Written by Kane on . Posted in Books.

Outlive

One Quote

The majority of people reading this book can expect to die somewhere in their seventies or eighties, give or take, and almost all from "slow" causes. Assuming that you're not someone who engages in ultrarisky behaviors like BASE jumping, motorcycle racing, or texting and driving, the odds are overwhelming that you will die as a result of one of the chronic diseases of aging that I call the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction. To achieve longevity - to live longer and live better for longer - we must understand and confront these causes of slow death.
Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how _well_ you live - the quality of your years. This is called healthspan, and it is what Tithonus forgot to ask for. Healthspan is typically defined as the period of life when we are free from disability or disease, but I find this too simplistic. I'm as free from "disability and disease" as when I was a twenty-five-year-old medical student, but my twenty-something self could run circles around fifty-year-old me, both physically and mentally. That's just a fact. Thus the second part of our plan for longevity is to maintain and improve our physical and mental function.
The key question is, where am I headed from here? What's my future trajectory? Already, in midlife, the warning signs abound. I've been to funerals for friends from high school, reflecting the steep rise in mortality risk that begins in middle age. At the same time, many of us in our thirties, forties, and fifties are watching our parents disappear down the road to physical disability, dementia, or long-term disease. This is always sad to see, and it reinforces one of my core principals, which is that the only way to create a better future for yourself - to set yourself on a better trajectory - is to start thinking about it and taking action now.

...

The bank's problem was not all that different from the situation faced by some of my patients: their seemingly minor risk factors had, over time, compounded into an unstoppable, asymmetric catastrophe. Chronic diseases work in a similar fashion, building over years and decades - and once they become entrenched, it's hard to make them go away. Atherosclerosis, for example, begins many decades before the person has a coronary "event" that could result in their death. But that event, often a heart attack, too often marks the point where treatment begins.
This is why I believe we need a new way of thinking about chronic diseases, their treatment, and how to maintain long-term health. The goal of this new medicine - which I call Medicine 3.0 - is not to patch people up and get them out the door, removing their tumors and hoping for the best, but rather to prevent the tumors from appearing and spreading in the first place. Or to avoid that first heart attack. Or to divert someone from the path to Alzheimer's disease. Our treatments, and our prevention and detection strategies, need to change to fit the nature of these diseases, with their long, slow prologues.

Big Ideas


Four main mindsets of medicine 3.0:

Place a far greater emphasis on prevention than treatment
Consider the patient as a unique individual.
Our starting point is the honest assessment, and acceptance, of risk - including the risk of doing nothing.
Pay more attention to maintaining healthspan, the quality of life.

Tactics

exercise
nutrition
sleep
emotional health
exogenous molecules

Tests I Might Want to Get

CT angiogram, which is better than garden-variety calcium scan because it can also identify the noncalcified or "soft" plaque that precedes calcification.
get tested for LDL-C, triglycerides, and apoB. $20-30 to test for apoB.
Ask for an Lp(a) test (a lipoprotein formed when LDL is fused with another rarer type called apolipoprotein(a) or apo(a). The apo(a) wraps loosely around the LDL with multiple looping amino acid segments called "kringles". elevated Lp(a) is largely genetic, so only need this once.
Colonoscopy by age 40. Why before guidelines? Because colorectal cancer is one of the easiest to detect, with greatest payoff of risk reduction. Before you get your first colonoscopy, ask what your endoscopist's adenoma detection rate (ADR) is. >30% for men and >20% for women. Also ask how many perforations he or she has caused, or other serious complications like intestinal bleeding episodes. Ask what is your endoscopist's withdrawal time, defined as amount of time spent viewing as the colonoscope is withdrawn during a colonoscopy. A longer withdrawal time suggests a more thorough inspection. A 6-minute withdrawal time is currently the standard of care.
VO2 max test
 
 

The Centenarian Decathlon

Dr. Attia encourages us to write down 10 things you want to be able to do when you're 100 years old. What a great exercise, and a starting point to figure out your own training plan. His list of suggestions has 20 things: hike 1.5 miles on hilly terrain, get up off the floor under his own power using a maximum of one arm for support, pick up a young child from the floor, carry two 5 lb bags of groceries for 5 blocks, lift a 20 lb suitcase into the overhead compartment, balance on one leg for 30 seconds (eyes open), have sex, climb 4 flights of stairs, open a jar, do 30 consecutive jump rope skips, swim half a mile in 20 minutes, walk with a 30 lb dumbell in each hand for one minute, draw back and fire a 50 lb compound bow, do 5 pull ups, climb 90 steps in 2 minutes, dead-hang for 1 minute, drive a race car within 8% of the pace I can do today, hike with a 20 lb backpack for an hour, carry my own luggage, walk up a steep hill.

Peter says "I suggest you join me and start training, with a very specific purpose, which is to be kick-ass one-hundred-year-olds." So, I made my own list. Here are 10+ things I want to still be able to do when I'm 100 years old. Perform one set from a murph (15 squats, 10 push ups, and 5 pull ups), hike 3 miles on a nature trail, pick up a young child off the floor, carry my groceries for the week 5 blocks, climb 4 flights of stairs, lift my suitcase into the overhead compartment, mow the lawn and pull weeds, tread water in a pool, drive my car, keep my home clean, balance on one leg for 30 seconds, put up Christmas lights.

Exercise is key. Dr. Attia says "I think of strength training as a form of retirement savings. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach older age with enough of a "reserve" of muscle (and bone density) to protect us from injury and allow us to continue to pursue the activities that we enjoy.".

 

Nutrition

I just had to include this graph because it's awesome.

While Dr. Attia is not dogmatic about nutrition, and doesn't subscribe to one-size-fits-all mentality, he says...

"Nutrition is relatively simple, actually. It boils down to a few basic rules: don't eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens like E. coli and toxins like mercury or lead. Beyond that, we know relatively little with complete certainty. Read that sentence again, please."

The SAD - Standard American Diet

Dr. Attia says that the SAD solves 4 problems that have plagued humanity: producing enough food, doing so inexpensively, preserving it so it can be stored and transported, and making it highly palatable. He says the elements making this possible (added sugar, highly refined carbs, processed oils, and other very densely caloric foods) are as devastating to the body as tobacco.

"The SAD disrupts the body's metabolic equilibrium. It places enormous strain on our ability to control our blood glucose levels, and causes us to store fat when we should be utilizing it. The leading source of calories that Americans consume is a category called "grain-based desserts," like pies, cakes, and cookies, according to the US Department of Agriculture. That is our number one "food group."... The farther away we get from the SAD, the better off we will be. This is the common goal of most "diets" -- to help us break free of the powerful gravitational pull of the SAD so that we can eat less, and hopefully eat better. But eating less is the primary aim. Once you strip away the labels and the ideology, almost all diets rely on at least one of the following three strategies to accomplish this:
1. Caloric restriction, or CR: eating less in total, but without attention to what is being eaten or when it's being eaten
2. Dietary restriction, or DR: eating less of some particular element(s) within the diet (e.g. meat, sugar, fats)
3. Time restriction, or TR: restricting eating to certain times, up to and including multiday fasting
In other words, if you are overnourished, and statistically speaking about two-thirds of us are, you will need to apply at least one of these methods of caloric reduction: deliberately tracking (and reducing) what you eat; cutting out certain foods; and/or giving yourself less time in which to eat. That's it."

Assorted Other Nutrition Ideas I Found Intersting

  1. Everyone tends to be more insulin sensitive in the morning than the evening, so it makes sense to front-load carbs earlier.
  2. Even one night of horrible sleep cripples our ability to dispose of glucose the next day.
  3. The oxidation of ethanol delays fat oxidation, so you can't process alcohol and lose weight effectively at the same time.
  4. Caloric restriction is by far the best method of diet, and has shown to extend lifespan in mice.
  5. Standard recommendations for protein are a joke - double the RDA should be a minimum. Try one gram per pound of body weight per day.
  6. Fasting can reboot a crashed metabolism.
  7. "If there is one type of food that I would eliminate from everyone's diet if I could, it would be fructose-sweetened drinks, including both sodas and fruit juices, which deliver to much fructose, too quickly"

 

Conclusion

There were a lot of great ideas in this book that I didn't add to these notes - please do yourself a favor and read the whole thing. I can (over)simplify the book to a few core pieces of advice. Eat healthy foods (not too much, quality over quantity). Exercise your body. Get good sleep. Focus on emotional wellbeing by building your 'eulogy virtues' rather than 'resume virtues'. Focus on your fundamentals to live longer and better, and outlive the majority of people.

 

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