Outlive: The Science and Art of Longevity

Cancer is one of Attia’s Four Horsemen diseases. Cancer is a group of diseases characterized by two properties: uncontrolled cellular growth (cancer cells do not stop growing when they should) and metastasis (or the ability of cancer cells to travel from one part of the body to another place where they should not be). The latter is responsible for most cancer patient deaths. Smoking, obesity, and type 2 diabetes are leading risk factors for cancer. Cancer prevention is more difficult than the other Horsemen diseases since it involves some degree of bad luck in the form of cellular mutations, which we cannot yet control. However, Attia advocates for one key prevention strategy: repairing metabolic health. By addressing our metabolic health (e.g., obesity, type 2 diabetes, and insulin resistance), we can reduce our cancer risk. Attia also believes that there are promising new cancer treatments on the market, such as immunotherapies, which might render cancer a manageable disease.

Emotional health is one of Attia’s five tactical domains that people can use to extend their healthspan and lifespan. He believes it represents the biggest roadblock to longevity because most people do not pay attention to their emotional health. By telling his own emotional health journey (Chapter 17), Attia encourages readers to take care of their emotional health just as they would their physical health, and to admit when they need help doing so. Failure to maintain emotional health will make our later years miserable. As Attia points out, “longevity is meaningless if your life sucks” (409).

Exercise is one of Attia’s tactical domains. To Attia, “exercise is the most powerful longevity drug” (216). Critically, it slows the erosion of our physical capacity, which is the hallmark of the aging process. Exercise strengthens the heart, maintaining the circulatory system. It also improves the health of mitochondria and thus, our ability to metabolize fat and glucose. It helps build and strengthen muscle and increase muscle mass and bone density, which supports and protects the body by keeping our “skeleton upright and intact” (226). Exercise also helps maintain metabolic health, improves emotional health, and slows cognitive decline.

Attia labels the four chronic diseases of aging—metabolic dysfunction, cardiovascular disease, cancer, and neurodegenerative diseases—the “Four Horsemen.” Age represents the common, most powerful risk factor associated with all Horsemen diseases. The risk that one or more of these diseases will embed itself in an individual’s body exponentially increases with age. While we cannot control the chronological aging process, we can control what is happening inside our bodies with Medicine 3.0. to lessen our risks of disease development.

Heart disease, which is part of atherosclerotic cardiovascular disease (ASCVD), is one of Attia’s Four Horsemen diseases (Chapter 7). Medicine 2.0 assumes heart disease happens later in life, while Attia argues that heart disease begins developing when we are teenagers. Medicine 2.0 also focuses heavily on cholesterol. However, the concentrations of ApoB and Lp(a) matter more than cholesterol—Attia argues that these two numbers are the most critical for predicting cardiovascular disease risk. Finally, while exercise and diet can help maintain or eliminate precursor conditions associated with heart disease, Attia also advocates for taking statins. Medine 2.0 has people taking statins when they already have heart disease, whereas Attia views it as an important preventative treatment.

Healthspan represents one of two components associated with longevity (the other being lifespan). Healthspan is often “defined as a period of life when we are free from disability or disease” (10). Attia finds this definition too simplistic. Rather, he argues that healthspan is about living better longer. To do this, people need to work on improving their mental and physical functions starting in at least their thirties. Healthspan is a key component of Attia’s Medicine 3.0.

Lifespan is one of two components associated with longevity (the other being healthspan). It represents how long someone lives, or their chronological lifespan. Medicine 2.0 focuses on lifespan. Attia finds fault with this approach since it does not care whether someone is living longer without experiencing pain.

For Attia, longevity is not about living forever or living later in life while the body declines. Rather, longevity is about living longer (chronological lifespan) and living better for longer (healthspan). Thus, longevity maximizes both lifespan and healthspan. Attia promotes a three-part approach to longevity: objective, strategy, and tactics.

Attia calls the “period of diminishment and limitation” (37), often caused by one of the Horsemen diseases later in life, the “Marginal Decade.” People live longer largely due to modern comforts and medicine, yet our cognitive and physical capabilities (which represent important aspects of healthspan) are often greatly diminished. Thus, Medicine 2.0 treats Horsemen diseases when healthspans are already compromised, so we now live longer with pain. The Marginal Decade sharply contrasts with the Bonus Decade.

Metabolic dysfunction, which is an issue with the body’s ability to process energy, is one of Attia’s Four Horsemen diseases (Chapter 6). Metabolic health matters because all of the other Horsemen diseases (cancer, heart disease, and neurogenerative diseases) are built on metabolic dysfunction. Throughout the book, Attia repeatedly underscores the importance of getting our metabolic health in order. Our best weapons include exercise, sleep, and nutrition.

Neurogenerative Disease is one of Attia’s Four Horsemen diseases (Chapter 9). While there are other types of neurogenerative diseases (e.g., Lewy body dementia and Parkinson’s disease), Attia focuses on Alzheimer’s disease since it is the most common. Attia argues that Alzheimer’s disease is the most difficult of the Horsemen diseases for Medicine 2.0 to manage, as we have a limited understanding of its origin and progression. Medicine 2.0 does not step in until a patient has already been diagnosed with dementia. At this point in time, dementia is not reversible. Attia argues that preventative strategies for neurodegenerative diseases should be based on four key principles: good vascular health; good metabolic health; thinking about Alzheimer’s disease prevention early, especially if someone is an APOE e4 carrier; and exercising, which helps improve vascular and metabolic health and preserves brain health.

Nutritional biochemistry is one of Attia’s five tactical domains that people can use to extend their healthspan and lifespan. Nutritional research presents conflicting and often flawed results: Because of the complexity of people’s individual circumstances and the biochemistry of our food, it is impossible to determine causal relationships. Attia now believes that there is no single diet applicable to every person. Instead, he believes people need to create their individual eating plans based on manipulating three levers of diet: caloric restriction (CR), dietary restriction (DR), and time restriction (TR); all of which are discussed in Chapter 15. Attia also strongly disagrees with the notion that nutrition is a magic bullet for longevity. Instead, he finds exercise to be a much more powerful tool.