A Summary of “Outlive”

I recently stepped away from a career practicing traditional medicine to build my own business. 

One of the reasons I pivoted careers was due to dissatisfaction with the modern medical system. 

Over the last year, I’ve found other experts in the field who feel the same way. 

And in my pursuit of a longer, healthier life, I look at a few role models for guidance. 

One such expert who has recently made waves in the longevity field is Dr. Peter Attia and his book “Outlive”. 

Given my experience in medicine and interests in longevity, I feel compelled to tell you what is missing in modern medicine and explore the how we can potentially extend our health span and lifespan using some of my favorite principles in “Outlive”. 

Healthspan vs. Lifespan

To highlight my dissatisfaction with modern medicine, let’s talk health span and lifespan. Lifespan is our total time on Earth. 

For example, if you pass away at 90, your lifespan is 90 years. 

Health span, on the other hand, is how long you remain healthy and able to do what you want—like playing with grandchildren, jogging, managing finances, or living without pharmaceuticals.

In a typical life, represented by the light blue line, we generally live well until our 40s or 50s. 

Then, factors like sleep deprivation, poor nutrition, lack of exercise, and high stress start to cause health issues, continuing this downward trend until we pass away. These health issues mainly consist of cardiovascular disease, cancer, metabolic dysfunction (like diabetes), and cognitive disorders (like Alzheimer’s). 

Modern medicine, shown by the red line, follows a similar trajectory until intervention occurs. 

For example, you go to your doctor and catch high blood pressure or high cholesterol and start medication. 

These interventions may increase lifespan slightly, but often with poor health. Medications rarely restore peak health; they merely extend life and manage the condition when damage is already done.

My goal, illustrated by the green line, is to correct lifestyle choices and improve overall habits from the start. 

This approach aims to maintain peak health for as long as humanly possible. 

This is why I want my “medical practice” to be lifestyle medicine. 

I want to be the doctor you see before you see a doctor because we focus on optimizing movement, nutrition, stress, and sleep.

Dr. Peter Attia refers to society’s current approach (the red line) as “Medicine 2.0,” where treatment typically begins only after a patient has fallen ill. 

Instead, he and I both advocate for a shift to “Medicine 3.0,” (the green line) a preventive approach that aims to stop diseases before they start. 

While his book does touch on treatment methods, its primary focus is on prevention strategies that we can all implement in our daily lives. 

So without further adieu, let’s get into the science of longevity and the top prevention strategies. 

Nutrition: The Foundation of Longevity

Nutrition is the cornerstone of longevity. 

Dr. Attia’s approach to diet is nuanced and tailored, recognizing that individual responses to different nutritional strategies can vary widely.

Heart Health

Given that heart disease remains the leading cause of death in the United States, it’s no surprise that Dr. Attia dedicates significant attention to cardiac health, and this will kick off our discussion on nutrition. 

He and I both have personal histories with this, with many male relatives succumbing to heart disease at relatively young ages. 

The good news is that medical advancements are making heart disease both easier to treat and prevent.

One intriguing approach Dr. Attia discusses is the ketogenic diet. 

However, he puts a unique spin on it. 

While many keto enthusiasts focus on saturated fats, Dr. Attia suggests a diet rich in monounsaturated fats. 

He recommends sources like extra virgin olive oil, macadamia nuts, and avocados. 

This is why I am big on the Mediterranean diet and high consumption of extra virgin olive oil – the heart health benefits are very real. 

Consuming a diet higher in monounsaturated fat may help prevent the rise in triglycerides often seen with high saturated fat intake, which can be detrimental to heart health.

The PREDIMED Trial: A Case for Healthy Fats

Dr. Attia cites the PREDIMED trial as compelling evidence for the benefits of a high-fat Mediterranean diet. 

This Spanish study involved 7,447 participants aged 55-80, all at high risk for heart disease. 

The participants were divided into three groups: two following a high-fat Mediterranean diet (one supplemented with olive oil, the other with nuts) and a control group on a low-fat diet.

The results were so striking that the study was halted after 4.5 years instead of the planned 6. 

The olive oil and nut groups showed significant improvements in cardiovascular health and memory, while the low-fat group experienced declines in both areas. 

This study underscores the potential benefits of incorporating healthy monounsaturated fats into our diets.

Beyond Diet: Other Heart and Brain Health Strategies

We all know we need to eat healthy, but there are a few other interventions that can significantly improve heart health. 

Attia also highlights two seemingly simple practices that could have profound effects on our health: daily flossing and regular sauna use.

Good oral health, maintained through practices like daily flossing, is associated with better overall health. 

Microbes known to cause gum disease have been found in other parts of the body, potentially contributing to various health issues. 

For instance, a microbe called Porphyromonas gingivalis, known for causing gum disease, has been found in the brains of Alzheimer’s patients.

As for sauna use, Finnish studies have shown that men who use saunas regularly (at least four times a week for 20 minutes at temperatures of 179°F/82°C or higher) experience fewer cardiac events than those who use them less frequently or not at all. 

If just sitting in a hot room for 20 minutes could potentially improve both brain and heart health, I’m going all in on that. 

But some people are already dealing with elevated triglycerides and LDL cholesterol, and medication shouldn’t be ignored if it’ll improve your health. 

Dr. Attia discusses various medications, including certain statins like Crestor, and other medicines such as Nexlizet, Zetia, PCSK9 inhibitors, and Vascepa. 

As for actionable steps, I’m interested in Vascepa which is derived from fish oil. 

Fish oil contains a high dose of EPA, an omega-3 fatty acid beneficial for heart health, so it’s one of my top recommended supplements for health. 

The Power of Omega-3s

Omega-3 fatty acids are going to be key for both heart and brain health. 

There are two main omega-3s: EPA and DHA. 

While EPA is particularly beneficial for the heart, DHA is crucial for brain health and may help prevent neurodegenerative diseases like Alzheimer’s, Parkinson’s, and dementia.

Given that few people have optimal omega-3 levels through diet alone, Dr. Attia suggests considering a high-quality omega-3 supplement, and it’s something I’ve been doing for years. For those following a vegan or vegetarian diet, algae-derived omega-3 supplements are available also. 

Eat Your Protein

If you know me, you know I love my protein. 

Adequate protein intake is essential for maintaining muscle mass as we age. 

This view contrasts with some other longevity researchers who advocate for protein restriction.

Dr. Attia suggests that protein is the most important macronutrient and that we should be consuming enough of it every day, ideally spread throughout the day. 

This recommendation is based on the crucial role protein plays in muscle synthesis and maintenance, which becomes increasingly important as we age. 

We naturally lose muscle mass each decade of our lives, so maintaining your protein consumption will be key to reducing muscle turnover.

However, it’s important to note that this view isn’t universally held in the longevity community. 

Researchers like Dr. David Sinclair and Dr. Steven Gundry often caution against excessive protein intake, particularly from animal sources, citing potential activation of mTOR pathways which may accelerate aging.

Continuous Glucose Monitoring

We have protein, now let’s go into arguably the most delicious macronutrient: carbs. 

While not advocating for complete carbohydrate restriction, Dr. Attia emphasizes the importance of maintaining stable blood glucose levels. 

He is a proponent of continuous glucose monitoring (CGM) for understanding and optimizing metabolic health. 

Excessive amounts of sugar can increase cellular aging. 

Basically, too much sugar may reduce your health span and lifespan. 

According to David Sinclair, it all comes back to Adenosine 5’ monophosphate-activated protein kinase (AMPK), an enzyme known as the body’s master regulator of energy metabolism. 

AMPK is linked to blood sugar. 

When cells are starved of sugar, like when fasting, AMPK is activated.

AMPK makes more mitochondria (the powerhouse of the cell), and we lose mitochondria as we get older. 

Poor mitochondrial function is linked to heart disease, dementia, type 2 diabetes, metabolic syndrome, and insulin resistance. 

Mitochondria are essential for metabolizing what you eat and making energy. 

So when you activate AMPK by fasting or maintaining stable blood sugar, you’ll have more energy and feel better. 

These CGM devices, usually implanted in the upper arm, provide real-time blood glucose data on your phone. 

While currently only available with a prescription, Dr. Attia believes they could be valuable tools for anyone looking to maintain healthy glucose levels.

For those without access to a CGM, a standard glucose meter can still provide useful insights into how different foods affect blood sugar levels. 

However, Dr. Attia cautions that glucose is just one health marker among many, and a holistic approach to health is crucial. 

I think CGMs aren’t the most sustainable for most people, but if you’re particularly into maximizing longevity, this could be a useful tool.

Beware of Alcohol

I don’t need to go into this one too much. 

Avoid alcohol as much as possible. 

Moderate alcohol consumption, even red wine, does not really have any health benefits. 

It will worsen sleep, cause deficiencies in certain vitamins and minerals, and lead to a less productive next day. 

The Fasting Controversy

One area where Dr. Attia’s views might surprise some readers is fasting. 

While he previously practiced and recommended prolonged fasting, he now expresses reservations about its widespread use. 

His main concern is the potential loss of muscle mass during extended fasts.

As I said earlier, Dr. Attia stresses the importance of consistent protein intake throughout the day to maintain and grow muscle mass.

He cautions against the mindset that fasting allows unrestricted eating during feeding windows, as this can lead to poor dietary choices and potential weight gain. 

In my opinion, this is highly individual though. 

I don’t think a daily intermittent fasting schedule will lead to reductions in muscle mass, instead it may be a healthy way to maintain blood sugar levels and eat in a sustainable style.

Exercise: The Ultimate Longevity Drug

But if there’s one takeaway from “Outlive” that overshadows all others, it’s the importance of exercise. 

Dr. Attia describes exercise as the best “longevity drug” available, capable of increasing both lifespan and health span. 

From aerobic training to endurance exercise and strength training, all forms of physical activity can significantly reduce all-cause mortality.

Zone 2 Cardio: The Sweet Spot

Dr. Attia places particular emphasis on Zone 2 cardio training. 

This refers to a level of exercise intensity where you’re working hard enough to elevate your heart rate and breathing, but not so hard that you can’t maintain a conversation. 

It’s often described as “comfortably hard.”

The beauty of Zone 2 training lies in its efficiency in improving cardiovascular health and metabolic flexibility. 

This type of exercise enhances your body’s ability to use fat for fuel, improves insulin sensitivity, and boosts mitochondrial function – all crucial factors in longevity.

To determine your Zone 2, Dr. Attia recommends using a lactate meter, aiming for a blood lactate level between 1.7 and 2.0 mmol/L during exercise. 

For those without access to a lactate meter, a rough estimate is about 70-80% of your maximum heart rate.

VO2 Max: Your Fitness Age

Another key metric Dr. Attia discusses is VO2 max – the maximum rate at which your body can use oxygen during intense exercise. 

It’s considered one of the best indicators of cardiovascular fitness and has been strongly linked to longevity.

Improving your VO2 max can effectively lower your “biological age,” potentially adding years to your life. 

High-intensity interval training (HIIT) is particularly effective for boosting VO2 max, but consistent Zone 2 training can also lead to significant improvements over time.

Dr. Attia suggests regularly testing your VO2 max and working to improve it as part of a comprehensive exercise routine. 

Many modern fitness trackers and smartwatches can estimate VO2 max, making it easier than ever to track this important metric.

Stability: The Unsung Hero of Longevity

Beyond traditional exercise, Dr. Attia emphasizes the importance of stability training. 

Good stability allows us to continue our favorite physical activities well into old age and reduces the risk of falls and injuries. 

While specific exercises are best demonstrated visually, incorporating stability work into your fitness routine could pay dividends as you age.

Balancing Different Types of Exercise

Overall, a balanced approach to exercise is key. 

This includes:

1. Zone 2 cardio for metabolic health
2. High-intensity interval training for VO2 max
3. Strength training for muscle mass and bone density
4. Stability work for injury prevention and functional fitness

Exercise doesn’t just benefit cardiovascular health; it also helps maintain muscle mass, which becomes increasingly important as we age. 

Muscle mass can protect against injuries from falls, a leading cause of accidental death in those over 65.

Be mindful of your exercise technique, however. 

Injuries will not be helping you out in your health and longevity journey. 

Periodically filming yourself during workouts can be a great tool to ensure proper form and prevent potential long-term damage.

But remember, the best exercise routine is one that you can maintain consistently over time. Start where you are, gradually increase intensity and duration, and listen to your body. 

The Crucial Role of Sleep

I feel like a broken record when I talk about sleep. 

Dr. Attia dedicates an entire chapter to sleep, emphasizing its importance for brain health, heart health, and overall well-being. 

Poor sleep quality can increase the risk of various health issues, including heart attack, type 2 diabetes, Alzheimer’s disease, elevated triglycerides, lower testosterone, and weakened immune function. 

Truth be told, I’m a miserable person when I don’t sleep enough, so that’s enough motivation for me.

On the flip side, good sleep can enhance endurance, strengthen muscles, improve VO2 max, and reduce the risk of injury. 

To improve sleep quality:

1. Sleep in a dark, cool room
2. Avoid alcohol, especially before bed
3. Limit caffeine intake, particularly late in the day
4. Abstain from stimulating electronics before bedtime

Neurodegenerative Disease

Neurodegenerative disease is a tough one. 

My grandmother had Alzheimer’s for years and it truly is a difficult sight to watch the progression of the disease. 

Dr. Attia acknowledges that there’s still much we don’t understand about the underlying causes of neurodegenerative disease.

While factors like amyloid beta and tau proteins are often found in the brains of patients with neurodegeneration, their exact role remains unclear.

Genetics play a part, with carriers of the ApoE4 gene at higher risk of developing Alzheimer’s. 

But genetics aren’t destiny. Many people with the ApoE4 gene never develop the disease, especially if they also carry the protective FOXO3 gene.

While there’s currently no cure for neurodegenerative diseases, Dr. Attia outlines several preventive measures. 

Many overlap with heart health strategies: sauna use, flossing, omega-3 fatty acids, ketones, monounsaturated fats, sleep, and exercise. 

Additionally, he mentions the potential benefits of B vitamins and vitamin D in preventing dementia and Alzheimer’s.

Interestingly, grip strength correlates with better cognitive function and could potentially help prevent neurodegeneration. 

This underscores the importance of maintaining overall physical fitness as we age.

Cancer

We all hate cancer. 

Unlike heart disease and neurodegenerative disorders, Dr. Attia doesn’t provide a comprehensive list of prevention strategies for cancer. 

Unfortunately, cancer is complex, and different types of cancer respond to different treatments and prevention methods.

However, he does offer some general advice for cancer prevention which I wholeheartedly agree with:

1. Exercise regularly
2. Practice calorie restriction (a 25% reduction in calories has been associated with a 50% lower incidence of cancer in animal studies)
3. Don’t smoke
4. Maintain a healthy weight
5. Avoid insulin resistance

Given the challenges in preventing all types of cancer, Dr. Attia emphasizes the importance of regular screenings. 

He recommends getting screened every two to three years, depending on age, to catch any potential issues early. 

This is especially important if you have any specific cancer genes or a family history.

The Future of Immunotherapy

One of the most exciting developments in cancer treatment that Dr. Attia discusses is immunotherapy. 

This approach involves helping the immune system recognize and attack cancer cells. 

While currently only effective for certain types of cancer, immunotherapy shows great promise. 

When it works, it often leads to long-lasting remission with a low chance of recurrence. 

I’m excited to see how cancer treatments (and hopefully cures) progress in our lifetime.

Longevity Drugs

While inaccessible to most, there is some interesting data on some longevity drugs and compounds that can dramatically improve your health span and lifespan, and I think they are worth mentioning.

Rapamycin

One of the most intriguing topics Dr. Attia discusses is rapamycin, a drug he considers highly promising for longevity. 

Originally discovered on Easter Island and used as an immunosuppressant for organ transplant patients, rapamycin has shown life-extending properties in various organisms.

Rapamycin works by inhibiting mTOR, a nutrient-sensing pathway that regulates protein production and cell division. 

When mTOR is inhibited, the body conserves energy, slows cell division, and activates autophagy (cellular “cleanup”). 

These effects mirror those seen with calorie restriction and fasting, both known to extend lifespan in various species.

The challenge with rapamycin is balancing its potential benefits with the risk of suppressing your immune system. 

Dr. Attia suggests that intermittent, high-dose use (e.g., once a week) might provide longevity benefits without compromising immune function. 

However, more research is needed in this area.

Metformin

Another medication worth mentioning is metformin, a type 2 diabetes drug that helps regulate blood sugar. 

Interestingly, researchers have noticed that diabetics taking metformin often live longer than non-diabetics and have lower cancer rates. 

The ongoing TAME (Targeting Aging with Metformin) trial aims to determine if metformin can delay the onset of age-related diseases in healthy individuals. 

Hopefully, there is more to come on this.

As you can see from many of these tips and strategies, our modern medical system does not really talk about optimization and getting you to peak health. 

I think “Outlive” offers some insights that challenge conventional wisdom or differ from other experts in the field, but I appreciate evidence-based approach and personal dedication to the subject make his work a valuable contribution to the longevity discussion.

By focusing on preventive strategies, maintaining heart and brain health, exercising regularly, prioritizing sleep, and staying informed about emerging treatments and technologies, we can all take steps toward living longer, healthier lives.

If you’re interested in more tips related to becoming a top tier human, fill out my 1 on 1 coaching application from the button below to become fitter and healthier – guaranteed in 90 days.

All the best,
Dr. Christian