When using your favorite retirement calculator, to what age do you assume you will live? 85? 90? 100+?
A common belief is that we are living progressively longer and will continue to do so. There is an industry capitalizing on people’s desire to live forever.
Then there is reality, as Peter Attia explains in his new book Outlive: The Science & Art of Longevity. Medicine has been incredible at reducing suffering and death attributable to a few key advances such as antibiotics, vaccines, and our ability to treat acute traumatic injuries.
After accounting for those advances, we’ve made little progress in the past one hundred years. We spend incredible sums of money on medical care in our final years, prolonging life when it often has little remaining quality. Billions of dollars are spent annually on pharmaceuticals in the U.S.
What are the results? Chronic diseases that decrease quality of life and eventually lead to death are becoming more prevalent and at earlier ages. Deaths of despair are increasing. For several years in a row, the average American lifespan has decreased!
Outlive focuses on teaching you to take control of your health, enabling you to be the captain of your own ship rather than a passenger being passively carried through our broken health care system. This is an important book for those not just looking to live longer, but to maintain their quality of life for as long as possible.
Objectives, then Strategy, then Tactics
Attia lays out Outlive in three distinct sections, which correspond to the way he proposes we should think about health and wellness. This is a great framework to think about many aspects of life, and is similar to how I think and write about finance.
Defining your objective helps to assure you are starting in the right general direction with appropriate baseline knowledge. Strategies are different categories of ways that you could approach the problem. Tactics are specific things you actually do. They can vary considerably from individual to individual.
Attia argues that it is tempting to want to jump straight to tactics, but that will likely lead to a lifetime of futilely hopping from one “miracle” diet, exercise routine, or drug to the next. I would argue the same is true in finances.
Attia starts the book by providing a brief history of medicine, to help explain how we’ve arrived where we are today. He calls the origins of medicine, first documented around 2,000 years ago, Medicine 1.0. Doctors were doing their best with the limited knowledge and tools available. Actions were guided by direct observation and guesswork. The Hippocratic Oath is its largest lasting contribution to modern medicine, for better or worse. Attia argues often worse as it establishes an overly simplistic view of risk.
Attia describes the beginnings of the scientific method and Medicine 2.0 beginning around the middle of the 19th century, though it took centuries to win favor. As it did, great advances were made: the advent of germ theory, the discovery of penicillin, the eradication of polio and smallpox. We continue to have occasional breakthroughs such as curing hepatitis C and turning HIV/AIDS from an epidemic of assured death to a manageable condition.
While celebrating the remarkable achievements of Medicine 2.0, Attia also clearly lays out its failures and limitations. Medicine 2.0 has been mostly unsuccessful against chronic diseases at great financial cost. He shared a remarkable statistic. If you eliminate deaths from the top 8 infectious diseases, which were controlled by antibiotics in the 1930’s, little additional decrease in mortality rate was accomplished in the 20th century.
Attia proposes the need to progress to what he calls Medicine 3.0, which:
- Places greater emphasis on prevention than treatment,
- Considers the patient as a unique individual,
- Starts with an honest assessment and acceptance of risk. This includes looking at risk over much longer time spans and considering the risk of doing nothing.
- Pays more attention to maintaining healthspan, the quality of life, than lifespan.
Lifespan vs. Healthspan
Medicine 2.0 focuses primarily with extending your lifespan, the amount of time you are alive. I recently shared an article covering the topic titled Aggressive Medical Care Remains Common at Life’s End. It hit me hard as I read it while seeing the “care” my mom was receiving in the hospital in her last months of life, after the point when it was clear that her chances of recovering to a reasonable quality of life were slim to none.
Healthspan refers to the time that you are functioning at a high level physically, mentally, and emotionally. This is what I wanted to focus on in my prior career as a physical therapist.
My immense frustration with a system that would pay for almost any test, medicine, surgery, etc. AFTER an injury or illness occurred, but required fighting tooth and nail for any preventative care is the primary reason I am sitting here writing an early retirement blog rather than still in practice.
In Outlive, Attia argues for a shift of focus from lifespan to healthspan. This requires identifying the areas that decrease quality of life, and being aggressive in our interventions in each area.
The 3 Categories of Healthspan Decline he identifies are:
- Emotional (Not as age dependent as the other two. However the loss of purpose, meaning, and relationships at retirement is a challenge. Dealing with the loss of a spouse, friends, siblings, etc. as we outlive them and deal with our own mortality presents more challenges.)
The Four Horsemen
The second section of Outlive focuses on strategies to address what Attia calls the “Four Horsemen.” They are:
- Metabolic Syndrome
- Heart Disease
- Alzheimer’s and Other Neurodegenerative Diseases
These diseases lead to tremendous loss of healthspan, drive enormous financial costs, and ultimately cause death in most people. He argues that Medicine 2.0 has mostly failed with these diseases and a radically different approach is warranted. Because these diseases are interrelated, lifestyle changes to prevent or treat one often help the others simultaneously.
This approach includes taking matters into your own hands and working outside of the current medical system. This has been my own conclusion and personal approach.
However, Attia is a medical doctor who also emphasizes taking a balanced approach, continuing to utilize parts of the medical system that work well, advocating for yourself, and being proactive to get the best care when you do engage the system.
Having become so disillusioned with the medical system, I had drifted too far to the extreme in doing almost everything possible to avoid it. This part of the book has already led me to take a few actions in just the past few weeks.
I’ll briefly highlight and summarize a few key points from each section, including new actions I took after reading it, but realize I can’t do this information justice in a blog post. If you are serious about improving your healthspan, I highly recommend spending some time with each of these chapters.
Attia presents metabolic syndrome first, though it is the least serious of the horsemen with regards to being the primary cause of death. However, it is probably the most important to understand for several reasons.
- It is highly associated with all of the other four, to such a degree that it may be the leading risk factor for each.
- It is extremely prevalent in our society as a result of the Standard American Diet (SAD) and our lack of physical activity.
- It is almost entirely preventable with non-medical interventions, and unlike the others it is often reversible even in extreme cases.
Metabolic Syndrome is defined as meeting at least three of the followin 5 criteria:
- Hypertension (BP > 130/85)
- High triglycerides (>150 mg/dL)
- Low HDL cholesterol (<40 mg/dL males, <50 mg/dL females)
- Central adiposity (Waist circumference > 40 inches for males, or >35 inches for females)
- Elevated fasting glucose >110 mg/dL
Attia explains that metabolic syndrome is a “Disease of Civilization.” Type 2 diabetes which just a few decades ago was rare, now affects over 11% of the US population and 29% of adults over age 65 years of age. Fatty liver disease, formerly only seen in alcoholics, is now being observed as non-alcoholic fatty liver disease even in teens and occasionally adolescents.
In my work in a diabetic clinic and later in my outpatient physical therapy practice, I witnessed the massive impacts metabolic syndrome can have on quality of life first hand. In addition to being a risk factor for the other horsemen, it can cause anything from blindness to extremity amputations.
Because of how devastating metabolic syndrome can be, Attia advocates being much more aggressive with preventative measures, primarily dietary and exercise interventions to control blood glucose and thus insulin which drive the process.
The second horseman presented, heart disease, is actually the leading cause of death. Attia makes this bold statement about that fact. “Bluntly put: this should be the tenth leading cause of death, not the first.”
A couple of points caught my attention. Half of all major adverse cardiovascular events (heart attacks and strokes) occur before age 65. A fourth occur before age 54.
These events seem sudden, but the problem builds slowly. Attia advocates again for looking at risk over a longer timeframe and being more aggressive by intervening earlier in the process.
His first two non-negotiables to prevent heart disease are to stop smoking and control hypertension. Insulin control (see metabolic syndrome above) is also very important.
Heart disease is one area where he advocates for medical intervention as well, primarily with statins unless they are not tolerated.
A little over a year ago, my doctor found my cholesterol was high. I was reluctant to start any medicine and argued for the lowest dose statin. After reading this chapter, I scheduled my overdue annual appointment immediately.
In addition to follow up blood work to see how my current statins were working, I requested two additional blood tests Attia recommends. One was a measurement of apoB, which is a more relevant measure than the total quantity of cholesterol particles to assess risk.
I also asked to have my Lp(a) measured because my uncle died of a massive heart attack in his 30’s. Lp(a) is the most prevalent hereditary risk of heart disease and often associated with events like this.
Lp(a) often is not tested, because it is hereditary and there is little you can do to directly address it. However, you can, and Attia argues should, be more aggressive with other preventative measures if you are at higher risk of cardiovascular events due to this factor.
Attia’s take on cancer was depressing. He points out how little we still know about how cancer begins and why it spreads.
Aside from a few types of cancer including testicular cancer and some lymphomas, we’ve made little progress in the ten year survival rate for cancer. Worse, many of those years are lived with diminished quality of life due to the toxic nature of currently available treatments.
One thing we do know is there is a strong link with metabolic dysfunction. Being overweight trails only smoking as the leading risk factor for both cancer cases and deaths. This is another strong argument for taking early and aggressive measures to prevent metabolic dysfunction and not smoking.
The other thing we do know is that your odds of success with cancer treatments are much better the earlier you find and start treating them. So Attia argues that until we develop better treatments “early detection is our best hope for radically reducing cancer mortality.”
This is one of the more controversial parts of the book, because screening involves a tradeoff of costs:
- Direct financial costs of screening.
- False positive results that can lead to more tests, unnecessary and harmful treatments, and psychological distress.
Despite those costs, reading the chapter led me to take another action. Last year, my doctor advised I get a colonoscopy. She informed me the guidelines have been changed to start this screening procedure at age 45 instead of 50.
I agreed, scheduled….and then canceled the procedure…. twice. This year, I admitted what I did and asked her to reorder the colonoscopy, which I again scheduled. This time I am eagerly (sarcasm font) awaiting the procedure.
Similar to cancer, a lot of money and effort has poured into research of Alzheimer’s and other neurodegenerative diseases. Even worse than cancer, Attia points out that medicine 2.0 can not help “at all” once you receive these diagnoses.
However, unlike cancer, there is a lot of reasonably strong evidence for preventative measures we can take to avoid, or at least substantially delay the onset of, these diseases.
Preventative measures emphasize addressing:
- Metabolic issues, with exercise being the most powerful tool for preventing cognitive decline.
- Sleep issues.
- Hearing loss (likely because not hearing well causes people to pull back socially and cognitively, depriving the brain of inputs).
- Dental care (particularly flossing and gum care) which reduces systemic inflammation.
Four Different Diseases, Much Common Ground
As mentioned earlier, a key point is that there is a lot of overlap in our interventions to prevent all four horsemen. What is good for the heart, liver and pancreas is also good for the brain and reduces cancer risks.
Also to reiterate, the risk for heart disease, cancer, and neurodegenerative disease, and to a lesser degree metabolic dysfunction, are all low when young, and increase considerably with age. But the process occurs over years and even decades, so we need to view risk over a longer time frame and take action sooner….like today!
The final section of Outlive focuses on tactics, what actions you actually take to address the biggest risks that are outlined in the earlier chapters.
Interventions in Medicine 3.0 fall into five broad domains:
- Emotional Health
- Exogenous molecules (drugs, hormones, supplements)
Our current medical system focuses almost exclusively on #5 (along with surgical interventions). There is virtually zero financial incentive to do otherwise. Attia points out that in his medical training at some of the top programs in the nation, education on exercise, diet, and sleep were minimal to non-existant.
Attia dedicated chapters to the first four categories. I particularly appreciated his attempts to cut through the noise around diet and exercise and dive into the science.
The exercise section is the one I got the least personal value from, as this is the one thing I went into the book knowing the most about. Still I enjoyed reading how he presented the information and supported it with science.
I also appreciated the emphasis he puts on exercise, which he calls “the most powerful longevity drug.” He writes “if you adopt only one new set of habits based on reading this book, it must be in the realm of exercise.”
Attia reports that data shows 77% of Americans do not exercise regularly. If you are in that group, the simple action of going from zero to ninety minutes of exercise per week (i.e. taking three brisk 30 minute walks, or walking just 15 minutes per day) decreases your all risk mortality by 14%. More importantly, exercise likely improves healthspan even more than lifespan.
Similar to finance, and particularly investing, I believe many people don’t start regular exercise because they get trapped by the overwhelming amount of noise. When they do start, they tend to make things more complex than necessary, often leading to injury or non-compliance.
Attia proposes the idea of the “Centenarian Decathlon,” the 10 most important tasks you will want to be able to perform for the rest of your life. As you think about what it takes to perform them, you can then reverse engineer your training program.
The idea of decathletes in general is that they are not world class at any one thing, but they are solid in many domains. A similar approach to exercised is required to function at a high level as you age.
Attia breaks down exercise into three broad domains to address and explains the importance of each.
The first domain is cardiovascular fitness. While just starting to walk will improve your health immensely, Attia states that once you get that initial benefit, you need to be more aggressive to achieve further gains with your cardiovascular fitness. This is because some loss of cardiovascular fitness is inevitable with aging, so we want to start from as high of a baseline as possible.
VO2MAX (the measure of the maximum rate at which a person can utilize oxygen) is the gold standard for measuring cardiovascular fitness. A higher VO2MAX is the most powerful marker for longevity.
Training to optimize VO2MAX requires more intensity than a simple walking program. However, Attia empahsizes an approach starting with low intensity exercise, then more intense “Zone 2” training for months before even discussing training to specifically target VO2MAX.
This makes sense. It emphasizes making gradual lifestyle changes that are sustainable while preventing injury, allowing people to maintain their program.
Unfortunately, finding a physician to guide you through a similar progression is highly unlikely. Having insurance cover it is simply not going to happen in the United States, unless you’ve already had a cardiovascular event and are in rehabilitation.
This is where health and finance intersect. You may have to invest money as well as time to learn to exercise correctly. In my opinion, there is no better investment you can make. Cardiovascular fitness can be improved with training, regardless of how old you are.
Attia shares evidence in Outlive that muscle mass is almost as closely correlated with longevity as cardiorespiratory fitness. I love this quote from the book that is a perfect analogy for a retirement blog:
“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 we enjoy… Like investing, strength training is also cumulative, its benefits compounding. The more of a reserve you build up, early on, the better off you will be over the long term.”
I will add that just like with investing, the earlier you start the better. However, it is never too late to add muscle mass and to a lesser degree improve bone density.
It is even more important to gain proper instruction with strength training than cardiovascular exercise to prevent injury, particularly if you are starting to exercise later in life. Investing in your health can pay major dividends with improved quality of life as you age.
The third exercise domain covered is what Attia calls stability, though he admits that may not be the correct term. He defines stability as “the subconscious ability to harness, decelerate, or stop force.” He adds, “stability lets us create maximum force while minimizing risk to joints, soft tissues, and the spine.”
I appreciate the attention and focus Attia gives avoiding injury. I explained above that my frustration with our medical system is the primary reason I chose to retire from practicing physical therapy. The fact that so many people don’t know how to exercise and end up injured is a major reason why I was able to retire early.
If increasing cardiovascular fitness and strength are hard for most people to safely figure out on their own, then the topics covered in this chapter about movement patterns and quality are monumentally more so. I hope I’m clear that this is not an excuse not to start exercising. Instead it is encouragement to invest in learning how to exercise properly.
To use one more quote from the book: “All the aerobic fitness or strength in the world won’t help you if you get hurt and have to stop exercising for several months – or forever.” Amen.
In Outlive, Attia went on the offensive against the religious like fervor with which many people advocate for one diet or another. He emphasized that the science around nutrition is poor and conducting good studies is inherently challenging.
There are a few things we do know with near certainty.
- Dont’ eat too much or too little.
- Consume sufficient protein and essential fats.
- Obtain the vitamins and minerals you need.
- Avoid pathogens like E. Coli and toxins like mercury and lead.
It is also hard not to observe that the standard American diet (SAD) is highly linked to metabolic dysfunction, which in turn is a risk factor for the other diseases discussed above. That’s about all we know with near certainty.
So it is vital to experiment until you find a diet that restricts calories enough to maintain your metabolic health including blood sugar, lipids and body weight, while not compromising your intake of protein and other essential nutrients.
Outlive covers many potential ways to do this, but trying to do them justice is way beyond the scope of this blog post.
Many people neglect sleep, or even wear lack of sleep as a badge of honor. Attia points out that many doctors not only neglect this topic with patients, but traditionally wear it as a badge of honor themselves. Going 24 hours plus without sleep as a resident has long been a norm and a right of passage for physicians in training.
Sleep is essential for recovery of the body, and even more so for the brain. Most people need 7.5-8.5 hours per night, and sleep quality is as important as quantity.
Poor sleep is strongly linked with metabolic dysfunction, which at the risk of sounding like a broken record is associated with all of the other “horsemen.” Medications typically don’t work well to improve sleep, particularly with regards to sleep quality.
The book does go into depth on a number of strategies that have been shown to improve sleep, starting with making it a priority and setting aside enough time, creating the right environment (cool, dark, quiet), avoiding alcohol and screen time (particularly interactive things like social media and email) before bed… and again at the risk of sounding like a broken record developing a regular exercise program.
The final chapter of Outlive is quite different than all of the others, exploring mental health. In it, Attia writes vulnerably from the perspective of a patient rather than the physician. He shares his struggles with emotional health, and how only recently he has accepted the importance of this aspect of health on quality of life.
Changing our physical health can be hard, but it is hard to not notice issues are present. We get out of breath walking up stairs, our clothes no longer fit, we fall, etc. In contrast, Attia notes that it often isn’t easy to recognize emotional health issues in ourselves. Often behaviors that harm us were at some point in our lives adaptations that helped us survive, or even thrive.
Attia shares a statistic that shocked me. Suicide ranks as among the top ten causes of death across all age groups, from teens to our eighties.
He argues that far more people slowly descend into poor mental and emotional health. This has consequences ranging from engaging in reckless behaviors, becoming socially withdrawn, and not having the motivation to do other things required to take care of yourself.
The take home message from the chapter is captured in a question psychotherapist Esther Perel asked Attia directly: “Why would you want to live longer if you’re so unhappy?”
However, one quote can not do justice to this powerful chapter and all that it contains. This book is worth reading for it alone.
My one criticism of Outlive is that in covering so many topics in such depth it may make the content feel overwhelming for many people, particularly those coming at the topic with little medical and wellness literacy. I hope I’m not adding to that feeling with a book review that is coming in at over 4,000 words.
My goal with giving this topic this level of attention on a site typically focused on personal finance is the opposite. I hope to convey the message of how much control you have over your health and how important it is to take action.
Ideally, we could all have doctors who approached health like Attia and a medical system that incentivied that. That’s a long way off, if it will ever happen.
Don’t let perfect be the enemy of good. Recognize that we are all at risk for the “4 horsemen” and act accordingly. Realize that many of the interventions to address one aspect of health will positively impact others, starting the ball rolling in the right direction.
Start exercising, even if that means starting the habit of walking regularly. Learn more about metabolic health and track what you are eating. Pay attention to your sleep and the health of your relationships. None of these actions are expensive or require any expertise. All are great first steps to developing sustainable habits that will improve your life.
Pick up a copy of Outlive: The Science & Art of Longevity. Spend some time with it. The more you struggle with the content in a particular area, the more help you may need. That’s OK. Go find that help.
This blog writes a lot about investing. There is no better investment you can make than one in improving your health.
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[Chris Mamula used principles of traditional retirement planning, combined with creative lifestyle design, to retire from a career as a physical therapist at age 41. After poor experiences with the financial industry early in his professional life, he educated himself on investing and tax planning. After achieving financial independence, Chris began writing about wealth building, DIY investing, financial planning, early retirement, and lifestyle design at Can I Retire Yet? He is also the primary author of the book Choose FI: Your Blueprint to Financial Independence. Chris also does financial planning with individuals and couples at Abundo Wealth, a low-cost, advice-only financial planning firm with the mission of making quality financial advice available to populations for whom it was previously inaccessible. Chris has been featured on MarketWatch, Morningstar, U.S. News & World Report, and Business Insider. He has spoken at events including the Bogleheads and the American Institute of Certified Public Accountants annual conferences. Blog inquiries can be sent to firstname.lastname@example.org. Financial planning inquiries can be sent to email@example.com]
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