Outlive

The book has three parts.

In Part I, Attia walks us through the evolution of health care and maps out the high level objectives, strategy, and tactics for the book.

In Part II, he walks us through what the longest-lived people have in common and the top three challenges we face in our quest to Outlive: heart disease, cancer, and Alzheimer’s.

In Part III, we get into the practical tactics for our plan to live longer, better including: exercise (Attia’s #1 recommendation for longevity!), nutrition (more specifically “nutritional biochemistry”!), sleep (learn to love it—it’s the best medicine for your brain!), and our emotional well-being (and the high price of ignoring it).

That passage is from the second chapter in Part I called “Medicine 3.0: Rethinking Medicine for the Age of Chronic Disease.” Here’s the quick overview of Medicine 1.0, 2.0, and 3.0…

Attia tells us that: “The first era, exemplified by Hippocrates but lasting almost two thousand years after his death, is what I call Medicine 1.0. Its conclusions were based on direct observation and abetted more or less by pure guesswork, some of which was on target and some not so much.”

Then we have Medicine 2.0 which “arrived in the mid-nineteenth century with the advent of the germ theory of disease, which supplanted the idea that most illness was spread by ‘miasmas’ or bad air. This led to improved sanitary practices by physicians and ultimately the development of antibiotics.” Although “Medicine 2.0 was transformational” in many ways, it “has proved far less successful against long-term diseases such as cancer,” heart disease and Alzheimer’s.

There are FOUR distinctions between 2.0 and 3.0: “First, Medicine 3.0 places a far greater emphasis on prevention than treatment.” Second: “Medicine 3.0 considers the patient as a unique individual.” Third: “In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing.” Fourth: “Perhaps largest shift is that where Medicine 2.0 focuses largely on lifespan, and is almost entirely geared toward staving off death, Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life.”

He brings it all together at the very end of the chapter when he tells us: “Which brings us to perhaps the most important difference between Medicine 2.0 and Medicine 3.0. In Medicine 2.0, you are a passenger on the ship, being carried along somewhat passively. Medicine 3.0 demands much more from you, the patient: You must be well-informed, medically literate to a reasonably degree, clear-eyed about your goals, and cognizant of the true nature of risk. You must be willing to change ingrained habits, accept new challenges, and venture outside of your comfort zone if necessary. You are always participating, never passive. You confront problems, even uncomfortable or scary ones, rather than ignoring them until it’s too late. You have skin in the game, in a very literal sense. And you make important decisions.

Because in this scenario, you are no longer a passenger on the ship; you are the captain.”

That’s from a chapter called “The Runaway Cell” in Part II in which Attia walks us through the leading killers of humanity and what they have in common.

The HYPER-abridged, oversimplified summary? All of the chronic diseases killing us (that Medicine 2.0 does a VERY POOR job of addressing!) are related to metabolic dysfunction.

For the record, here’s how Attia defines metabolic dysfunction: “Today we call this cluster of problems ‘metabolic syndrome’ (or MetSyn), and it is defined in terms of the following five criteria: (1) high blood pressure (＞130/85); (2) high triglycerides (＞150 mg/dL); (3) low HDL cholesterol (＜40 mg/dL in men or ＜50 mg/dL in women); (4) central adiposity (waist circumference ＞40 inches in men or ＞35 in women); (5) elevated fasting glucose (＞110 mg/dL).

If you meet three or more of these criteria, then you have the metabolic syndrome—along with as many as 120 million other Americans, according to a 2020 article in JAMA. About 90 percent of the US population ticks at least one of those boxes.”

Quick check in: How are YOU doing with those numbers?!

Now… I pulled out that particular passage regarding cancer’s preferential metabolism of glucose because it struck a nerve. As you know if you’ve been following along, my brother died of pancreatic cancer several years ago. Immediately after he had an emergency surgery and was diagnosed with Stage IV pancreatic cancer, I immersed myself in the literature to support him.

In the process, I created Notes on some of the leading books on the subject, including The Metabolic Approach to Cancer by Nasha Winters, Cancer As a Metabolic Disease by Thomas Seyfried, Keto for Cancer by Miriam Kalamian, and Tripping Over the Truth by Travis Christofferson. I also created classes called Conquering Cancer 101 and Conquering Cancer 102.

And… I wrote a Note on *the* mainstream book on cancer by one of Medicine 2.0’s leading thinkers: Siddhartha Mukherjee’s The Emperor of All Maladies.

In that Note, I came as close to being rude/belligerent as I have ever gotten in a Note. Why? Because, in his 592-page book—which is considered THE best book on cancer by Medicine 2.0—he didn’t mention Otto Warburg and his theories on metabolism. Not even a single reference.

It was infuriating for me when I read it. Almost as infuriating as going to my brother’s oncology appointment with him to get a PET scan (which, as Attia points out measures hot spots of glucose metabolism to identify potential cancerous tumors that preferentially feast on glucose) and seeing a CANDY BOWL at the reception desk. They were feeding my brother the very food that would feed his cancer and HAD NO IDEA that was a bad idea.

Then there was the Pancreatic Cancer society’s walk-a-thon fundraising event I went to that was sponsored by a fast food restaurant. Free soda and hot dogs were served and beach balls with their logo were handed out to kids and adults alike.

To be blunt: That is all CRAZY. Which is why I was very happy Attia talks about this and also mentions a chat in which he talked to Mukherjee. Apparently he has evolved his thinking and is now pursuing metabolic solutions to cancer.

P.S.: The way I tried to help my brother be the “Captain” of his ship rather than a mere passenger as he navigated his cancer treatment was to encourage him to see himself less as a “patient” (which literally means “one who submits”) and more as a CONQUEROR (which literally means “one who seeks successfully”).

That’s from the first practical chapter in Part III.

Once we’ve established the high-level intellectual framework (Medicine 3.0!) and clarified our objectives and strategies (optimize our metabolism/mitochondria to increase BOTH our lifespan AND our healthspan!), we get to work on the TACTICS that will enable us to succeed.

Attia tells us we want to dominate the same core fundamentals we come back to ALL THE TIME: Eating, moving, and sleeping. But… He tells us the place to start is with… EXERCISE.

I’m going to repeat this line: “So, if you adopt only one new set of habits based on reading this book, it MUST be in the realm of exercise.”

Attia italicized “must.” I put it in ALL CAPS bold italic just to make sure you got the memo. And, I want to emphasize that Attia isn’t a bio-hacking nut. He’s a relatively conservative (and VERY rigorous thinking!) Stanford-trained medical doctor.

So… I personally took him at his word and have rearchitected my training protocol to meet his standards. The biggest shift for me? Zone 2 training. Although my VO2 max (I got it tested immediately after reading his book!) was in the highest/“superior” category for my age (I guess the 101 burpees, 1,000 meters of rowing, and 10,000 steps a day EVERY DAY for a decade have helped!), I was only getting about an hour of Zone 2 in per week. Frankly, I was seeing how LITTLE I could train to feel great.

But… I wasn’t even hitting the standard American recommendation of getting 150 minutes (or 2 and 1/2 hours per week) of Zone 2. Attia recommends THREE to FOUR hours per week. I can assure you I hit 3 hours the week I read the book and I’ve hit 4 hours the last three weeks since.

Attia says this about Zone 2 (which is 60-70% of your max): “I am so persuaded of the benefits of zone 2 that it has become a cornerstone of my training plan. Four times a week, I will spend an hour riding my stationary bike at my zone 2 threshold.”

In addition to strength and stability training as part of our new exercise protocol, he’s ALL about optimizing our VO2 max which is why hitting his standard is my current #1 Energy goal: “I push my patients to train for as high a VO2 max as possible, so that they can maintain a high level of physical function as they age. Ideally, I want them to target the ‘elite’ range for their age and sex (roughly the top 2 percent). If they achieve that level I say good job—now let’s reach for the elite level for your sex, but two decades younger. This may seem like an extreme goal, but I like to aim high, in case you haven’t noticed.”

As you might have guessed, that’s from the chapter on Nutrition. I’m going to skip the details on this chat and encourage you to check out the Notes on Gabrielle Lyon’s Forever Strong for more wisdom on the subject.

For now, remember: High-quality protein (about 1 gram per pound per day!!) does a Hero good!

P.S. Attia says: “In case my point here isn’t clear enough, let me restate it: don’t ignore protein. It’s the one macronutrient that is absolutely essential to our goals. There’s no minimum requirement for carbohydrates or fats (in practical terms), but if you shortchange protein, you will most certainly pay a price, particularly as you age.”

Sleep! It does a Hero good!

Right after that passage, Attia references the same Stanford study we talk about in our Notes on Arianna Huffington’s The Sleep Revolution. Then he talks about how LeBron James “makes sleep a key part of his recovery routine, always trying for nine and sometimes ten hours of sleep per night, plus a daily nap.”

Then… He tells us “Yet we are often unaware of the devastating effect that poor sleep is having on our energy levels and our performance. Research has found that people who are sleep deprived almost always underestimate its effects on them, because they adapt to it… we come to accept the resulting state of mild exhaustion and mental fog as a new normal, a process called ‘baseline resetting.’ … It’s like a regular TV looks fine if that’s all you’ve ever seen. But once you see a 4k screen, you realize that your old cathode-ray tube TV was not very clear at all. The difference is that dramatic.”

And THAT’s how we’ll wrap up this SUPER quick look at this GREAT book.

How’s YOUR metaphorical TV resolution? Here’s to dialing it up to Heroic levels as we DOMINATE the fundamentals as we optimize our lifespan AND our healthspan, while showing up with all the Energy we need in our Work and our Love… TODAY!