Outlive (2023) is a comprehensive guide to living a longer, healthier, and more fulfilling life. Drawing on cutting-edge science and practical advice, it empowers you to optimize your exercise, nutrition, sleep, and emotional health for maximum longevity.
Introduction: Unlock the secrets to living a longer and better life.
Our modern world has brought us a host of deadly diseases – cancer, heart disease, and type 2 diabetes are just a few. And even though we now have a better lifestyle than our ancestors, some things about our world are causing our health to suffer.
The main issue is that our environment has changed a lot in the last couple of centuries but our genes are still the same. Take fructose, for example. It used to be our friend when it came in fruit and honey, but now it’s everywhere in our food, causing us to store more fat than we need. And it’s not just modern food that’s not great for our health – how much we move, our sleep habits, and even the effect of social media on our emotions are having a major toll. So we need to come up with a game plan to live well in this weird new world.
This Blink focuses on the four main areas you can concentrate on to improve your health: exercise, nutrition, sleep, and emotional health. Now, you won’t find a one-size-fits-all plan here because everyone’s different. Instead, this Blink will help you build a framework to manage these four aspects of your health. There’s not just one specific diet or exercise ideology you should follow, and you should be open to testing and changing tactics as needed. The ultimate goal? To live longer and better, making each decade of your life even better than the one before.
An athlete of life
You’ve probably heard of the many benefits of regular exercise. But did you know how important it is for living a long life? Well, it turns out that even a little bit of exercise can make a huge difference. Not only does exercise strengthen your heart and muscles – it improves circulation and benefits your brain by producing a molecule called BDNF – brain-derived neurotrophic factor – which helps with memory.
All in all, exercise is like this magical potion that can help you live longer, healthier lives, and it’s not even about picking sides between cardio or weights – it’s all about finding exercise habits that work for you individually.
Now, here’s the amazing part – even just a little bit of regular exercise can make a huge difference and actually lengthen your life by several years, delay chronic diseases, and even slow down or reverse cognitive decline. Simply going from zero to 90 minutes a week can lower your risk of dying from any cause by 14 percent!
And of course, being super fit means you’re much less likely to die than if you’re a couch potato. Studies show that the fittest people have the lowest mortality rates. In fact, having a low level of cardiorespiratory fitness is more dangerous than smoking.
You might be thinking, “I’m old, how am I supposed to start lifting weights?” Well, it turns out strength training is really important for everyone, even the elderly and frail. It can improve mobility and physical function, which can help prevent falls and other health problems.
Here’s a fun way to think about staying active as you age: become an athlete of life! Imagine you’re training for a centenarian decathlon, a list of ten physical tasks you want to be able to do when you’re 100 years old. These might be climbing stairs, getting up off the floor, or hiking a trail. This will help you set goals for your fitness journey and keep you motivated.
So, pick your ten events and start training for them. It’s all about being well-rounded and staying active in different ways. That way, you’ll be much more likely to be fit and healthy at 100 years old – and break the stereotype that old age has to be all about decline and misery.
The three dimensions of fitness
So now that you know the importance of a lifelong love of exercise, let’s get into some specifics that you can apply to your training regimen. There are three key dimensions of fitness – aerobic endurance and efficiency, strength, and stability. It’s essential to train in all of these areas to maintain health and strength as you age.
Aerobic endurance and efficiency can be improved by training with zone 2 cardio, a specific intensity level that can be sustained for longer periods. This implies a moderate intensity level, usually requiring 60 to 70 percent of your maximum heart rate. In other words, at this pace, you should still just about be able to hold a conversation but definitely not sing a power ballad.
This type of training promotes using fat as fuel and is important for nonathletes, as it builds endurance and helps prevent chronic diseases. An example of zone 2 training is walking briskly for six to ten miles daily. To start, two 30-minute sessions per week can provide significant benefits. To make zone 2 training more enjoyable, try listening to podcasts or audiobooks during your workouts.
Next up are VO₂ max workouts – these are training sessions designed to increase the maximum amount of oxygen that your body can use during exercise. This sort of exercise typically involves high-intensity interval training, otherwise known as HIIT. What exactly is that? In HIT, you alternate between periods of high-intensity exercise and rest. What’s more, HIT is associated with longevity and functional capacity. To get started, try supplementing zone 2 work with one or two VO₂ max workouts per week, consisting of intervals lasting three to eight minutes at maximum sustainable pace, followed by easy exercise.
It’s important not to forget about strength when it comes to exercise – it’s crucial for protecting against physical frailty and injury in old age. Muscle mass and bone density decline over time, so it’s essential to incorporate heavy resistance training to improve muscle fibers and maintain bone health. Exercises like rucking – hiking with a loaded backpack – or carrying heavy metal weights can help strengthen the body.
Last but not least, grip strength is a vital aspect of overall strength and is also linked to longevity. To improve grip strength, try exercises like farmer’s carries and dead-hanging from a pull-up bar. Also, focus on eccentric strength and pulling motions, as well as hip-hinging movements like single-leg step-ups and split-stance Romanian deadlifts. That might sound like a lot to take in, so definitely learn these exercises from a knowledgeable trainer or use instructional videos as a resource.
By incorporating these training methods and focusing on aerobic endurance, strength, and stability, you can set yourself up for a fulfilling and active life as you age.
Revamping your diet
Now that you have your exercise regimen cut out for you, let’s shift gears and take a look at all things diet. A big problem Americans face these days is what’s known as the Standard American Diet, or SAD. It’s loaded with sugar, refined carbs, and processed oils, which can lead to overeating and poor health. To break free from the SAD trap, you can try caloric restriction, dietary restriction, or time restriction. Remember, each approach has its pros and cons, so choose what fits your lifestyle best.
Caloric restriction is the most flexible option but requires tracking everything you eat and resisting the urge to cheat. Dietary restriction involves cutting specific foods but only works if it leads to a caloric deficit. Time restriction, like intermittent fasting, can backfire if you overeat or don’t get enough protein.
Let’s flip this around for a minute and switch focus to what you should be eating. First up is protein – it’s essential for building and maintaining muscle, especially as we age. Aim for at least one gram of protein per pound of body weight daily, or 2.2 grams per kilo. Spread your protein intake throughout the day, and choose high-quality sources like whey protein isolate over soy protein isolate. Eating enough protein can also help you feel full, so you’ll consume fewer calories overall. Remember, protein helps you feel full and maintain muscle mass, especially as you age. And animal sources of protein are more effective than plant sources, so keep that in mind.
Next up are fats. Not all fats are created equal! We need a mix of saturated, monounsaturated, and polyunsaturated fats, with a focus on omega-3s for heart and brain health. Opt for extra virgin olive oil, avocados, and nuts, while cutting back on butter, lard, and omega-6-rich oils like corn, soybean, and sunflower.
Time-restricted eating, or fasting, can be helpful, but it’s not for everyone. There are short-term eating windows, alternate-day fasting, and longer-term fasting. Intermittent fasting and time-restricted eating are popular weight-loss methods, but their effectiveness and potential downsides are debatable. Fasting triggers physiological and cellular mechanisms like insulin level drops and cellular repair gene activation. Still, prolonged fasting can lead to muscle loss. Having said all that, fasting can work for weight loss, but it must be approached with caution and precision. It’s probably best to consult your doctor before beginning a fasting regimen.
Lastly, let’s talk about adopting what Attia calls a Nutrition 3.0 mindset. It’s all about finding the right balance that works for you. Don’t overthink it – focus on reducing overall energy intake, getting enough protein, and finding the right mix of fats. Also, remember that exercise and spending time outdoors are just as important for your health. Ultimately, there’s no one-size-fits-all approach, so it’s up to you to find your own balance.
The power of sleep
Armed with the essentials for exercise and nutrition, it’s time to delve into the profound impact sleep has on your health and well-being. Attia’s eyes were opened to the significance of sleep for both physical and cognitive health after flirting with death – having gone without sleep for 60 hours, he found himself dozing off at the wheel and narrowly avoiding a serious car accident. This harrowing experience should serve as a powerful reminder for everyone to reevaluate their relationship with sleep and prioritize it as a vital component of a healthy lifestyle.
Anecdotes aside, there are plenty of studies showing the negative effects of lack of sleep – indeed, it’s been linked to an increased risk of things like heart attacks, type 2 diabetes, and even workplace accidents. It’s not just about feeling tired – it’s about your overall health. For example, one study showed that sleeping less than seven hours a night can increase your risk of dying prematurely by 12 percent. The statistics don’t lie – sleep-deprived drivers cause around 20 percent of all car accidents, and sleep deprivation also leads to more workplace accidents and medical errors.
But let’s switch gears and get back to the positives. Studies have shown that we need about seven and a half to eight and a half hours of sleep each night. With good sleep, your physical and cognitive performance can improve, including things like athletic performance and memory consolidation. Also, sleep helps to keep your metabolism in check and reduces the risk of chronic health problems such as metabolic dysfunction, type 2 diabetes, heart disease, and obesity.
Many people search for that magic pill to put them to sleep, but the reality is, many sleep aids out there don’t actually improve sleep quality. In fact, some can even harm your sleep, like Ambien or Valium. So, what can you do to improve your sleep naturally?
First, it’s essential to evaluate your sleep habits. Use sleep trackers or take sleep questionnaires like the Pittsburgh Sleep Quality Index to figure out how you’re doing. Don’t forget, everyone’s different – some of us are morning people, while others are night owls. So, try to work with your natural rhythm.
Now onto some more concrete tips. It’s definitely a good idea to cut down on blue light exposure before bed, maybe by swapping out those LED bulbs for warmer ones. Keep your bedroom cool, around 65 degrees Fahrenheit or 18 degrees Celsius – and make sure your bedroom is as dark as possible. Try to avoid screens an hour before bedtime – that late-night social media scroll isn’t helping.
Be mindful of what you consume, too. Keep caffeine and alcohol in check, as they can mess with your sleep. And finally, don’t forget to manage stress – meditation can be a game-changer for winding down.
Even superstar athletes like LeBron James prioritize sleep for peak performance. He reportedly sleeps about 12 hours a day with a special mattress and pillows! So, take a page out of LeBron’s playbook and create a sleep routine that works for you. Stick to it, and you’ll be on your way to better sleep and improved overall well-being.
Embracing emotional health
You’ve reached the final component of longevity – emotional health. When you think about being healthy, you probably focus on your physical well-being, but your emotional health is just as important, if not more so. After all, what good is living a long life if you’re not happy or fulfilled?
For example, someone struggling with depression might not see the point of getting a cancer screening or monitoring their blood sugar levels. On the other hand, someone who’s physically fit might not realize how emotional issues can impact their overall health. So, if you’re dealing with emotional or mental health struggles, don’t hesitate to seek professional help. It’s crucial to address these issues to maintain good physical health.
Dealing with emotional health can be tricky. Unlike physical health, it’s hard to recognize and diagnose. That’s why you need a proactive and individualized approach. Look out for signs of emotional health issues, seek help early, and commit to daily practices that promote long-term emotional well-being.
There are a number of tools to monitor and maintain emotional equilibrium. Medications, meditation, and psychedelics can help, but they’re not quick fixes. They should be seen as part of real psychotherapy, like dialectical behavior therapy or DBT. This is a proven method that helps regulate emotions and tolerate emotional stressors. DBT is built on four pillars: emotional regulation, distress tolerance, interpersonal effectiveness, and self-management, all linked to mindfulness. It’s important to remember, though, that change takes time and effort. Practicing daily and working through issues in therapy is key to achieving true recovery.
Another thing to consider is self-reflection. Many people struggle with self-hatred and the need for external validation. It’s essential to work on your relationship with yourself and recognize how your past experiences shape your present behavior. Take childhood trauma, for instance. It can show up in various forms, like addiction, codependency, and attachment disorders. It’s important to address such issues, but this can be a real challenge. So what can you do? Look out for signs of emotional health issues, seek help early, and commit to daily self-reflection or meditation. And remember, healing takes time, so be patient with yourself during the process.
Lastly, let’s go back to longevity. To stay “young” and healthy, focus on looking toward the future and pursuing your dreams and aspirations. Find activities that bring you joy and fulfillment, like spending time in nature, practicing mindfulness, or journaling.
Remember, emotional health is just as important as physical health. Take care of yourself and don’t be afraid to seek help if needed. With time, patience, and the right tools, you can make progress toward a happier and healthier life.
Insights from Outlive by Peter Attia, MD
To live well into your tenth decade, you must avoid the four aging diseases: cancer, heart disease, Alzheimer’s disease, and metabolic disease. Insulin resistance is the lead domino for all four aging diseases.
“Studies have found that insulin resistance itself is associated with huge increases in one’s risk of cancer (up to twelvefold), Alzheimer’s disease (fivefold), and death from cardiovascular disease (almost sixfold).” – Peter Attia
You can avoid insulin resistance and prolong your life by committing to a longevity training program that includes the following:
- Zone 2 training
- VO2 max training
- Strength training (with a focus on developing grip strength and hip-hinging exercises).
“More than any other tactical domain we discuss in this book, exercise has the greatest power to determine how you will live out the rest of your life…Going from zero weekly exercise to just ninety minutes per week can reduce your risk of dying from all causes by 14 percent. It’s very hard to find a drug that can do that.” – Peter Attia
Zone 2 training for longevity
Zone 2 training involves any aerobic exercise on a stationary bike, treadmill, rower, or outside for 45 minutes, four days a week at a pace you can sustain while barely being able to have a conversation with someone. Zone 2 training time is a good time to watch your favorite TV show. A zone 2 workout should feel “almost hard” without any “muscle burn” (excess lactic acid in the muscles). As you do zone 2 training, you are training the mitochondria in your muscle cells (the cell’s power plants) to use fat as fuel.
VO2 max training for longevity
VO2 max training involves doing any aerobic exercise close to your all-out maximum for four minutes, go easy for four minutes, and repeat four times. You will feel like you’re dying during a VO2 max training session but it’s worth it! People increase their VO2 max from below average in your age group, to above average, experience a 50% reduction in all-cause mortality. Attia says, “VO2 max is perhaps the single most powerful marker for longevity.” Take an annual VO2 max test with a medical professional (search “VO2 max tests near me” on Google) and strive to get in the top 5% of your age group.
Strength training for longevity
Strength training vastly improves metabolic health because it creates more lean muscle mass that soaks up excess glucose like a sponge. A 10-year study of 4,500 subjects over fifty found that those with low muscle mass and strength were three times more likely to die early. Set a strength training target to lift heavy weights three times a week. Focus on grip strength (exercises like the farmers carry – carrying two heavy objects in your hands) and hip-hinging exercises (exercises that involve bending at the hip without bending the spine – like deadlifts, squats, or step-ups on a large box). Your goal is to be able to do a farmer’s carry for one minute while holding half your body weight in each hand.
“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 older age with enough of a ‘reserve’ of muscle (and bone density) to protect us from injury and allow us to continue to pursue the activities that we enjoy.” – Peter Attia
Eating for longevity
No diet is proven to prolong life for everyone. But there are three eating rules anyone without kidney damage can follow to extend life:
- Consume enough protein to match one’s weight in grams (triple the daily recommended minimum) to maintain lean muscle. For example, I weigh 195 pounds, so I need to consume 195 grams of protein every day. However, I must space out my protein intake so I do not consume more than 25% of my daily protein in a single sitting (excess protein gets turned into glucose by the liver). Therefore, I aim to eat roughly 50 grams of protein four times a day (around 9 AM, 12 PM, 3 PM, 6 PM). Peter Attia says, “One macronutrient, in particular, demands more of our attention than most people realize: not carbs, not fat, but protein becomes critically important as we age.”
- Don’t eat within three hours of bedtime. Eating too close to sleep reduces sleep quality.
- Stick to an eating plan that keeps average blood glucose in a safe range. One week every few months, I will measure my blood glucose after I eat common meals with a simple drugstore glucose monitor. I’ll take a glucose measurement at 30-minute intervals for up to 2 hours after each meal to see if what I ate spiked my glucose levels above 160 mg/dL on the meter (which would lead to an insulin spike) and see if my average glucose throughout the week is above 100 mg/dL. If either is true, I will eliminate foods like refined carbohydrates and add more whole foods to my weekly eating plan.
“The time to repair the roof is when the sun is shining.” – John F. Kennedy www.ProductivityGame.com
Exercise, a balanced diet, quality sleep, and emotional health are crucial components of living a longer, healthier life. Exercise improves your circulation and brain function, while a well-rounded diet, including protein, healthy fats, and caloric restriction, can help you maintain muscle mass and overall health. Prioritizing your sleep and creating a consistent routine promotes physical and cognitive performance. Your emotional health is just as vital, and addressing issues like depression or trauma can contribute to your overall well-being. By focusing on all these areas, you can work toward a fulfilling, active, and healthy life.
About the author
Peter Attia, MD, is the founder of Early Medical. He received his medical degree from the Stanford University School of Medicine and trained at the Johns Hopkins Hospital in general surgery. He also trained at the NIH as a surgical oncology fellow at the National Cancer Institute, where his research focused on immune-based therapies for melanoma. He serves on the editorial board for the journal Aging. He is the host of The Drive, one of the most popular podcasts covering the topics of health, medicine, and longevity.
Bill Gifford is a veteran journalist and author of the New York Times bestseller Spring Chicken: Stay Young Forever (Or Die Trying). His work has appeared in Outside, Scientific American, Bloomberg Businessweek, Men’s Health, and numerous other publications.
Health, Nutrition, Personal Development, Aging Well, Rejuvenation, Healthy Living, Diet, Fitness, Nonfiction, Science, Self Help, Medicine, Biology, Aging Medical Conditions and Diseases, Longevity, Anatomy
Table of Contents
Introduction 1 (6)
Chapter 1 The Long Game: From Fast Death to Slow Death 7 (13)
Chapter 2 Medicine 3.0: Rethinking Medicine for the Age of Chronic Disease 20 (16)
Chapter 3 Objective, Strategy, Tactics: A Road Map for Reading This Book 36 (23)
Chapter 4 Centenarians: The Older You Get, the Healthier You Have Been 59 (14)
Chapter 5 Eat Less, Live Longer: The Science of Hunger and Health 73 (15)
Chapter 6 The Crisis of Abundance: Can Our Ancient Genes Cope with Our Modern Diet? 88 (23)
Chapter 7 The Ticker: Confronting—and Preventing—Heart Disease, the Deadliest Killer on the Planet 111 (29)
Chapter 8 The Runaway Cell: New Ways to Address the Killer That Is Cancer 140 (37)
Chapter 9 Chasing Memory: Understanding Alzheimer’s Disease and Other Neurodegenerative Diseases 177 (32)
Chapter 10 Thinking Tactically: Building a Framework of Principles That Work for You 209 (7)
Chapter 11 Exercise: The Most Powerful Longevity Drug 216 (19)
Chapter 12 Training 101: How to Prepare for the Centenarian Decathlon 235 (28)
Chapter 13 The Gospel of Stability: Relearning How to Move to Prevent Injury 263 (28)
Chapter 14 Nutrition 3.0: You Say Potato, I Say “Nutritional Biochemistry” 291 (16)
Chapter 15 Putting Nutritional Biochemistry into Practice: How to Find the Right Eating Pattern for You 307 (42)
Chapter 16 The Awakening: How to Learn to Love Sleep, the Best Medicine for Your Brain 349 (28)
Chapter 17 Work in Progress: The High Price of Ignoring Emotional Health 377 (32)
Epilogue 409 (4)
Acknowledgments 413 (4)
Notes 417 (14)
References 431 (40)
#1 NEW YORK TIMES BESTSELLER • A groundbreaking manifesto on living better and longer that challenges the conventional medical thinking on aging and reveals a new approach to preventing chronic disease and extending long-term health, from a visionary physician and leading longevity expert
Wouldn’t you like to live longer? And better? In this operating manual for longevity, Dr. Peter Attia draws on the latest science to deliver innovative nutritional interventions, techniques for optimizing exercise and sleep, and tools for addressing emotional and mental health.
For all its successes, mainstream medicine has failed to make much progress against the diseases of aging that kill most people: heart disease, cancer, Alzheimer’s disease, and type 2 diabetes. Too often, it intervenes with treatments too late to help, prolonging lifespan at the expense of healthspan, or quality of life. Dr. Attia believes we must replace this outdated framework with a personalized, proactive strategy for longevity, one where we take action now, rather than waiting.
This is not “biohacking,” it’s science: a well-founded strategic and tactical approach to extending lifespan while also improving our physical, cognitive, and emotional health. Dr. Attia’s aim is less to tell you what to do and more to help you learn how to think about long-term health, in order to create the best plan for you as an individual. In Outlive, readers will discover:
- Why the cholesterol test at your annual physical doesn’t tell you enough about your actual risk of dying from a heart attack.
- That you may already suffer from an extremely common yet underdiagnosed liver condition that could be a precursor to the chronic diseases of aging.
- Why exercise is the most potent pro-longevity “drug”—and how to begin training for the “Centenarian Decathlon.”
- Why you should forget about diets, and focus instead on nutritional biochemistry, using technology and data to personalize your eating pattern.
- Why striving for physical health and longevity, but ignoring emotional health, could be the ultimate curse of all.
Aging and longevity are far more malleable than we think; our fate is not set in stone. With the right roadmap, you can plot a different path for your life, one that lets you outlive your genes to make each decade better than the one before.
“One of the most important books you’ll ever read.”—Steven D. Levitt, New York Times bestselling author of Freakonomics
“Outlive completely transformed my approach to growing old. Peter Attia is among the most brilliant people I’ve ever met, and he’s succeeded in packing a life’s worth of insights into this book. It promises to be one of the most important books you’ll ever read.”—Steven D. Levitt, New York Times bestselling author of Freakonomics
“In Outlive, Peter Attia explores the science of not just prolonging life, but also prolonging aliveness. Attia makes the crucial connection between overall health and relational health.”—Esther Perel, New York Times bestselling author, psychotherapist, and podcast host of Where Should We Begin?
“Finally, there is a modern, thorough, clear, and actionable manual for how to maximize our immediate and long-term health. Firmly grounded in data and real-life conditions, Outlive makes obvious which actions we all need to take, and just as important, what all we need to pay attention to in order to live a long, vital life. As the most accurate and comprehensive health guide published to date, Outlive is not just informative, it is important.”—Andrew Huberman, PhD, professor, Department of Neurobiology at Stanford University School of Medicine, creator of the Huberman Lab podcast
“Dr. Peter Attia is my doctor and also my friend. He is a specialist in longevity and someone I trust with my life. What separates him from others is his pursuit of quality of life from all angles—physical, emotional, mental, relational, and spiritual health. This incredible book is a call to action and a reminder to always participate, and never be passive. It will arm you with the tools you need to live a long, meaningful, and fulfilling life.”—Hugh Jackman
“In Outlive, Peter Attia has delivered the definitive look at the complex subject of longevity. Comprehensive and rigorous, Outlive is full of surprising insights into the diseases of aging that will likely kill most of us, and the tactics and techniques that can help us live longer and in better health. Attia’s writing surprises and delights us, while provoking a new way to think about longevity.”—Siddhartha Mukherjee, author of the Pulitzer Prize winner The Emperor of All Maladies and the New York Times bestseller The Song of the Cell
Video and Podcast
Read an Excerpt/PDF Preview
The Long Game
From Fast Death to Slow Death
There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in. —Bishop Desmond Tutu
I’ll never forget the first patient whom I ever saw die. It was early in my second year of medical school, and I was spending a Saturday evening volunteering at the hospital, which is something the school encouraged us to do. But we were only supposed to observe, because by that point we knew just enough to be dangerous.
At some point, a woman in her midthirties came into the ER complaining of shortness of breath. She was Black, from East Palo Alto, a persistent pocket of poverty in that very wealthy town. While the nurses snapped a set of EKG leads on her and fitted an oxygen mask over her nose and mouth, I sat at her side, trying to distract her with small talk. What’s your name? Do you have kids? How long have you been feeling this way?
All of a sudden, her face tightened with fear and she began gasping for breath. Then her eyes rolled back and she lost consciousness.
Within seconds, nurses and doctors flooded into the ER bay and began running a “code” on her, snaking a breathing tube down her airway and injecting her full of potent drugs in a last-ditch effort at resuscitation. Meanwhile, one of the residents began doing chest compressions on her prone body. Every couple of minutes, everyone would step back as the attending physician slapped defibrillation paddles on her chest, and her body would twitch with the immense jolt of electricity. Everything was precisely choreographed; they knew the drill.
I shrank into a corner, trying to stay out of the way, but the resident doing CPR caught my eye and said, “Hey, man, can you come over here and relieve me? Just pump with the same force and rhythm as I am now, oaky?”
So I began doing compressions for the first time in my life on someone who was not a mannequin. But nothing worked. She died, right there on the table, as I was still pounding on her chest. Just a few minutes earlier, I’d been asking about her family. A nurse pulled the sheet up over her face and everyone scattered as quickly as they had arrived.
This was not a rare occurrence for anyone else in the room, but I was freaked out, horrified. What the hell just happened?
I would see many other patients die, but that woman’s death haunted me for years. I now suspect that she probably died because of a massive pulmonary embolism, but I kept wondering, what was really wrong with her? What was going on before she made her way to the ER? And would things have turned out differently if she had had better access to medical care? Could her sad fate have been changed?
Later, as a medical resident at Johns Hopkins, I would learn that death comes at two speeds: fast and slow. In inner-city Baltimore, fast death ruled the streets, meted out by guns, knives, and speeding automobiles. As perverse as it sounds, the violence of the city was a “feature” of the training program. While I chose Hopkins because of its excellence in liver and pancreatic cancer surgery, the fact that it averaged more than ten penetrating trauma cases per day, mostly gunshot or stabbing wounds, meant that my colleagues and I would have ample opportunity to develop our surgical skills repairing bodies that were too often young, black, poor, and male.
If trauma dominated the nighttime, our days belonged to patients with vascular disease, GI disease, and especially cancer. The difference was that these patients’ “wounds” were caused by slow-growing, long-undetected tumors, and not all of them survived either—not even the wealthy ones, the ones who were on top of the world. Cancer doesn’t care how rich you are. Or who your surgeon is, really. If it wants to find a way to kill you, it will. Ultimately, these slow deaths ended up bothering me even more.
But this is not a book about death. Quite the opposite, in fact.
More than twenty-five years after that woman walked into the ER, I’m still practicing medicine, but in a very different way from how I had imagined. I no longer perform cancer surgeries, or any other kind of surgery. If you come to see me with a rash or a broken arm, I probably won’t be of very much help.
So, what do I do?
Good question. If you were to meet me at a party and ask me that, I would do my best to duck out of the conversation. Or I would lie and say I’m a race car driver, which is what I really want to be when I grow up. (Plan B: shepherd.)
My focus as a physician is on longevity. The problem is that I kind of hate the word longevity. It has all sorts of terrible associations, with a centuries-long parade of quacks and charlatans who have claimed to possess the secret elixir to a longer life. I don’t want to be associated with those people, and I’m not arrogant enough to think that I possess some sort of easy answer to this problem, which has puzzled humankind for millennia. If longevity were simple, then there might not be a need for this book.
I’ll start with what longevity isn’t. Longevity does not mean living forever. Or even to age 120, or 150, which some self-proclaimed experts are now routinely promising to their followers. Barring some major breakthrough that, somehow, someway, reverses two billion years of evolutionary history and frees us from time’s arrow, everyone and everything that is alive today will inevitably die. It’s a one-way street.
Nor does longevity mean merely notching more and more birthdays as we slowly wither away. This is what happened to a hapless mythical Greek named Tithonus, who asked the gods for eternal life. To his joy, the gods granted his wish. But because he forgot to ask for eternal youth as well, his body continued to decay. Oops.
Most of my patients instinctively get this. When they first come to see me, they generally insist that they don’t want to live longer, if doing so means lingering on in a state of ever-declining health. Many of them have watched their parents or grandparents endure such a fate, still alive but crippled by physical frailty or dementia. They have no desire to reenact their parents’ suffering. Here’s where I stop them. Just because your parents endured a painful old age, or died younger than they should have, I say, does not mean that you must do the same. The past need not dictate the future. Your longevity is more malleable than you think.
In 1900, life expectancy hovered somewhere south of age fifty, and most people were likely to die from “fast” causes of death: accidents, injuries, and infectious diseases of various kinds. Since then, slow death has supplanted fast death. The majority of people reading this book can expect to die somewhere in their seventies or eighties, give or take, and almost all from “slow” causes. Assuming that you’re not someone who engages in ultrarisky behaviors like base jumping, motorcycle racing, or texting and driving, the odds are overwhelming that you will die as a result of one of the chronic diseases of aging that I call the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction. To achieve longevity—to live longer and live better for longer—we must understand and confront these causes of slow death.
Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live—the quality of your years. This is called healthspan, and it is what Tithonus forgot to ask for. Healthspan is typically defined as the period of life when we are free from disability or disease, but I find this too simplistic, too binary. For example, I’m as free from “disability and disease” as when I was a twenty-five-year-old medical student, but my twenty-something self could run circles around fifty-year-old me, both physically and mentally. That’s just a fact. Thus the second part of our plan for longevity is to maintain and improve our physical and mental function.
The key question is, Where am I headed from here? What’s my future trajectory? Already, in midlife, the warning signs abound. I’ve been to funerals for friends from high school, reflecting the steep rise in mortality risk that begins in middle age. At the same time, many of us in our thirties, forties, and fifties are watching our parents disappear down the road to physical disability, dementia, or long-term disease. This is always sad to see, and it reinforces one of my core principles, which is that the only way to create a better future for yourself—to set yourself on a better trajectory—is to start thinking about it and taking action now.