I am a fan of Dr. Peter Attia who is a physician focused on the science of longevity.  He strives to help his patients simultaneously improving lifespan (delay the onset of chronic disease) and healthspan (quality of life). In 2023 he released the book Outlive where he systematically explains his approach to healthcare which is focused on prevention (sneak peak… exercise is the most powerful tool) and personalization. He has a podcast call The Drive where he interviews people whose work can inform anyone interested in long term health and fitness.

I appreciate that Attia is science oriented and he is willing to re-think his positions when data contradicts his beliefs. He isn’t overly certain, saying he has “strong opinions which are loosely held.” He has written a nice series on studying studies which discusses how to read and evaluation the quality of published research which often has flaws.

I have been inspired by his idea of training for the centenarian decathlon (additional details in AMA 39 and Drive #261, videos of some of the exercises). Identify what you want to be able to do when you are in your 90s such as lifting a child to decorate a tree. Backcast what fitness needs to be achieved earlier in life in view of the typical loss of strength due to aging and drop of VO2max. Your training program should strive to improve your fitness so that your fitness level bisect the backcast projection. Once you are at the level, it’s ok to ride the enviable decline. Make sure you don’t injure yourself while training.

Some of my fondness likely comes from confirmation bias. Attia’s material is very close to many of the conclusions I reached when I was trying to understand what leads to a healthy life. I captured my preliminary conclusions in Health and Fitness in One Post.

Attia notes that the biggest threat to longevity are chronic diseases (CDC). He groups these into four catagories of chronic diseases which he sometimes refers to as the four horseman:

• Metabolic Disease (a spectrum of everything from hyperinsulinemia to insulin resistance to fatty liver disease to type 2 diabetes). These are arguably the most preventable diseases through diet and exercise. Metabolic disease also contributes to atherosclerotic and possibility neurodegenerative diseases and some forms of cancer.
• Atherosclerotic Disease (comprised of cardiovascular disease and cerebrovascular disease). I haven’t personally studied this group of diseases. It’s the next thing I want to study. Number one on all cause mortality.
• Cancer: until there are major breakthroughs early detection is key. Survival once the cancer has metastasized is poor and hasn’t significant improved in 70 years, though there are some promising approaches that might finally result in breakthrough treatments
• Neurodegenerative Disease (Alzheimer’s disease being the most common). As far as I can tell, there are no effective treatments. While there are some theories and ideas of how to prevent, there are not strong causal links. 

Attia has identified what he believes are the  Five Tactics for Longevity which are:

• Exercise physiology: the most “powerful drug” in our arsenal
• Nutritional Biochemistry: Diet, fasting
• Sleep: 7-8.5 hours. Not too little. Not too much.
• Increase distress tolerance: Constance, chronic stress has negative consequences to health and wellness. Controlled, acute stress is helpful.
• Exogenous Molecules: medications, supplements, hormones

Exercise

Attia has a framework of exercise includes four areas which provide unique benefits:

• Stability: Balance, efficient movement. This is particularly important as people age because it reduces the likelihood of injuries due to  falling. Some forms of yoga, Pilates, and Dynamic Neuromuscular Stabilization (DNS)  are examples. Having good stability is key to training without injuring yourself.
• Strength: Developing muscle strength. The more strength you have the easier it is for you to engage in heavy work. It is easier to build strength when we are young, and we have a tendency to lose strength as we age. BUT there are a numbers of studies that show people who are in their 60s (and older) can gain strength with training.
• Aerobic Efficiency which focuses on metabolic “base” (zone 2): improving mitochondrial function which is key to your ability to burn fat, reduce the risk of diabetes, and be able to sustain endurance. Cycling, running. and rowing are some of the best options for zone 2 workouts.
• Anaerobic peak: High Intensity (zone 5): Builds your metabolic systems ability to handle peak exertion and grows VO2max. Often part of an high intensity interval (HIIT) protocol.

Nutritional Biochemistry

The area of diet and fasting is one of the areas that Attia demonstrates his strong opinions held loosely. His position has shifted since I started to follow him. First, the things which have been consistent

• Except for people who are food insecure, one of the biggest health threats is eating too many calories. Excess calories is a huge driver of metabolic diseases, and contributes to the other horseman
• Sugar is a lot like a poison to our metabolic system. Minimize it.
• Get enough protein to maintain and build muscles. The amount of protein we need goes up as we age

When I first starting to reading material by Attia he had a strong beliefs which including the following (which he has backed away from)

• Good nutritional practices (the right diet) can had a significant improve on overall health / longevity
• Fasting is a useful technique for almost everyone to optimize health
• While note advocating it for everyone, lived a strict keto diet for several years and wrote about the benefits.

With the publishing of Outlive his position is slightly different

• Bad nutrition can really hurt health, good nutrition doesn’t significantly improve health
• Extended fasts are useful when people have severe metabolic issues, but the typical lost of muscle is not worth the benefits for most people.
• Intermittent fasting can be useful if it helps someone avoid eating too much food, but has little or no additional value over eating the same number of calories spread out over a longer period of time.