Wednesday, October 4, 2023

Unpacking Peter Attia's "Outlive": Is This The Fountain of Youth?

I just finished reading Peter Attia's excellent book "Outlive." The book was the topic of Attia's appearance on Jocko Willink's  podcast, which I recommend. I'm glad I gave this episode a listen, otherwise I probably wouldn't have bothered reading the book. 

The topic of Attia's book is longevity, which is a subject I typically associate with dumbass dogma and bizarre, ritualistic practices like eating nothing but kale and organ meat, injecting themselves with the blood of children, and drinking their own piss. 

Much to my delight, Attia openly criticizes these charlatans. He begins the book by setting expectations - his advice, which is based on an honest assessment on the empirical evidence, won't allow you to live forever. Or even increase your lifespan significantly. His advice is meant to improve what he calls "healthspan", or the length of time you live a healthy life, which he defines as the time you're capable of doing (and enjoying) the things you like to do. Basically, he's making the case that living a long time is pointless if your quality of life sucks. 

His approach to improving our healthspan involves accounting for the gradual decline of aging we'll all experience, then using exercise, diet, stability, good sleep habits, and emotional health to get ourselves in a condition that will decrease the probability of developing what he refers to as the Four Horsemen - cardiovascular disease, diabetes, cancer, and dementia. These four diseases are the main diseases that lead to a miserable existence later in life and, eventually kill most of us.

Basically, his approach is to make the last decade of our lives worth living. Attia frames this preventative approach as "Heathcare 3.0" (where Healthcare 1.0 was medieval quackery and Healthcare 2.0 was using science to treat disease.)

This affirms many of my recent experiences as a cop. I regularly interact with a cross-section of the population, and there are stark differences in people's healthspan. I deal with 95 year old fit, spry ranchers who spend their days literally wrangling cattle. I also deal with morbidly-obese 50 year olds who can't walk up a flight of stairs without taking a break and take fifteen prescriptions every day in a feeble attempt to manage the dozen serious medical conditions they've developed because of their shitty life choices. But there's evidence that's closer to home.

My own life affirms Attia's premise. At 47, I've prioritized all of Attia's recommendations (which I'll discuss shortly.) There's nothing I cannot do today that I couldn't do decades earlier. I don't have any chronic diseases and I do not take any medication. I work and train with people half may age without "old man" accommodations. The n=1 considerations aside, his stuff works

Of course, 47 is still "young" in regards to the arc of age-related degradation. It's still pretty easy to keep up with the young bucks. Physical and mental decline has already started, but it's barely noticeable, and will remain minimal through my 50's. Things typically start declining faster through our 60's, and faster still through our 70's. By eighty, the majority of people start declining rapidly. The goal of improving healthspan outcomes is to delay that decline as long as possible.

Based only on my current age, I can expect to live to 81.8 years (via the Social Security Administration calculator.) I theoretically have 34 years remaining. Based on standard decline models, I can maintain my current lifestyle for about 12-15 years, about ten years of significantly diminished capacity, then about ten years of seriously diminished capacity.

The idea of Attia's methodology is to push that decline back to the point where that last decade is way better than the standard rate at which we decline would predict. The benefits of living a better lifestyle obviously improve our functioning in the earlier years, too. 

Attia recommends listing the activities you would like to be able to do late in life, account for the inevitable age-related decline, and work backward to determine where you should be today. 

For example, our VO2 max (the efficiency our body uses oxygen, which we colloquially call "cardio" capacity) declines about 10% per decade starting in our 30's. My current estimated VO2 max is around 46 ml/kg/min of oxygen. This should allow me to run about a 22 minute 5k. If I continued my current exercise routine, that VO2 max will decrease to about 33 ml/kg/min by my 70's. That should result in a 29 minute 5k. 

Let's say I wanted to run that 5k in 22 minutes at age 77. I'd need  VO2 max of 46 ml/kg/min at that age. Working backward, I'd need a VO2 max TODAY of about 61 ml/kg/min. If that time were my goal, I'd need to start developing my VO2 max today to get to that point. 

The same concept works for strength. Starting at about 50, we lose about 15% of our muscle mass and strength by decade. Right now, I can bench press about 225 pounds. If I maintain my same workout routine, I would only be able to lift about 160 pounds or so at age 80. If I wanted to bench 225 at age 80, I'd need to be benching about 345 today. 

The idea is to figure out what you want to be able to do late in life, then get yourself in condition today to be able to do that while accounting for the normal decline that happens with aging. For some, this might include things like being able to walk up stairs, be able to go shopping, or lift a baby (grand kids, great grand kids, etc.) Me? At age 80, I want to be able to do a 30 minute jiu jitsu roll, run a 100 miler in 30 hours, and score at least a 50 on the NTOA Fitness Test

That's probably pretty unrealistic, but it does give me concrete fitness goals for today.

The Actual Advice

Attia's advice covers five domains, which consist of exercise, diet, stability, sleep, and emotional health. As I said earlier, nothing in his recommendations will be surprising if you're an objective observer of health and fitness best practices. Here's a summary of each:

Exercise and Stability

Attia considers exercise to be the most important element. His recommendation is to do four 45 minute sessions of cardio at 60-70% of max heart rate, and one or two sessions of high-intensity exercise. He also recommends strength training (for strength, not mass) two to three times per week. Finally, he recommends doing some sort of stability training a few times per week. The stability bit was interesting. The idea is to prevent falls as we age. Apparently 25-30% of people over the age of 65 who break a hip die within a year, which was mind-blowing. Serious injury as we age basically keeps us from moving, and when we can't move, we tend to die pretty quickly. 

Attia's recommendation mirrors my own routine pretty closely, though the ratio of running and lifting ebbs and flows. I get plenty of stability work in bjj and trail running. Attia does mention injuries, which has been a minor issue the last few years (chronically-dislocated rib, injured abdominal muscle, etc.) He notes we should be cautious about the intensity of exercise as we age as injuries that take us out of training can have disastrous effects. In the Jocko podcast, he notes a 60 year old person will lose 10-12 months of strength gains with only a 10 day absence from training, which is crazy. Personally, I need to be more cautious with some of my exercise routines, especially jiu jitsu and mma-related stuff. 

Attia recommends creating a "centenarian decathlon" of 10 things we would like to do in old age. These 10 things are the skills we will "train" starting right now, which will allow us to do them when we're significantly older. I love this idea! Younger people (under age 60 or so) always fail to account for that inevitable decline and think, just because they can do something today, that they will be able to do that several decades into the future. Which, of course, doesn't happen. 


This is the realm where Attia really won me over. He notes almost all diet advice is shit, and this space is filled with fanatics who treat diet like a religious cult. Attia affirms my approach - if you need to gain weight, eat more. Lose weight? Eat less. Limit processed foods, especially sweets, fast food, and junk food snacks. Limit alcohol. Make sure you get about 1 gram of protein per pound of body weight per day. Be strategic about the timing of eating carbs (mornings or before exercise.) 

I usually do fairly well here. My Achilles heal are sweets and occasionally alcohol, though I consume far less of each than I did a decade ago. I played around with various forms of fasting, but Attia notes the rewards (calorie restriction and cellular health) probably don't outweigh the costs (muscle loss), especially as we age and if we follow the exercise guidelines (which also aids in cellular repair.) 


I really like that Attia gives sleep a great deal of attention. Until about a decade ago, even the scientific community minimized the importance of sleep. Now, we have all kinds of data that sleep (and the recovery that occurs when we sleep) is absolutely critical for a healthy life (and healthy aging.) As a society, we still tend to glorify lack of sleep, which is utterly ridiculous.

Attia recommends seven to nine hours of high-quality sleep each night, and gives a slew of excellent suggestions on attaining it. When I work the day shift (6am to 6pm), I routinely get a solid seven to eight hours nightly. Night shift is still a challenge, though I'm continually experimenting (which will be a separate post in the near future.)

Emotional Health

This was an interesting chapter. In my own lifestyle design roadmap, I've always focused on mental health, not emotional health. However, I like Attia's approach as mental health is almost always predicated on emotional health. In this chapter, he gives several excellent nuggets of advice, such as work with a therapist on occasion, maintain healthy social relationships, and practice mindfulness. In the podcast, Attia discusses the book "4000 Weeks" by Oliver Burkeman, which is an excellent follow-up read to "Outlive." Burkeman expands on the ideas in this emotional health chapter.

For me personally, mental health is pretty much optimized through exercise, diet, and sleep, so shifting to an emotional health focus makes more sense. I can take care for the mindfulness bit through meditation, which I need to start doing regularly, which will probably involve re-reading "10% Happier" by Dan Harris and "Why Buddhism is True" by Robert Wright

The healthy social relationship bit is a little more of a challenge, though. Being an introvert, social interactions are mentally and emotionally draining. After interacting with people for a period of time, I need significant alone time to recharge. I love interacting with people, but it's draining. Once the "social" tank gets close to empty, I start experiencing debilitating anxiety, which makes me really irritable. The problem is my job requires a whole lotta socializing... I talk to people all day long AND many of these interactions involve people who are in crisis, emotionally-charged, under the influence of drugs or alcohol, or are just lonely and super-chatty. Work drains the social tank pretty quickly. 

Unfortunately, that doesn't leave a lot left over for socializing with friends or family. I don't have a solution to this problem unless the friends and family are also introverts (and are okay with infrequent social interactions.) The best hacks I've discovered involve socializing in settings where we're active (namely jiu jitsu and running, which is good from a health perspective, or drinking, which is bad from a health prospective.) Introvert readers - if you have any tips, please share!


For most of the population who aren't critical consumers of health and fitness advice, this book could be life-changing. As a society, we're not healthy. And we're aging. Over the next few decades A LOT of us are going to be trapped in a miserable existence as we run out the clock on our lives. Attia's book can change that grim outlook.

For those who are already objective consumers of health and fitness advice, this book will affirm what you already know, and probably give you a plethora of actionable strategies that will further improve your lifestyle outcomes. You're probably already living a pretty healthy lifestyle, but this book will give you a framework for continuing that lifestyle when things really start to decline.

Either way, this is one of the few books I'd place in the "must read" category. Pick it up. Read it. Let me know what you think.



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