieting” as it is practiced is usually to lose fat and there are three basic strategies....calorie restriction, dietary restriction (certain foods) and time restriction (fasting). In Attia's words avoiding “over-nourished” is the goal. But with all the strategies picking the right foods (appetite suppressors being important) is important.

Attia has had faith in and used ketogenic diets (restricting carbohydrates) to better control type 2 diabetes. He regards “alcohol”, the way many drink) as a food component to be considered. It has no nutrition and is an empty calorie. Additionally it is a negative for extending life.

Basically people need the right mix of carbohydrates, fat and protein.

He praises the use of continuous glucose monitoring (CGM) as a big step beyond medicine 2.0's one test per year, which is almost useless. Often people only need to use a CGM for a couple of months to educate themselves on how food effects their glucose. And control of blood glucose is a step to preventing Alzheimer's.

Another factor in nutrition is when you eat and what relative to working out, sleeping and other activities.

As one ages they need to ensure they are getting enough protein, especially if they hope to forestall loss or even gain muscle mass.

If one insists on getting their protein from plants more conscious effort is required since it is less available in plants than in animals and some components are missing. It takes time and calculation.

There is no minimum requirement for fat and carbohydrates, but there is for protein, especially in aging.

While few fats are actually bad, a nutritional emphasis on that from oily seafood, nuts and flax add important components. In recent years soya oil has become too prominent.

Fasting is a powerful tool and should be used with a specific goal and not necessarily indefinitely without specific reason. Protecting muscle mass is a more important consideration.

While diet is not the most important component to living long, it becomes more important for the metabolically unhealthy, which is a large component of American society. Many people are over-nourished and under muscled.

The food most to be avoided, says Attia, are fructose sweetened drinks, both soda and fruit juices.

And pick foods that most carefully address your health vulnerability, your health profile.

He starts off his chapter on sleep with the ludicrous medical tradition where training physicians are required to work 12-hour shifts regularly and often 24 and more. Here not only is the practice disregarding the “health” need for regular sleep for the physician, but also the consequences to the patients of practitioners who are so tired mistakes become more likely. It seems some sort of a spartan regime one might expect for elite training military, where it is also ludicrous.

As recently as 20 years ago little was known about sleep's role in health and functioning. Now it is believed that lack of it, especially in 40s through 60s, may increase the likelihood of Alzheimer's.

Physical functions falter following lack of sleep. Meanwhile memory may not be consolidated and the brain is not ready for new inputs.

While 7 to 8 hours is regarded as optimum, and may be evolutionarily programmed, 11 hours or more (poor sleep) may present negative health consequences. Too little may increase hunger and hence excess calories.

Optimal sleep may involve 90 minute cycles and different levels of sleep, REM being the best known.

As many as 50 per cent of older adults may suffer from insomnia.

And while sleep aids ($28 billion market) are prescribed, Attia points out that, while they 'may knock you out', they don't facilitate the needed stages of sleep. One called trazodone seems to improve “sleep architecture”.

Then there is the problem of guilt that equates sleep to lazy and slothful. Many people have to become tolerant of the part sleep plays in efficiency and health.

Attia introduces the “chronotype” which refers to a person's alert time (morning person). This variability may have evolved so people could “take watch” and protect the group. This can also vary with age, as in teenagers are night people, not morning.

Enemies of sleep include screens, light, noise, alcohol and caffeine. Sleep can be helped by endurance exercise two or three hours before.

Like exercise sleep is a “wonder drug”.

Attia believes emotional health characterized by happiness through connections with family and friends may be the most important aspect of health-span. Absence of such may provide a comparable threat to health that cancer or heart disease can.

He differentiates between “mental health” with diagnostic and recognized symptoms and “emotional health” with more subtle and elusive origins. The changes needed are not as apparent as those for physical health.