Notes on Outlive by Peter Attia

Several of my friends had recommended to me the book Outlive: The Science and Art of Longevity by Peter Attia and Bill Gifford, and I recently finished reading it. It was super dense and packed with so many practical details. It reminded me of The Obesity Code and How Not to Die. Dr. Attia's book added a lot to those, and I now have a lot of things to look into and work on in terms of improve health and longevity.

I like the preventive, holistic approach he took, and I really appreciated all the personal anecdotes and stories. Below are my main notes and takeaways.

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​Intro
Not about catching falling eggs with medicine but stopping the guy throwing them from the roof

Part 1

1 the long game from fast death to slow death
Acute injuries can be dealt with easier sometimes than the slow ones like heart disease, cancer, metabolic disease, and neurological disease
Don’t wait on prediabetes until develops too far
Proactive not reactive
Intervene early
Exercise most important
Health span not just life span

2 medicine 3.0
Time to repair the roof is when the sun is shining
Do no harm not very helpful view of risk
Medicine 1.0 disease caused by nature, guesswork 
Medicine 2.0 germ theory, scientific method, stopping fast death 
Medicine 3.0 avoiding chronic diseases and slow death
Continuous glucose monitoring
Prevention instead of treatment
Patient as unique individual
Honest assessment of risk including that of doing nothing
Health span not just life span
Patient much more active driver of destiny

3 objective, strategy, tactics
Plan for later decades of our lives
What do you want to be doing in final decades of life
Squaring the longevity curve by improving health span now and throughout life
Deterioration from age preventable 
Cognitive decline
Decline in loss of physical body
Activities of daily living
Emotional health
Actions to improve healthspan improve lifespan
Medicine 2.0 is procedures and medication
Medicine 3.0 tactics
Exercise
Strength
Stability
Aerobic efficiency
Peak aerobic capacity 
Nutrition
Key is how much not just what
Sleep
Emotional Health
Exogenous molecules
Learn from centenarians

Part 2

4 centenarians the older you get the healthier you have been
Horsemen diseases delayed by decades
Behavior choices can give benefits like genes that give long life
Centenarian genes push to the right the bad diseases
Compression of morbidity
Several bonus decades
Can test for variants of genes for mental diseases
Delay the onset of disease not just extend the duration of living with it
Cultivate resilience to disease

5 eat less, live longer: science of hunger and health
Easter island
Rapa Nui
Rapomycin extends life span 
Slows down cellular growth
Eating less extends life
Epophagy cellular cleanup
MTOR
Cyclical dosing of rapomycin helps immunity and lifespan
Metformin reduces cancer risk

6 the crisis of abundance: can our ancient genes cope with our modern diet?
Non alcoholic fatty liver disease nafld
Nash
Liver can regenerate if fix issues
Metabolic syndrome mesyn 
High blood pressure over 130/85
High triglycerides over 150
Low hdl less than 30
Waist circumference over 40”
Elevated fasting glucose over 110
Meeting at least 3 criteria means you have metsyn
Obesity symptom of other problems
Excess fat gets stored in places that contribute to metsyn
Annual dexascan for visceral fat not just total body fat
Inactivity creates insulin resistance more quickly
Environment changed faster than genes
Fat storage genes can’t cope with so many calories
Too much fructose. Eating apples fine but not apple juice or processed stuff 
Check uric acid
Oral glucose tolerance test to check for insulin resistance 

7 the ticker confronting and preventing heart disease
CT scan to check calcium score in arteries of heart
Need to begin treatment and prevention much earlier
Cholesterol in diet not the main problem
CT angiogram better test to detect early disease
Need to test apo b
Elevated LPOA
How to reduce cardiovascular risk
Get these and ldl cholesterol as low as possible
Blood pressure control
Change diet
Ketogenic diet
Olive oil and macadamia nuts
Statins for lipid management
Specific drugs mentioned
Aggressive precautionary measures early

8 runaway cell: new ways to address cancer 
Book the transformed cell
Harness immune system to kill cancer
Early screening like colonoscopy at 40
Many cancers linked to excess weight and obesity
Eating less protects from cancer
Ketogenic diet plus chemo even more effective
Fasting improved chemo too
Immunotherapy helps
Stacking therapies
Adoptive cell therapy
First colonoscopy by age 40. Screen early. 
Liquid biopsies using blood tests
Gallery test
Early detection critical

9 chasing memory: neuro diseases
Memory loss
Always check lpoa and apob values and apoe
Apoe genotype for Alzheimer’s risk
Prevention important 
Exercise and complex movement sports prevents Parkinson’s
Musical learning and foreign language helps prevent
Diseases caused by reduced blood flow to brain
Preventive plan
Address metabolic issues
Switch to Mediterranean diet and take DHA
Ketogenic diet
Exercise
Steady endurance exercise 
Strength training
Grip strength
Sleep
Hearing aids
Treat depression
Improve oral health
Use saunas
4 sessions per week, 20 min per session, at least 179 F
B vitamins
D vitamins
Hormone replacement therapy for women
What’s good for heart good for brain
What’s good for pancreas good for brain
Time is key
Most powerful tool is exercise 

Part 3

10 thinking tactically 
Exercise
Aerobic efficiency
maximum aerobic output VO2 max
Strength
Stability
Diet
Nutrition
Sleep
Emotional health 
Drugs and hormones

11 exercise most powerful longevity drug
Just 90 min per week enough to make difference
30 min aerobic activity per day plus 2 days of strength training weekly targeting all major muscle groups
Higher vo2max associated with lower mortality
Can improve vo2max with training
Muscle strength and muscle mass associated with lower mortality
Maintain higher level of activity
Falls leading cause of accidental deaths in age 65+
Lift heavy weights 4 times per week every week no matter what
Decathlete approach
Centenarian decathlon
10 most important tasks you’ll want to be able to do for rest of life
Activities of daily living and also things important to you
Hike
Pick up child
Carry groceries
Get up from floor
Lift suitcase onto plane
Balance on one leg
Climb stairs
Open jar
Jump rope skips
Need to be able to do much more of this now with higher weight and speed since later there will be decline in abilities
Be pretty good at everything 

12 training 101: preparing for centenarian decathlon 
Aerobic efficiency
Strength
Stability
Long steady endurance work
Concentrated aerobic efforts
Stability to avoid getting injured
Aerobic efficiency zone 2
Slow enough speed to maintain convo but still a bit tough to talk
Moderate speed
Maximum effort without producing lactate and burn 
Brisk walk or walk uphill or jog
3 hours per week or 4 45 min sessions
Stationary bike ride
Maximum aerobic output
Hard minutes long effort
Annual vo2max test
Target elite level for your age then after target elite range for 2 decades younger
Supplement zone 2 work with 1-2 short vo2max 3-8 min intervals 
4 min sprint, 4 min jog, and repeat 4-6 times
Single workout like this per week
Strength
Inactivity dangerous
Measure bone middle density BMD annually at hips and lumbar spine using dexa
More protein
Heavy load bearing activity with heavy weights
Hormone replacement therapy
Drugs to increase bone density
Build up reserve with strength training early in life, which can be depleted later in life like saving for retirement
Focus on how much heavy stuff you can carry
Rucking 3-4 times per week
Go up hill
Goal is to carry one third of body weight on back
Strength exercise focus
Grip strength
Farmers carry of full body weight between both hands for a minute
Dead hang from pull up bar at least 2 minutes 
Concentric and eccentric loading for all movements, rucking downhill 
Controlled step down from tall block over 3 seconds
Pulling motions at all angles, pull ups, rows
Rowing machine
Hip movements like dead lift and squat and step up, hip thrusters, single leg movements 
Do not bend spine
Hip hinging
Split stance Romanian dead lifts

13 stability: relearning how to move to prevent injury
Work smart than too hard
DNS to learn proper body movements rehabps.com and posturalrestoration.com 
First get stability right before strength training
Twice per week spend hour on stability training and other days 10-15 min per day 
Breathing right is critical
Breathe from belly
Breathing exercise quiet
Full inhale then full exhale 
5 breaths repeat
Do 2-3 sets
Practice 360 degree abdominal breathing filling in whole cylinder daily
Stability in feet
Toe yoga peterattiamd.com/outlive/videos
Root all 4 corners of feet to ground
Lift all 10 toes on ground and lift big toe only
Then opposite
Then lift all and try to drop one by one
Get toe spacers
Lift barefoot
Balance on one leg and time how long
Back
Cat cow sequence very slowly 
Hold weights in hands and move shoulder blades up and around controlled
Hands
Learn to do exercises on own without trainer eventually
Film self working out
Phone on tripod
Film 10 important sets daily
To go faster, you need to go slower
How to do step up onto box
Box or chair where thigh parallel to floor when stepping up
Put one foot on box barefoot
Inhale
Step up and exhale 
Step down with prior front foot
Step and even tempo
3 seconds per transition
Start with body weight and later can do with weights in hands
Power of exercise
Learn to get up without hands

14 nutrition 3.0
Nutritional biochemistry not diet
Reduce energy intake and add lean muscle mass
Don’t eat too many calories
Consume sufficient protein and fats
Obtain vitamins and minerals you need
Avoid pathogens and toxins
Epidemiology misleading
Healthy user bias
Efficacy vs effectiveness
Compliance issues
Mediterranean diet with nuts and olive oil good

15 nutritional biochemistry into practice
Get away from SAD
Caloric restriction
Diet restriction
Time restriction
Caloric restriction is winner among all these but need to track carefully everything you eat 
Diet restriction simplest but can still overeat with it so tricky
Time restriction the easiest but can still overeat 
Calories matter
Don’t take in more than you can store
If you eat a higher quality diet, only a small amount of caloric restriction can help reduce cancer and diabetes and other problems
Diet restriction
Different results for different people so hard to get right
Wean off carbs and sports drinks
Metformin
Manipulate quantities of Alcohol, carbs, protein, fat to find right mix to sustain 
Alcohol
Net negative
Carbs
Continuous glucose monitoring
Use it for a month or two to see what foods spike glucose and how 
Hawthorne effect which makes people pick better foods now that they know what effect it has and that they’re being monitored
Keep glucose below 100/dl
Timing important to when eat and affects spikes of glucose and amount of sleep
The more refined and processed the carbs the worse
Rice and oatmeal high glycemic
Fructose can also spike
Timing and duration of exercise affect spikes. High intensity can spike glucose
Bad sleep and stress impacts glucose
Spinach and broccoli have no effect
Protein doesn’t hurt glucose a ton
Tracking glucose has positive impact on eating behavior
Protein
Need 1.6 g per kg per day
4 servings of protein spread throughout day with at least one being a protein shake
Protein shake, protein snack, and 2 high protein meals
The more protein you consume the better
Fat
Boost mufa to 50% and drop pufa and sfa to 15-20%
Dha and marine fat sources good and need to take capsules
Want 8-12% of rbc membrane composed of right fat
Eat more extra virgin olive oil, avocados, and nuts and salmon and anchovies and reduce butter and seed oils 
Time restriction
Fasting helpful
Must eat enough to maintain muscle and protein
Can do hypocaloric diet to reach goals
Eliminate fructose sweetened drinks 

16 sleep best medicine for brain 
Sleep deprivation increases insulin resistance
Full darkness
No phones for an hour before bed
Keep bedroom cool
Cultivate sleep pressure with outdoor exercise 
Meditation
Sauna use in evening
Don’t eat 3 hours before bed
Sleep restriction to restore sleep pressure
Cognitive behavioral therapy for insomnia
Don’t do work if wake up at night

17 work in progress
Emotional health
The bridge in Kentucky
Trauma tree
Setbacks can be net positive long term
Reframing
Resume virtues vs eulogy virtues
Affirmations
Dialectical behavioral therapy
Emotional regulation
Distress tolerance
Interpersonal effectiveness and making needs known to others
Self management 
Mindfulness meditation
Create gap between stimulus and response
Cold shower or ice plunge to refocus
Slow deep breathing
Opposite action force self to do opposite
Weekly therapy
Write in journal
Believe that real change is possible
Being instead of doing

Epilogue
Set up life worth living
Stay young even when grow older

References 
The comfort crisis