Review of "Outlive" Dr. Peter Attia's longevity magnum opus
Unless you have been under a rock you have likely followed at least some of Dr. Peter Attia’s thinking on health and longevity over the past few years. I had the good fortune of meeting Peter many years ago. He was one of many people who played a consulting role in the Reno Risk Assessment program.
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Around 2012 I got to see a draft of an early longevity book Peter was working on. At that point I think both he and I were hopeful some mix of fasting, pharmaceuticals and good luck might manifest in not only a solid health span, but a truly extraordinary lifespan. That was however more than 7 years after releasing my first published piece on intermittent fasting, and I’d long known by this point that fasting could be powerful medicine. Powerful medicine usually implies the ability to both heal and harm, and I’d squarely place fasting in that category…But I might be getting a bit ahead of myself here, you want to know about the book “Outlive: The Science and Art of Longevity” (release date March 28, 2023) not necessarily a historical accounting from an aging Lobo. Well, I feel a little compelled to put a bit of historical context out here as at a minimum I’ve been early to a lot of the conclusions folks in the general health space have arrived at of late, but I think I was particularly early (and accurate) about many elements of this longevity story. My best stab at that was likely my talk “Longevity: Are We Trying Too Hard?”
I gave a few public presentations of that material in 2019, but I’d been talking about the broad brush strokes since 2016. Perhaps the most salient point to that talk, and the book Outlive, is that most of what we want and need for longevity, we already have. It’s sound nutrition, exercise, good sleep, solid social connections and MAYBE some nifty pharmaceutical interventions that could meaningfully move the needle.
One thing that Outlive is NOT: It is not an outlandish book claiming arcane secrets to get you to 150 years of age. There is a pasty, sarcopenic huckster in the health space claiming he is going to make it to 150 years old. He’s not. Not unless we have some massive breakthroughs in the next few years. Outlive does not claim to double total human lifespan via fasting, pharmaceuticals and pixie dust. It does make a very compelling case that we could all likely make it to our 9th, perhaps 10th decade of life and still be kicking some reasonable ass. In many regards what Outlive offers is a process to perhaps double effective human lifespan. If you can be as fit as an average 40 year old, at 90…then just die after a short decline, that’s a shockingly different process than the decades long decline that most face today.
Peter has been working on this book for a very long time, he is a great communicator and this material is remarkably accessible. Peter is phenomenal at organizing information and presenting it in ways that further understanding but also suggests solutions by the very organization.
Please note: I’m working from a pre-release copy of the book which may be a bit different than the one you end up purchasing.
The first few chapters delve into Peter’s background, entry into medicine, departure for a tenure in consulting and finance, and subsequent reentry to medicine and development of his paradigms surrounding health. He does a great job of identifying the top most likely ways of dying in the West (CVD, type 2 diabetes, neurodegenerative disease and cancer) and how we might go about addressing these issues (exercise, diet, sleep, targeted pharmaceuticals). In his 2nd chapter (medicine 3.0) he categorizes medicine into 3 phases: Medicine 1.0 was Hipocrates to essentially the modern era. Medicine 2.0 is the modern era (say, 1940’s onward) but with a powerful emphasis on the development of antibiotics, vaccines and surgery. I’ve made the case this 2.0 era is effectively the “prescriptive” era. Take this pill, do this surgery, and you are good to go. This era made massive strides in emergency medicine, mitigating infectious disease, but clearly it’s been lackluster in addressing chronic degenerative disease. This is where Peter’s vision of “medicine 3.0” emerges. It looks at each person as a unique individual AND it makes the case that we do not wait around for “disease” to occur, we should be looking for ways to optimize health well in advance of disease process. I’m hard pressed to agree with this more than I do. The process of massive studies, taking an average that is then applied to a heterogeneous population is…well, missing the mark. It literally makes no sense. And sitting on our thumbs while a person just hovers around prediabetes is similarly, dumb. As a bit of a side-note and soapbox: this is all due in part to the diagnosis code/3rd party payer system that is modern medicine. If you don’t fit into a specific box, doctors and hospitals cannot get reimbursed…and if you DO fit into a diagnosis box, you’d better hope standard of care addresses your needs. Anyway, I like how Peter parcess this out and it creates an almost obvious path for how to start unwinding most of the problems folks face.
Chapter 3 (Objective, Strategy, Tactics) shows some of Peter’s true genius/tallent IMO. In short, our objective is to push out both lifespan and healthspan to the greatest degree we are capable. This image is a good illustration of what we might be shooting for:
Ok, that’s the objective, how do we get there? This is another smart organizational perspective Peeter lays out, which is the acknowledgement that tactics flow from strategy. To enhance healthspan, we need to minimize our risk exposure to the “four horseman.” That’s our strategy. What we actually DO…diet, exercise, targeted pharmaceuticals etc, those are our tactics. This may seem like an overly complicated way of addressing things, but it goes pretty deep. If we want to avoid cancer, dementia, type 2 diabetes and CVD (the four horseman) there are some specific things we can do to minimize our risk exposure there (diet, exercise etc). That’s fairly straight forward, but like I said, this objective, strategy, tactic story can run deep and is really informative. For example, if you are 40 and want to not just live to be 90, but want to be fairly functional (objective) in old age, your strategy means you need to consider the fairly predictable decline in physical performance with age, and you need the tactics of building enough capacity TODAY so you still have enough left in 50 years to meet your goals. This is a major departure from how medicine is generally practiced (2.0 vs 3.0) and shows much more of an engineering orientation to this story. A major point of evolution Peter acknowledges in this chapter is he has put nutrition in a back seat to exercise as THE hedge against aging. He lays out a pretty thoughtful case for why (which I largely agree with) but Peter also has figured out a way to lay out dietary recommendations without getting as embroiled in the tribalistic shit-show that involves giving any way of eating a name (XYZ diet). I’ll flesh that out more later.
Chapter 4 looks at Centenarians and what we can and cannot learn from them. It’s a solid chapter that if anything makes the case that, yea, your genetics matter, but epigenetics (diet/ lifestyle) may be a far more important consideration in the vast majority of situations.
Chapter 5 looks at fasting, the story of rapamycin and all the goodies that go with these topics like autophagy, AMPK, mTOR etc. It seems like over the past few years folks have pumped the brakes on the fasting madness a bit…my God, the number of people I’d encounter that looked like death warmed over yet were fasting 20 hrs per day, 7 days per week. I’d put some of that on Peter in that he was writing about (and doing) a whole lot of fasting…but he seems to have modified his position in more recent times and seems to be much more circumspect about fasting, calorie restriction et all as it pertains to an effective health span. If you took the time to watch my talk above you will find a lot of overlap with what’s in the book in that CR appears to work primarily when the food quality is garbage. In the rare instances animals were feed a more species appropriate diet, CR actually shortened life, while lab animals fed properly, but protected from predators and most disease, lived about as long as the CR would produce. Peter does not really recommend much in the way of fasting as part of his program and this is largely in line with my thinking as of the past perhaps, 5-7 years. There might be a case for a hard system reset if one has been sick for a long time, or perhaps every few years…but IMO it needs to be weighed heavily against what one might be giving up, namely muscle mass. In many regards I can see nothing that fasting and CR offer that exercise does not also offer, with the added benefit of adaptation to the exercise.
Chapter 6 “The Crisis of Abundance” looks at the emergence of non-alcoholic fatty liver disease. This is a massive problem and growing worse by the day. As a side-note and bit of personal soapboxing: This is yet another topic that leaves me absolutely flabbergasted by the “healthy at any size” crowd. NAFLD was literally UNHEARD of in children 30 years ago. It is commonplace now and portends wretched health outcomes.
Chapter 7 “The Ticker” looks at the number 1 killer on the planet: heart disease. Peter details his own family history of heart disease (which ain’t good…his uncles died of heart attacks at young ages, his father suffered an initial heart attack at a relatively early age, and Peter has documented early stages of CVD which he is managing with VERY aggressive drug therapy). This is one area in which folks who follow my work, and the work of folks like Malcolm Kendrick may feel a bit at odds with what Peter recommends, which is eye-wateringly low LDL-C in the 10-20mg/dl range. Yea, that’s low! Peter fully acknowledges there are a host of risk factors involved in this process, and although he places lipoproteins in the “necessary but not sufficient” category for this process, he takes a very aggressive approach to lipid lowering.
Chapter 8 “The Runaway Cell” looks at cancer. An interesting angle on cancer is if one is not obese, does not smoke, and if one partakes in regular exercise, your likelihood for all cancers is dramatically reduced. Peter devotes a lot of time to discussing the strategies we have at our disposal to prevent cancer, but he also digs into the promise of some of the newer immunotherapy options which may really change the landscape of cancer treatment. He also provides a nice hat tip to the potential of a ketogenic diet and fasting as effective ADJUNCTIVE cancer therapies. I think there is a lot of low hanging fruit to be had here.
Chapter 8 “Chasing Memory” looks at Alzheimers and neurodegenerative disease. At the end of the day we all have certain genetic predispositions such as APOE status…but it also appears that how we play the hand we are dealt may be equally if not more important. Diet, exercise, enriched environments all may play massive roles in if we develop these conditions and if we do, to what degree they progress. Peter makes a great point which I think is often lost on just about everyone: We don’t really need to do a bunch of different things to reduce our risk of CVD, NAFLD, neurodegeneration, cancer etc. Sound diet, good sleep, exercise…they all benefit these seemingly disconnected topics. That should make all this easier, as what's good for the heart, is good for the brain.
Chapter 10 “Thinking Tactically” lays out the gridlines for a plan of how to age most effectively. This segues immediately to chapter 11 (Exercise) which Peter makes the case is the most important lever we have control of. He makes the case for a broad ranging kind of fitness, one with strength training, a solid mix of Zone 2 capacity as well as VO2 max training. And again, Peter makes what can only be described as an engineering observation about exercise: If you are 40 or 50 and want XYZ capacity as you age, you need to build enough headroom today to buffer the inevitable decline you will face with aging. Peter proposes a slick thought experiment via the “Centenarian Decathlon” in which you pick any 10 activities you’d like to kick ass at and then retro engineer how to arrive at your 9th or 10th decade with that capacity. In simple terms, if you are middle age and you want some good capacity in your later years, you need to be in REALLY good shape now. And then not lose much of that as you age! Chapter 12 “training 101” looks specifically at how to structure the various cardio zones, looks at elements of strength training…this is effectively how you begin training for your Centenarian Decathlon. Chapter 13 “The Gospel of Stability” considers the interrelated topics of mobility, stability and movement quality. If your hips are out of line, you will wear out a hip joint, knee, ankle etc at a rapid clip. All of this information is fantastic from a big picture perspective, but most folks will need some help constructing the details of a long arc plan. Quick side notes here: I think the Morpheus platform is fantastic for tracking and monitoring not just recovery, but also specific training bouts. For strength and mobility I highly recommend Power Athlete and Basis S&C. I have NO affiliate relationahsip with any of those links, I’ve just used them all and find them to be fantastic and completely in line with what one might need for an effective training program.
Chapter 14 “Nutrition 3.0” is quite good and Peter does a slick thing here. He claims to step above the vagaries of the nutrition wars by leaning into not diets, but “nutritional biochemistry.” He may in fact do that, but what he absolutely does is just avoids calling his dietary approach any specific name and instead lays out some lane lines to stay within. Eat on the higher protein side (up to a gram of protein per lb of body weight) be aware of glycemic load and perhaps wear a continuous glucose monitor to be aware of what does and does not work for you (same as I did for the 7 day carb test in Wired To Eat) and be aware that some folks see potentially negative lipid shifts with high fat and or high saturated fat, while others do and might want to tweak things a bit. In essence Peter ends up recommending a high protein, low to moderate carb diet, but without saying that directly, but rather by laying out lane lines to stay within. I think this IS a smart way to de-emotionalize the whole process. This flows into Chapter 15 where you learn some strategies for how to “Put nutritional biochemistry into practice.” This is where Peter lays out one of his simple yet really elegant insights: you can calorie restrict, you can dietary restrict (paleo, vegan etc) or you can time restrict…or clearly some combination of these. At the end of the day the main issue is calorie control but there are some caveats here. Remarkably well done primate studies looking at CR vs food quality showed that the higher quality diet fared just as well as the CR animals, with far fewer downsides. The “evidence based” crowd hates this type of stuff, but…the results are what they are. If you want to weigh and measure pop tarts, knock yourself out, it’s better than overeating that garbage, but one of the things that really emerges in this chapter is food quality IS king. It IS a bit interesting that Peter talks a fair amount about evolutionary biology, makes perhaps one the the best cases for food quality one can find in any book…yet just can’t quite step up to the plate and say “yea, some kind of low-glycemic, paleo type diet is likely optimal.” In a way, that’s fine, and he leads readers to that place without the baggage of saying something which will alienate many people. The last part of this section looks at the potential pros and cons of fasting, time restricted eating etc. Peter ultimately makes the case that extended fasting is not just unnecessary, but likely counter productive for many people. I completely agree. There has been a strong push for folks to eat one, perhaps 2 meals per day. That’s fine if that’s what you want to do, but I’ve had the notion of late that it might be smart to be active enough to NEED 3 good meals per day. Think about that for a moment, I think there is a lot to it.
Chapter 16: “Sleep: The Awakening”
As important as exercise is for a healthy life and health span, I think one could make the case sleep IS more important. I’d had an inkling of this since 2001 and the release of the book “Lights Out: Sleep, Sugar and Survival” (still one of my favorite books) but it was not until meeting my dear friend, retired Navy SEAL and physician, Dr. Kirk Parsley, that the full magnitude of the importance of sleep hit me. Peter appears to have had a similar “come to Jesus” in talking to Kirk (who he references significantly in this chapter). If you have followed my work, or Kirk’s, not much more to say on this chapter other than the stories Peter relates about his residency are…well, super concerning. All doctors run this gauntlet, and although it makes for some mental toughness, it almost certainly has cost lives in the form of impaired judgment on the part of doctors. This arcane process is slowly changing but when we honestly acknowledge the impacts of poor and or short sleep on metabolic health, increased cancer rates, accidents, suicide…It’s nothing short of stunning how important good sleep and circadian biology is.
Chapter 17 “Work In Progress”
Peter is one of the most high-achieving people I’ve ever known, and I’m fortunate to have an interesting group of hard charging friends that include: Doctors, SEAL’s, researchers, parents, professional athletes, interrogation specialists (as in made for TV movies about these folks breaking cases in amazing ways)...and most of these folks seem to also be BJJ black belts, firearms experts…I’m fortunate to run with an eclectic crowd of interesting, high achieving people. When Peter would meet these people I knew, these ultra high achievers, just about to a person their comment about Peter was something to the effect “Damn, that guy is buttoned up!” And, indeed, he is. But sometimes, this degree of achievement either comes at a price or more accurately perhaps, is the outgrowth of trying to fill a void that past trauma has created. Peter get’s quite raw and honest about some very painful tendencies and behaviors that gave him stunning success on the one hand and very nearly ruined his life on the other. This chapter was a hard read. I think in part because Peter in many regards seems like an unflappable super hero. And he is in many regards, but like any truly good superhero story arc, there is profound pain and loss that often nearly consumes the individual. This chapter is much more than the need for community (it does include that) but it details the experience of an ultra-high achiever coming to brinkmanship with self destruction. This chapter is, without a doubt, the most important of the whole book, and although Peter has swore that this is the one and only book he ever writes, I do hope he expands on this material in some future ways, as I think it’s crucially important for many people to read it.
This final chapter gives way to an epilogue that (paraphrasing) says “I used to subscribe to the Silicon Valley view of longevity: I could biohack and hack and hack my way to longevity…but if my life sucked, what was the point?” I think for Peter this final chapter on emotional health ended up being a bit of a surprise late entrant to the book…I’m speculating on that, but I suspect this is the case. But that paraphrased bit, although the energy is focused on the mental health part of this story, is applicable to every facet of this book.
My take on longevity is that there should be little if ANY loss of quality NOW in the hopes we will somehow have something good later.
A good diet, sound sleep, a solid cardio and strength base, good mobility and meaningful relationships will profoundly improve our lives now. Every minute.
Starving ourselves such that we are chronically cold, have no sex drive and could not save ourselves if our car slid down an icy embankment is not a viable option for “a better tomorrow.”And it kinda makes our lives suck today.
I found this book to be outstanding, particularly that last chapter which I have no doubt was very difficult for Peter to write. I have no doubt some will bemoan the simplicity here-in. “Yea, we already knew sleep, diet and exercise are good!” Well, simple though that may seem, there are a lot of details along the way. And Medicine 2.0 is not just ignorant of this material and framework, but openly antagonistic to Medicine 3.0. Human lifespan seems to have been selected for fairly significant longevity, I touch on this in my talk above. The strategy and tactics in Outlive offer our best options to not just live an optimal life now, but to get the fullest extent of that life.
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"There is a pasty, sarcopenic huckster in the health space claiming he is going to make it to 150 years old"
Oooooooof shots fired! 😂😂😂😂😂
Robb I always love your take on most things. I really wish you would write more!