Outlive: The Science & Art of Longevity

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Lemur
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Re: Outlive: The Science & Art of Longevity

Post by Lemur »

@IDave

No doubt that insulin resistance plays a large role in western lifestyle diseases but I disagree with a few of the points above regarding CICO vs Carbohydrate-Insulin model. Gonna send you a PM instead as to not derail the thread on that discussion.

theanimal
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Re: Outlive: The Science & Art of Longevity

Post by theanimal »

The last section of the book takes a more tactical approach and looks at Exercise, Nutritional biochemistry (as Attia calls it), Sleeping and Emotional/Mental Health. This post is some of my notes from the sections on exercise and nutrition.

Exercise
Attia states that if you are only going to take one thing away from the book, it is that exercise is by far the best practice for improving one’s health span and lifespan. Exercise has been widely demonstrated to decrease the risk of succumbing to one of the four horsemen and also puts one in the best place to weather the effects of aging. Most people will peak in muscle mass by their early 30s and from there it is a constant decline. It is far harder to put on muscle as you age, so it is easier to start from a place where you have muscle than scrambling late in life to put it on. Attia’s approach to exercise is centered around the idea of a centenarian decathlon. The idea is to come up with things that you think you’d want to do in your ninth or tenth decade of your life (pick up a grandkid off the floor, go for a hike, be able to scale four sets of stairs etc) and work back from there to establish some type of routine. He looks at what strength and aerobic threshold those activities require and where his patients are now. So making this up, if it takes a VO2 Max of 30 to climb 4 sets of stairs and your peak VO2 max is at 33 at age 55, you are not going to be able to do that when you’re 80 as your VO2 max declines with age. So you need to be far above whatever level you want to be at, now, to account for decline.

His exercise approach focuses on 4 pillars: VO2 Max, Zone 2 training, strength, and stability.

The higher VO2 max you have, the lower your risk of all cause mortality. Those in elite levels of VO2 max decrease their risk of all cause mortality by 5 times that of those in the lower 20%. It scales all along the ranges, so that someone right around the mid level of VO2 max for their age bracket has half the risk factor as those same people in the bottom 20%. This can be improved on at any age and not training extensively in your past does not preclude you from starting and obtaining benefit. Training for this is relatively short and Attia recommends a minimum 24 minutes of work capacity twice a week, preferring activities that allow him to go near all out sprint for 4 min, rest for 4 min and repeat until hitting the working total.

Zone 2 training is very important to improve endurance and reducing risk/preventing chronic disease. It helps build mitochondrial health and improve glucose homeostais. He recommends at least 3 hours per week of zone 2, or four 45 minute sessions, as a minimum. Below that, he does not think that one will see any benefits. He says is so persuaded by benefits of zone 2 that he spends 4 days a week riding a stationary bike for an hour. The same can be achieved via running, swimming, rowing etc.

Strength – Having muscle mass prevents decay and strength exercises help to increase bone density, lowering the risk for future injury. He structures his strength training around exercises that improve the following:
1. Grip strength, how hard you can grip with your hands, which involves everything from your hands to your lats (the large muscles on your back). Almost all actions begin with the grip.

2. Attention to both concentric and eccentric loading for all movements, meaning when our muscles are shortening (concentric) and when they are lengthening (eccentric). In other words, we need to be able to lift the weight up and put it back down, slowly and with control. Rucking down hills is a great way to work on eccentric strength because it forces you to put on the “brakes.”

3. Pulling motions, at all angles from overhead to in front of you, which also requires grip strength (e.g. pull-ups and rows)

4. Hip-hinging movements, such as the deadlift and squat, but also step ups, hip-thrusters and countless single-leg variants of exercises that strengthen the legs, glutes and lower back.

Pg 257 & 258
Stability- This is a really broad chapter that takes a look at stability through body composition and compensations. Basically avoiding specific injuries through bad posture or habits. Such as how sitting in a chair destroys your ability to squat well or how keeping your body in certain positions can put your joints out of balance and susceptible to injury.

Nutritional Biochemistry
He is no longer interested in dogmatic, tribal approaches to nutrition and realizes that each person responds differently to foods. He no longer believes that diet/nutrition can cure everything (as noted in the photo excerpt above). The medicine 3.0 approach takes a personalized look at nutrition and finds what works best for the individual, rather than following blanket restrictions of some certain diet. Attia details the common approach of most diets as follows below.

1. Caloric Restriction- eating less in total, but without the attention to what is being eaten or when it’s being eaten.
2. DietaryRestriction- eating less of some particular element within the diet (meat, sugar, fats)
3. Time Restriction-Restricting eating to certain times, up to and including multiday fasting

Taking this approach, he looks at each category in more detail and how it pertains to increasing healthspan.
  • Calorie restrictions
    Calories matter. He says early there are no “good” or “bad” calories (which seems like a direct shot against his former colleague!) Calorie restriction has been shown in studies to reduce risk of cancer. In studies with mice and monkeys, it has been shown to increase longevity. He draws some conclusions from some high profile studies of monkeys on caloric restriction. Namely that there seems to be a strong link between calories and cancer; the quality of food you eat could be as important as the quantity of food you eat; if your diet is high quality to begin with and you are metabolically healthy, then only a slight degree of caloric restriction (or simply not eating to excess) can still be beneficial. However, following these conclusions he notes the following (original emphasis):
    Note that these study results do not suggest that everyone needs to undertake a drastic, severe reduction in caloric intake. Limiting calories can be helpful for people who are metabolically unhealthy and/or overnourished. But I’m not convinced that whatever longevity boost long-term, deep caloric restriction may confer is worth some of the trade-offs- including potentially weakened immunity and greater susceptibility to cachexia and sarcopenia (muscle loss), not to mention constant hunger. These unwanted side effects would accelerate some of the negative processes that already go along with aging, suggesting that in older people especially, caloric restriction might do more harm than good.

    pg 316
  • Diet Restrictions
    • Alcohol- Avoid if possible. There are no health or longevity benefits. If you are to drink (as Attia does) he recommends no more than 7 drinks per week, with no more than 2 during one day.
    • Carbohydrates- This will vary depending on a person’s tolerance for carbohydrates. Some people can eat a lot of carbohydrates and be metabolically healthy, while others will be destroyed by the same eating regimen. He suggests eating as cleanly as possible in this regard and avoiding very refined processed goods and things with high fructose. For someone who suffers from hyperinsulinemia or is near diabetic, he is advocate for total carbohydrate restriction or severely low carb. He suggests that the best way to establish an individual protocol is to get a continuous glucose monitor and wear it for a couple months as that will tell you how you react to specific foods. They are costly though ($150/mo) and not widely available so I’m not sure how practicable this is. He suggested that you could also go get a handheld glucose monitor and prick yourself every few hours for a couple weeks to get a rough estimate.
    • Fat- Monounsaturated fat (MUFA) is best ie olive oil, nuts, avocados, coconuts etc. He says that the data are not as clear as to whether polyunsatured (PUFA) or saturated fats take the next spot in the pecking order. Both have questionable aspects and have been shown in some studies to increase risk of some of the four horsemen. But Attia says the data is still not entirely clear. Either way, best to minimize but need to recognize that all fats include a mix of MUFA, PUFA and SF, so impossible to completely avoid while consuming fats. Omega 3s have been shown to be very beneficial in reducing risk of heart disease and Alzheimer’s and should definitely be part of one’s personal diet.
    • Protein- Very important for maintaining lean muscle mass and immune function. The current recommended dietary allowance (RDA) is 0.8 g/kg. Attia says this number is a joke. It is far too low and should be better interpreted as the bare minimum, not the number to strive for. There have been studies where people in their 60s have had protein intake at the RDA and have lost muscle mass in a span as little as two weeks. He recommends double that, 1.6 g/kg, as a starting point for his patients with higher amounts necessary for those who are more active, up to about 2.4 g/kg. This is a lot of protein and comes out to about 4 servings of 6 oz fish/chicken/beef/pork. Or for those of us here, lentils and tempeh. Attia is not able to eat 4 meals like that himself and uses protein supplements to achieve his total. There are some studies in mice that suggest that higher protein levels reduce longevity but Attia dismisses those, detailing how humans and mice react to protein are very different.
  • Time Restricted Feeding
    Attia has grown skeptical of the effectiveness of intermittent fasting. Insulin goes down during a fast and the body enters ketosis, turns down mTOR (pro growth/aging pathway) and begins autophagy. All good, but he said that the original 16:8 window of intermittent fasting came from a study in mice. Mice live only 2-3 years and will die if they don’t have food within 48 hours, so he considers that timeline to be more akin to a multi day fast with humans. He then goes on to share how clinical trials and studies have failed to find much of a benefit in humans in terms of weight loss or cardiometabolic state. However there was one human study that saw success with an earlier feeding window (from 8 am to 2 pm) suggesting that eating earlier with this approach may be beneficial. He goes on to state that another drawback is that you are pretty much guaranteed to miss your protein target eating this way and can be very easy to fall into the trap of overindulgence (too many calories).
    He then talks about alternate day fasting, which has been shown to help people lose weight but also more lean mass (muscle) than others who just ate 25% fewer calories per day. Longer term fasting only amplifies this effect. He quotes and agrees with the lead investigator of one particular alternate day fasting study that said, “ If you are following a fasting diet, it is worth thinking about whether prolonged fasting periods [are] actually making it harder to maintain muscle mass and physical activity levels, which are known to be very important factors for long term health.”

    Because of this research, Attia has come to the conclusion that frequent prolonged fasting is not smart nor necessary for most patients. He does have some patients follow this practice, particularly those for whom no other dietary intervention has worked.

UrbanHomesteader
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Re: Outlive: The Science & Art of Longevity

Post by UrbanHomesteader »

I'm curious what members of the forum have done with regard to getting the measurements of the markers mentioned in this thread?

Are people asking for specific tests from their G.P., and are the tests being covered by insurance? If not, what are the costs?

Or are there at home tests people are using (like the blood glucose monitor The Animal mentioned)?

My strategy has been to stay active and eat a varied diet, but I don't really have any data on my biomarkers. Whatever tests the doctors run always come back "good". I get the impression there is more to know if I look further.

Scott 2
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Re: Outlive: The Science & Art of Longevity

Post by Scott 2 »

US health insurance includes an annual physical with some baseline labs. I ask for whatever I'm looking for during that visit. My doctor is generally on board, though doesn't necessarily have an option for more cutting edge stuff. She'll tell me when she doesn't think insurance can cover something. She's also been willing to order labs based upon a my chart message.

I've found through an in network lab, the cost of blood tests is dramatically less. Insurance dictates a 10x reduction in some cases. The ACA plan I'm on, I pay something like 20% of the negotiated rate. I just checked free and total T, shbg, and a pair of pituitary markers. It was $16 out of pocket.

Absent the insurance, I'd order ad hoc tests online. Cash pay prices are fairly accessible, similar to negotiated insurer rates. What you don't want to do, is use insurance at an out of network lab. That's how you end up paying $120 for something as simple as a vitamin D test.

I just asked my doctor for a CGM Rx - the Dexcom G6. She told me insurance wouldn't cover it, but that if I requested a free sample via the device makers website, she'd approve the script. The site makes it clear how to submit a successful request. I'm waiting for that to arrive, which should give me 10 days of readings.

Depending how they go, I may use goodRx coupons and cash pay for a month's supply. Cost is about $170 in my area. Not something I'd pay for year round, but I think a month could be worth it. There are services that offer a health optimization based CGM. They're just adding an app layer over the standard medical devices. That doubles the price, but includes expert guidance.

M
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Re: Outlive: The Science & Art of Longevity

Post by M »

UrbanHomesteader wrote:
Sun May 28, 2023 1:03 pm
I'm curious what members of the forum have done with regard to getting the measurements of the markers mentioned in this thread?

Are people asking for specific tests from their G.P., and are the tests being covered by insurance? If not, what are the costs?

Or are there at home tests people are using (like the blood glucose monitor The Animal mentioned)?

My strategy has been to stay active and eat a varied diet, but I don't really have any data on my biomarkers. Whatever tests the doctors run always come back "good". I get the impression there is more to know if I look further.
https://www.ultalabtests.com/testing/ca ... /all-tests

Also - there are some online stores that will sell you cgms with no prescription....I'm not gonna link them here, because I'm not sure about the legality of if, but if you search around some....

ETA: I mean - normal price cgms, with no app layer..

Scott 2
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Re: Outlive: The Science & Art of Longevity

Post by Scott 2 »

Just finished listening to this. If one was going to pick and blindly follow a health book, I think it'd be a pretty good choice. For the most part, recommendations match what I've gleaned from other sources. But it's nice to see them consolidated in one place. I try to do a lot of it.


Some parts did not sit well with me:

1. There may be an over-emphasis on testing, especially for someone who is DIY or has constrained resources. To fully implement his described monitoring strategy would be a part time job. I assume the intent is to funnel high value prospects into his medical practice. If you've got the cash and can fully abdicate, I see the appeal.


2. Similarly - there's an assumption of means and privilege in Attia's work that will not hold true for most. His article on colon cancer screening is a good example:

https://peterattiamd.com/colorectal-cancer-screening/

Dude throws out doing self-pay exams at $1-3k per pop. Maybe doubling up on the first one, if you aren't satisfied with the quality of the results. He also suggests things like "You should ask what your endoscopist’s adenoma detection rate..." There's no way I'm getting stats like that from my local medical system.


3. Fully implementing his recommendations around cardio, strength, stability, food, sleep, medical care, therapy, meditation, sauna, etc. would be extremely time consuming. At a certain point, obsessive self care crosses over into mental illness. For me, he passes that line. This dances on the privilege issue as well.

An example - 20 minutes of sauna, at 180-190 degrees, at least 4x a week, ideally right before bed. This implies a home sauna, and not the cheaper infrared options. Add on prep and cleanup, you're also spending 2-3 hours per week just playing with the sauna.


4. For all the talk of customizing intervention to the person, the tactics struck me as fairly one size fits all. Why not ignore all the testing and simply focus on incremental lifestyle improvements? Especially when one looks at diminishing returns- the book could be distilled down to "make reasonable choices around managing food, exercise, sleep and stress."

He dangles the carrot of personalized medicine, so one only has to make targeted sacrifices. There's an implication one can cheat the system with science. But in practice, it looks to me like tricking people into making the same old trade offs.

He describes a patient who uses his glucose monitor to eat whatever he wants! Because he times sugary foods for when his body wants sugar (like say after exercise) and eats portions that don't throw his blood sugar out of whack. I'm not sure a $200/month device is needed there.


5. We're all gonna die. When it happens, we might not have any control over how, or even the timing. It's very tempting to lead a "fear of death" driven lifestyle and miss what matters. He touches on this a little in the very last section, but IMO, under-emphasizes it. I'd appreciate if he spent more time on choosing your personal point of diminishing returns.

I think of the cancer doctors, who understanding trade offs, opt out of treatment. There can be wisdom in living simply, with uncertainty.

Dave
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Re: Outlive: The Science & Art of Longevity

Post by Dave »

Over the years I’ve become increasingly conflicted about these sorts of books. At the surface level, a book like this adds to the health dialogue with useful information, much of which is actionable for at least some subset of people. But when considered from the life system perspective, I think it can break down and cease to be net positive for some people.

A lot of my point can be boiled down to the items @Scott 2 list, so I won’t rehash them in detail here. Continuous one-off and ongoing blood/other testing. Significant financial resources required to deep dive. Massive time commitment across numerous modalities. Increasing neuroticism.

No doubt many of these approaches help people dealing with specific issues, but I wonder what % of people consuming this sort of material are those truly in need vs. those that are dancing along the obsessive self-care arguably mental illness line. Cynically, I have to think a fairly high % of the people that funnel through to the guru's 1 on 1 services are at the intersection of wealthy and neurotic.

I’ve jokingly called this the Hubermanization of life, referring to the never-ending integration of biohacking tricks that people like Andrew Huberman propose. For the record, I think highly of Andrew Huberman and Peter Attia and have learned useful things from both of them.

But I am cognizant of that there is a subset of people (and I was one of them for a long time - this post is me speaking to/about myself) who collect and collate an ever-growing list of tips and tricks and metrics to track (VO2max, A1C, coffee >60 minutes after waking but not within 8 hours of bed, sunlight within 30 minutes of sunrise/sunset, this micronutrient, that supplement, intermittent fasting, foam rolling, triglycerides/HDL, ApoB, daily steps, blah blah blah) where your life becomes increasingly constrained by “scientific’ literature (oftentimes with questionable value) and the pursuit of a parameter-constrained life becomes ever more controlling. This very group of people, who are already probably focused with the big picture ideas – eat mostly whole foods, try to move the body in different ways, spend time outside – are arguably already deeply into diminishing returns territory, and the people who need help the most don’t need to worry about chasing the last 20-10-5-3% of benefits.

Just to be clear, my post is not challenging the value of these kinds of books or their authors, but rather just an encouragement to consider how such information and action fits into the broader system of our lives, with full consideration of web of goals and byproducts and costs of our actions.

Ironically, I think the majority of people (who should) don't care enough about their health, and (some of) the minority of people (who have it mostly locked down) care too much about their health.

In my view, our purpose in this life is not to optimize health for the sake of it. Health is not an end goal, but an input, to the life we want. After some point of education, I think it wise to follow @Scott 2’s comment that “There can be wisdom in living simply, with uncertainty.”

AxelHeyst
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Re: Outlive: The Science & Art of Longevity

Post by AxelHeyst »

Your second to last paragraph reminds me of a line where David Allen says ~"GTD tends to attract the people who need it the least: people who are already at least moderate high achievers." Beware yak shaving.

I also recently reread Daily Rituals, and it's remarkable how much people accomplished with such dysfunctional habits. Loads of people who've made enormous contributions to culture were basket cases; massive procrastination struggles, loads of benzedrine, agoraphobia, highly neurotic, etc etc. Not to glorify dysfunction or to day none of this stuff matters, but at some point optimization becomes a form of indulgence/missing the point. (Like Dave, I'm talking at myself here...) Just because youve optimized yourself six ways from Sunday doesn't mean you're going to accomplish what you envision the optimizations will empower you to accomplish (presuming accomplishing anything is part of the aim and defining it liberally).

Dave
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Re: Outlive: The Science & Art of Longevity

Post by Dave »

Haha, yeah same dynamic. Hadn't heard of "yak shaving", funny!

Agreed on the observation of many accomplished people often having highly dysfunctional habits. It's almost like for those people the dysfunction is an essential part of their system, even if conventional standards would deem it negative. Remove it, they lose balance and their edge.

At least in some cases. Certainly not suggesting this always holds true! As with most things, each person has to find the balance of testing and incorporating changes that are net positive. This was the essence of my prior post: there are in fact downsides/tradeoffs to these habits and they need to be considered rather than mindlessly added to an increasingly large set of "Must Dos".

But again, I'm speaking to myself (and any others who have similar proclivities) here, I don't think most people don't fall victim to this sort of thing!

Smashter
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Re: Outlive: The Science & Art of Longevity

Post by Smashter »

I really enjoyed Peter Attia's appearance on the EconTalk podcast to talk about "Outlive".

The discussions around the book were good, especially when Russ Roberts challenges him on his "test for everything all the time" philosophy. But the most interesting parts to me were when he talks about his struggles with anger, self hatred, and workaholism. He had to go to inpatient clinics to deal with his anger because it was affecting his home life so severely. Kudos to him for overcoming that and openly talking about it.

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