The book is similar to ERE book in the sense that it places a priority on strategy over tactics. This was a pleasant surprise and something I have not encountered in nearly any other book on the subject. For anyone that has listened to his podcast, The Drive, it is occasionally extremely technical and I was worried that the book would be similar and not approachable for laymen like myself. Apparently that was how the first draft of the book went and he completely rewrote it. What's published is very much approachable while still standing well above the pop science fluff books that are more anecdotes and stories than actual information. Attia writes about how we should think about approaching increasing health span, helps to reframe the concept of risk with regards to personal healthcare and what categories are most important on looking at and dialing in on an individual basis.
He starts out by talking about the different levels of medicine throughout history, what he calls Medicine 1.0 and Medicine 2.0. Medicine 1.0 existed from Hippocrates to around the mid 19th century and is the idea that there is something in the environment that can affect human health and that we can treat that (often erroneously as in the case of bloodletting). Medicine 2.0 was the improved sanitation, introduction of scientific process and increased experimentation and an increase in medical technologies and is most of what is practiced today. Medicine 2.0 is good at treating problems. Thanks to Medicine 2.0 human society has gone from dying from fast deaths like infections, accidents, broken bones etc to slow deaths like atherosclerosis, cancer, alzheimers etc. But Medicine 2.0 focuses on treating diseases and is terrible at preventing them. Medicine 2.0 has increased lifespan, but it has not increased healthspan, the amount of time someone lives unencumbered by disease. Which brings us to Medicine 3.0, which Attia says takes a longer look at health from an individual perspective with a far greater focus on preventing or forestalling the diseases that nearly everyone ends up succumbing to.
The above quote reminded me of @iDave, who has fully embodied that quote over the last few months.“Medicine 3.0 demands much more from you, the patient: You must be well informed, medically literate to a reasonable 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.
Part two starts off discussing some of the genetics of longevity and will be familiar to many on here who are interested in the topic and have followed the works David Sinclair and Andrew Hubermann. He discusses centenarians and how their key to longevity is not likely in the specific way they live, given that many of them engaged in habits like drinking, smoking and poor diet that would be harmful to the average person, but rather the luck of the draw in having specific genes and molecules that promote longevity. He discusses a few examples including APO-E, rapamyacin and mTor, all of which have been shown to slow cell aging.
The rest of part 2 looks at each of what he calls the Four Horsemen of Chronic disease: "foundational disease", atherosclerotic disease, cancer and Alzheimer's. He first looks at "foundational disease" (insulin resistance/diabetes and a few other things) and posits that the first and most important step in delaying death is getting metabolic health in order. Medicine 2.0 doesn't treat someone for diabetes or metabolic syndrome until they have already passed the threshold of meeting at least 3 of the markers*. Attia argues that is foolish as the person is already more likely to develop disease down the line and is already at impaired health. He prefers to use more specific measurements to keep track of whether someone is at risk For his patients, he monitors for things like elevated uric acid, elevated homocysteine, chronic inflammation, the ratio of triglycerides to HDL cholesterol (says it should be less than 2:1, better would be less than 1:1) as well as levels of VLDL (lipoprotein that carries triglycerides. However, the most important thing he looks for to indicate metabolic disorder is elevated levels of insulin, which on its own is associated with huge increases in risk of cancer, Alzheimer's disease and cardiovascular disease, not to mention the risk of type 2 diabetes. Along with those markers, he makes his patients take a yearly DEXA scan to check for visceral fat.
*High blood pressure (>130/85; high triglycerides (>150 mg/dL);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. in women); elevated fasting glucose (>110 mg/dL)
Heart disease is the leading cause of death by far, killing 2,300 people in the US every day. Men are not he only one's at risk. American women are ten times more likely to die from atherosclerotic disease than from breast cancer (1 in 3 versus 1 in 30). Commonly thought to be a disease of the old, half of cardiac events happen before age 65 in the US and frequently cardiac damage is found in people as early as their teens. He says cholesterol numbers do not tell much whereas the far more useful metrics are their lipoprotein carriers, specifically apoB and Lp (a). He argues that apoB and Lp(a) are the first things he looks at in a blood panel for his patients when concerned about cardiovascular disease. These vehicles of cholesterol have shown to be causal whereas while ""bad" and total cholesterol may be associated with increased risk of heart disease, they have not shown to be causal. He takes an aggressive stance against minimizing apoB, with both diet and medicine. Diet wise it is mainly limiting saturated fat, as for some people that can significantly increase apoB levels. But his aim is to get apoB levels as low as possible, to that of babies, which cannot be achieved by diet alone, especially if you have already suffered cardiac damage. There are currently no drugs on the market which reduce Lp(a) so instead he focuses on decreasing apoB. He prescribes statins and other lipid managing drugs to his patients early and often and takes them himself as well. There is also a section in the beginning of the chapter how he talks about how he was more or less awakened to the risk of cardiovascular disease after getting a coronary arterial calcium (CAC) test at age 36 and having a level of 6**. He now recommends coronary angiograms over CAC tests if possible (although they do cost more) as they can show a buildup of soft plaque and evidence of cardiovascular disease that a CAC scan would otherwise miss.
**Low in an absolute sense but at that age higher than 75-90% of people in his age cohort and equivalent to that of a 55 year old. This was weeks after he swam across the Catalina Channel (21 miles).
pg. 135
Nearly all adults are coping with some degree of vascular damage, no matter how young and vital they may seem, or how pristine their arteries appear on scans. There is always damage, especially in regions of shear stress and elevated local blood pressure, such as curves and splits in the vasculature. Atherosclerosis is with us, in some form, throughout our life course. Yet most doctors consider it "overtreatment" to intervene if a patient's computed ten year risk of major adverse cardiac risk (e.g., heart attack or stroke) is below 5 percent, arguing that the benefits are not greater than the risks, or that treatment costs too much. In my opinion, this betrays a broader ignorance about a time horizon. If we want to reduce deaths from cardiovascular disease, we need to begin thinking about prevention in people in their forties and even thirties.
Another way to think of all this is that someone might be considered "low risk" at a given point-but on what time horizon? The standard is ten years. But what if our time horizon is "the rest of your life?"
Then nobody is at low risk.
That is roughly the first third of the book. The rest of part 2 discusses cancer and Alzheimer's disease. Part 3 focuses on 4 of Attia's 5 pillars of health and is more of a tactical approach: Movement/Exercise, Sleep, Nutritional biochemistry and Emotional health (the 5th is medication/supplements). I will post updates as I read. So far, I would highly recommend it.pg. 137
Once you understand that apoB particles-LDL, VLDL, LP (a)- are causally linked to ASCVD, the game completely changes. The only way to stop the disease is to remove the cause, and the best time to do that is now.
Still struggling with this idea? Consider the following example. We know that smoking is causally linked to lung cancer. Should we tell someone to stop smoking only after their ten-year risk of lung cancer reaches a certain threshold? That is, do we think it's okay for people to keep smoking until they are sixty-five and then quit? Or should we do everything we can to help young people, who have maybe just picked up the habit, quit altogether?
When viewed this way, the answer is unambiguous. The sooner you cut the head off the snake, the lower the risk that it will bite you.
