Outlive Part 1: Principles for Longevity
Setting the stage for living longer
This is the first in a three-part summary of Peter Attia’s Outlive. It’s not at all like what I normally write about, but I really enjoyed and got a lot out of the book, and felt compelled to write up. If you end up liking this and want more like it, let me know!
I was introduced earlier this year to Peter Attia’s book Outlive by my friend Aadil Mamujee, who wrote a post on taking a broader look at his health and inspired me (and Lindsay) to do the same. I am turning 40 this year, and it seemed like a good time to take a look at my overall health. Aadil shared his notes from Outlive with me, but I was inspired to read the entire book. Because I read it on Kindle, I was unprepared for just how large a tome it was—it is effectively a textbook, a fact which I discovered only after buying a physical copy to keep as reference.
Outlive is worth reading in full, but it could benefit from some prioritization and editing. Suggestions like “use a dry sauna at 179F or hotter four times a week to combat cardiovascular disease”—not entirely practical for most people, and certainly less critical—are scattered in the text alongside the important stuff.
The book also frequently jumps from topic to topic. Attia discusses the importance of zone 2 endurance training in the early chapter on metabolic syndrome, but then returns to it hundreds of pages later in the chapter on exercise. If you’ve listened to any of his (typically 2+ hour) podcasts, you’ll know what I’m talking about.1 Even the community crowdsourced summary is fifteen pages long. It’s not entirely his fault; health does appear to be (unsurprisingly, annoyingly) interconnected.
So this is my effort to make Outlive more actionable and organized. I’ve spent hours going through the book and other material online to try and condense things, as well as choosing to include only the bits I think are most widely actionable (e.g., we’re not going to talk about taking rapamycin). Just to be clear, this is my summary which explicitly doesn’t cover everything in the book—I hope it is as useful to you as it has been for me.
Unfortunately even the condensed version would be too long if I tried to cram it into one post so my summary is going to be divided into three(!) parts.
In part one, we’ll talk about the setup: the guiding principles behind Outlive.
In part two, we’ll excitingly cover all the ways you are most likely to die.
Finally, in part three, we’ll discuss what you can do about it.
The framework
Outlive spends a lot of time establishing underlying principles and framework for approaching health and longevity, before getting into the meat of things. The book’s basic approach is this:
We should focus on prevention of disease instead of only on treatment.
We should work backwards from what activities we want to do when we’re older (Attia specifically uses centenarians, or 100+ year olds as the target).
We should understand what our biggest risks are, and use tests to diagnose which ones we are specifically at greater risk for versus.
Finally, we devise a plan to both a) help us achieve our centenarian goals in light of natural fitness decay as we age, and b) mitigate our biggest risks. (Spoiler: it involves exercise.)
Prevention instead of only treatment
A key concept in Outlive is what Attia calls “Medicine 3.0”. The short version is that current medicine—Medicine 2.0—focuses on treating disease, whereas Medicine 3.0 focuses on preventing it.2
With Medicine 2.0, when you discover you have a problem (usually due to some acute event or pain) we jump into action to try and treat the condition. Medicine 2.0 is centered on treatment, and it focuses on short-term risk.
For example, if you are young and eating too much McDonald’s, your ten-year risk of a heart attack is likely lower than a 75-year old who eats a more balanced diet, even if you would end up less healthy than them by age 75 if you kept it up. Because the 75-year old’s risk is higher simply due to age, Medicine 2.0 would rather treat them first.
Medicine 3.0 says if our goal is to have long healthy lives, we should be working to fight and reverse these problems early on, instead of ignoring them until our ten-year risk crosses some arbitrary threshold.
Attia compares this to how we now view smoking:
We know that smoking is causally linked to lung cancer. Should we tell someone to stop smoking only after their ten-year risk of lung cancer reaches a certain threshold?
This sounds absurd, but is actually how we manage our health in many areas. For some reason, our cultural norms around avoiding an unhealthy lifestyle that leads to our most common causes of death have not yet caught up to our views on smoking. We are mostly content to let things be until a red alert sounds in the form of bad blood test results, or worse.
You might wonder whether this topic is really that important to include in an already long book. Attia doesn’t say this, but my view is that you need to buy into this philosophy to bother doing all the work needed to make a difference. Continuing to not smoke is not hard if you have never been a smoker. But taking on the amount of exercise and other activities Attia covers in Outlive takes a lot of time. Like, a lot of time.3
You have to believe it’s worth it, because watching Netflix on the couch is much, much easier.
Working backwards
So maybe you’re sold on the philosophy of prevention. That’s half the battle—as much as we can, we want to prevent getting afflicted with the most deadly diseases. The other half of Attia’s philosophy is figuring out what we want to do with our lives, specifically our lives as elderly people.
Enter what he calls the “Centenarian Decathlon”. That is, literally what are ten activities that are meaningful to you that you want to be able to do when you're a hundred.
People have a conceptual idea of what they will do when they’re old, like play with their grandkids or travel. But fitness declines basically across all metrics as we age. We lose strength. We lose aerobic fitness. We lose muscle mass. It's one thing to imagine these things now when you're young, and another to have the fitness to do them decades from now.
He gives an example of wanting to be able to pick up your grandkids:
Let’s say the kid weighs twenty-five or thirty pounds. That’s basically the same as doing a squat while holding a thirty-pound dumbbell in front of you (i.e., a goblet squat). Can you do that now, at age forty? Most likely. But now let’s look into the future. Over the next thirty or forty years, your muscle strength will decline by about 8 to 17 percent per decade—accelerating as time goes on. So if you want to pick up that thirty-pound grandkid or great-grandkid when you’re eighty, you’re going to have to be able to lift about fifty to fifty-five pounds now. Without hurting yourself. Can you do that?
By identifying your Centenarian Decathlon you can create a plan to help make it happen. Or at least in theory. In reality, throughout Outlive, the prescription seems to be the same regardless of what activities you choose. (We'll get there in part three.) That's okay because most of us want to be some version of “a functional human” and the exercises you need to accomplish that are generalizable, but still it feels like an underdeveloped idea.
Regardless of what your Centenarian Decathlon looks like, working backwards helps us avoid what Attia dubs the “marginal decade”: For many people the last ten years of their life are not great. Medicine 2.0 has gotten better at increasing lifespan, but that doesn’t mean what you’re up to during that extended lifespan is very fun. Outlive proposes the idea of healthspan, which is a subjective (but useful!) measurement of how many healthy years you live, and therefore get to actually enjoy.
Improving your healthspan is sort of like building up a retirement account. You know that later in life you won’t be earning as much and want a nest egg of cash built up you can slowly draw on so you don’t have to go back to work. Given that our fitness also declines steadily as we age, we similarly want to aim to be as healthy as possible now to counteract the drawdown.
And that’s it! Between the ideas of prevention over treatment, working backwards, and the concept of healthspan, you are caught up on roughly 17% of the book. Next up, we dive into the details on the major afflictions out to get us: the Four Horsemen.
Seemingly part of the value you get for paying for membership on his site (which I have not done) is in making his knowledge more accessible and systematic. His podcasts are free, but getting full notes or Attia’s takeaways from his interviewees are gated behind the paywall.
Given even the notes are sprawling, you’re still going to have to do a ton of work to make use of them.
Medicine 1.0 was basically pre-modern medicine before germ theory: trepanation and the like. We don’t really need to think about Medicine 1.0.
One critique of Peter Attia is that he is a little bit intense and his recommendations are extreme (remember the sauna?). I tried to keep track of all the things he says are in his weekly routine in Outlive, and it adds up to at least thirteen to fourteen hours a week alone of just exercise, and I’ve probably missed some. Still, you don’t have to be as hardcore as him to benefit.
appreciate the shout out!