The new bible of longevity has finally arrived—Peter Attia, M.D.’s long awaited brainchild, Outlive: The Science and Art of Longevity. The 400-page textbook-like masterpiece outlines the relationship between healthspan and lifespan and gives solid advice on how to maximize your chances of developing life-shortening disease and cut down how long you spend being frail and infirm as you age.
Attia, a Stanford, Johns Hopkins, and NIH-trained physician who specializes in human longevity, envisions a shift from what he calls “Medicine 2.0,” a reactive approach to medicine that focuses on treating “acute illnesses and injuries,” into “Medicine 3.0,” a model that prioritizes preventative care. It’s a passion born from personal experience—in his 30s Attia realized that his unhealthy habits were slowly killing him.
“The goal of 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 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,” writes Attia, who also regularly tackles these topics with longevity experts like Rhonda Patrick and David Sinclair in his podcast The Drive.
The Importance of Optimizing Your Healthspan
One of Attia’s goals in writing Outlive was to make people more focused on their healthspan by understanding the complex science behind preventing what he calls the “four horsemen” of chronic disease—cancer, diabetes, heart disease, and Alzheimer’s— by employing easily digestible advice on exercise, nutrition, sleep, and more. No magical potions (or snake oil) needed.
In Attia’s own medical practice, Early Medical, he helps patients assess their risk for these diseases (like he did for Chris Hemsworth’s risk of Alzheimer’s disease on Limitless) and identify ways to improve their healthspan. “We ask our patients to think of a far more sophisticated and personalized view of their healthspan,” Attia said in an interview with Worth. What matters to you in three buckets—the physical bucket…the cognitive bucket, and the emotional bucket. All of those things speak to quality of life.”
Outlive offers solutions for how to optimize each of these pillars. The below are some of the highlights.
“My patients fear dementia more than any other consequence of aging, including death. They would rather die from cancer or heart disease than lose their minds, their very selves,” Attia writes.
And for good reason. Many neurodegenerative diseases like ALS and Alzheimer’s don’t have a cure yet— but there are tactics that may stave off these diseases, even if you have a genetic predisposition.
Eat for your brain
While Attia avoids the “diet wars,” he recommends two diets to patients whose genes indicate a high-risk for Alzheimer’s disease: keto and Mediterranean.
“Because metabolism plays such an outsize role with at-risk patients, our first step is to address any metabolic issues they may have. Our goal is to improve glucose, metabolism, inflammation, and oxidative stress,” he writes.
Attia points to studies that suggest that a ketogenic diet could benefit brain function in patients with mild cognitive impairment. When your body enters ketosis, your brain is fueled by a mix of ketones and glucose. Research shows that Alzheimer’s patients start to lose their ability to use glucose for brain fuel, but maintain the ability to use ketones— this means that being in ketosis could prevent rapid cognitive decline and even work as a preventative measure for people with Alzheimer’s or a high-risk of developing it (3).
“It makes sense to try to diversify the brain’s fuel source from only glucose to both glucose and ketones. Think of it as a flex-fuel strategy,” he says.
The Mediterranean diet relies on monounsaturated fats and less carbs. Plus, eating fatty fish regularly boosts omega-3 fatty acid to maintain brain health.
Even if you’re in prime outward physical condition, not getting enough sleep puts you at risk for developing “old-man blood.” Attia points to research by Kirk Parsley, M.D., a physician to Navy SEALs, in which he discovered that these guys who looked ultra built and healthy had hormone and inflammatory levels of men decades older than them.
“Now I recognize that sleep, diet, and risk of long-term disease are all intimately connected to each other. Knowing what I do now, I would bet that a few months of perfect sleep could have fixed 80 percent of my problems, even on a crappy diet,” Attia writes.
Not clocking in enough Zs can also put you at risk for cardiovascular disease and reduced long term metabolic and cognitive health, Attia writes. Struggling to fall asleep? Attia suggests sleeping in a dark room, ditching electronics before bed, and keeping your bedroom cool (around 65 degrees Fahrenheit).
While being buff in your prime is a fine goal to have, Attia looks at physical health as a preventative measure against injury and isolation as you age.
“I think of strength training as a form of retirement saving. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach an older age with enough of a “reserve” of muscle and bone density to protect us from injury and allow us to pursue the activities that we enjoy,” he writes.
Train for the centenarian decathlon
Think of the last decade of your life. Do you picture yourself bed-ridden or basking on the couch in front of the television? Or do you see yourself golfing with your grandkids and going on walks with your family?
Attia suggests intentionally training for the activities you care most about continuing into your later years. He notes that you should start building up strength and cardiovascular stamina beginning in your middle years in anticipation for a normal, but sharp, drop in your 70s.
“I know, it’s a somewhat morbid topic, thinking about our own physical decline. But not thinking about it won’t make it any less inevitable,” Attia says.
Attia works with patients to develop a list of physical aspirations for this last decade, which may include having sex, hiking 1.5 miles on a hilly trail, opening a jar, or climbing four flights of stairs—activities you might take for granted now. Then, he helps them put together a plan to train now for those mundane, but independence-supporting tasks in the future.
“We must stop pointlessly exercising just because we think we are supposed to, banging away on the elliptical trainer at lunch hour. I promise, you can do better,” he writes.
Engage in zone 2 exercises
Zone 2 training, or aerobic training, is essential to support longevity in the last decade of your life, Attia writes. This is because zone 2 training stimulates mitochondrial function, which is important for metabolic health and athletic performance.
“Mitochondrial health becomes important as we grow older, because one of the most significant hallmarks of aging is a decline in the number and quality of our mitochondria,” Attia writes.
Zone 2 exercises like jogging, cycling, or swimming should put you at around 60-70% of your maximum heart rate and be maintained for 30-45 minutes.
“I think of zone 2 as akin to building a foundation for a house. Most people will never see it, but it is nevertheless important work that helps support virtually everything else we do, in our exercise regimen and in our lives,” Attia says.
Attia calls out the “epidemic of emotional health disorders” as one of the largest roadblocks to longevity in his patients. In the final chapter of Outlive, he gets vulnerable about his own treatment for depression and how emotional health can exacerbate other threats to healthspan.
Attia says that preventative measures for emotional well-being are just as important to the goals of Medical 3.0 as cognitive and physical maintenance.
“Taking care of our emotional health requires a paradigm shift similar to the shift from Medicine 2.0 to Medicine 3.0. It’s about long-term prevention, just like our approach to preventing cardiovascular disease,” he writes.
Work with a therapist
Attia highlights his positive experience with dialectical behavior therapy (DBT) in the book. DBT is used by therapists to help improve a patient’s distress tolerance, which breaks the chain between negative stimulus and negative reaction.
“One thing I like about DBT is that it is backed up by evidence: clinical trials have found it to be effective in helping suicidal and self-harming patients stop their dangerous behavior,” Attia writes.
While DBT is generally something that should be guided by a trained mental health expert, you can incorporate some of its tactics like mindful breathing into your routine.
“Even just living alone, or feeling lonely, is linked to a much higher risk of mortality,” Attia says.
While you can experience the negative emotional impacts of loneliness at any age, he says that the health “risk factor” grows more dire the older you get.
“It took me a while to recognize this, but feeling connected and having healthy relationships with others, and oneself, is as imperative as maintaining efficient glucose metabolism or an optimal lipoprotein profile,” he writes. “In my own practice, I witness first hand how many of my patients’ physical and longevity issues are rooted in, or exacerbated by, their emotional health.”
- Meira, et al (2019). Ketogenic Diet and Epilepsy: What We Know So Far.
- Danan, et al (2022) The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients.
- Tabaie, et al (2022). A narrative review on the effects of a ketogenic diet on patients with Alzheimer’s disease.