Peter Attia - Outlive Part II

Part III

Chapter 10: Thinking Tactically

• Civilization has led to an increase in certain diseases such as cancer, heart disease, diabetes and dementia, collectively known as "diseases of civilization".
• Despite this, civilization has also extended life spans and improved living standards.
• The environment has drastically changed over the last century or two, including food supply, eating habits, activity levels, and social networks.
• Conversely human genes have barely changed.
• A toxic environment has thus emerged, affecting what humans eat, how they move, how they sleep, and their emotional health.
• The genes no longer match the environment, necessitating cunning tactics to adapt and thrive.
• Medicine 3.0 involves five tactical domains to alter health: exercise, nutritional biochemistry, sleep, emotional health, and exogenous molecules.
• Exercise is the most potent of these, impacting both lifespan and healthspan.
• Exercise can be divided into aerobic efficiency, maximum aerobic output (VO2 max), strength, and stability components.
• Sleep has been underappreciated by Medicine 2.0 until recently. Emotional health is a fourth domain
• Exogenous molecules are drugs, supplements, and hormones ingested from outside the body.
• Effective tactics dig deeper than the obvious, and can change course as needed.
• Car accidents are used as an example: despite one person dying every twelve minutes, deaths could be prevented with proper tactics.
• Fatalities occur disproportionately at intersections, so tactics need to be developed, including special attention to the left side.
• Data and intuition are used to focus efforts, and feedback determines what is/isn't working.
• Nutrition and exercise are the most complex tactical domains.
• New patients are asked if they are over/undernourished, undermuscled, and metabolically healthy.
• There is a high overlap between overnourished people and those with poor metabolic health and those who are thin with metabolic problems.
• Poor metabolic health often accompanies being undermuscled.
• Tactical interventions are coordinated, and none of the domains are fully separate.
• Static and dynamic biomarkers and anthropometric measures are used in decision-making.
• Objectives and science underpin strategy.
• A framework is learned for movement, nutrition, sleep, and emotional health, rather than blindly following prescriptions.
• Changing habits and doing the work is essential.

Chapter 11: Exercise

• Exercise is the most powerful longevity drug.

• Even a minimal amount of exercise can lengthen life and delays chronic diseases.

• Exercise extends and improves healthspan, reverses physical/cognitive decline, although the emotional health benefits are harder to quantify.

• A little daily activity is far better than nothing; 90 minutes/week reduces death risk from all causes by 14%.

• Regular exercisers live as much as a decade longer than sedentary people.

• Medical schools teach little about exercise, and Medicine 2.0 advice is usually move more and sit less per government guidelines of 30 minutes of moderate intensity activity, 5x per week + 2 strength training days.

• Specific guidance is needed to achieve efficient and safe goals, especially exploring why exercise persuades changes.

• Data shows high aerobic fitness and strength associate with longer lifespan and healthspan.

• Key consideration is cardiorespiratory or aerobic fitness (efficient oxygen delivery to/extraction from muscles) for activities and physical stamina.

• Peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, serves a powerful longevity marker.

• VO2 max is the maximum rate of oxygen utilization.

• More oxygen use = higher VO2 max.

• The human body responds well to demands.

• Oxygen demand increase when jogging or running uphill at pace for fitter that consumes ATP quicker to run up hill fast

• VO2 max is typically expressed in terms of the volume of oxygen a person can use, per kilogram of body weight, per minute.

• Average 45-year-old man will have VO2 max around 40 ml/kg/min vs elite endurance athlete likely score in high 60s and above, vs an unfit person in their 30s or 40s, might score only in the high 20s on VO2 max test.

• Higher VO2 max = more oxygen consumption to make ATP = run/ride faster.

• A 2018 JAMA study found higher VO2 max associated with lower mortality across the board.

• A person of below-average VO2 max for their age/sex has double the risk of all-cause mortality compared to someone in the top quartile (75th-97.6th percentiles).

• Poor cardiorespiratory fitness carries a greater relative death risk than smoking.

• Someone in the bottom quartile of VO2 max for their age group (least fit 25%) is ~4x likelier to die as someone in the top quartile or 5x more than has elite-level (top 2.3%) VO2 max.

• Improving from bottom-25% to below-average cuts death risk nearly in half.

• A 2022 Journal of American College of Cardiology study of 750,000 US veterans ages 30-95 found nearly identical result: least-fit 20% has 4.09x greater death risk than someone in top 2% of their age and sex category.

• Even moderate fitness (40-60th percentile) is still more than double the risk of all-cause mortality than the fittest group; being unfit carries a greater risk than cardiac risk factors.

• Multiple factors increase confidence in causality, including magnitude of effect size, consistent/reproducible data across many studies/disparate populations, and the dose-dependent response (fitter you are, longer you live).

• Cardiorespiratory fitness inversely associated with long-term mortality with no observed upper limit of benefit, and extremely high aerobic fitness was associated with the greatest survival.

• High VO2 max will offset high blood pressure or smoking habit may not be true as these hazard ratios suggest.

• VO2 max can be increased through training.

• Muscle may be almost as powerfully correlated with living longer than cardiorespiratory fitness.

• 10 year study of ~4,500 subjects ages 50+ found low muscle mass associated with 40-50% greater mortality risk than controls over the study period.

• It's not mere mass, but muscles' strength/ability to generate force matters.

• Low muscle strength associated with double the risk of death vs metabolic syndrome associated with low muscle mass and/or low muscle strength associates a 3-3.33x greater all-cause mortality risk.

• Even strength may trump cardiorespiratory fitness.

• Study of ~1,500 men over 40 with hypertension for ~18 years found all-cause mortality risk was almost 48% lower if someone were in top third for strength versus the bottom third. It's the same story as VO2 max.

• No other intervention/drug can rival exercise's benefit magnitude; exercise effective against aging diseases-the Horsemen-that has often been compared to medicine and more effective at treating mortality from coronary heart disease, prediabetes/diabetes, and stroke.

• Exercise strengthens heart/helps systems maintain, improves mitochondria health, improves ability to metabolize glucose/fat, consumes energy, and helps human machine perform far better/longer.

• Prompts productions of cytokines (signals to other body part) which strengthen immune system plus BDNF (improves function/health of hippocampus/plays essential memory role)/keeps brain vasculature-healthy may help preserve volume.

• Exercise on lifespan is irrefutable; more effective at preserving healthspan.

• Even if the exercise shortened one's life by a year it would still worthwhile for the healthspan benefits including middleage.

• One of aging's hallmarks is eroding physical capacity: cardiorespiratory declines because of lower cardiac output due to reduced maximum heart rate/lost strength; bones grow fragile and joint stiffen, causing a balance loss.

• After 80, the average person will have lost 8 kgs of muscle from their peak. maintaining levels can higher activity lose much less, at like 3 kgs on average.

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Centenarian Decathlon

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• Hike 1.5 miles on a hilly trail.
• Get up off the floor under your own power; using a maximum of one arm for support.
• Pick up a young child from the floor.
• Carry two five-pound bags of groceries for five blocks.
• Lift a twenty-pound suitcase into the overhead compartment of a plane.
• Balance on one leg for thirty seconds, eyes open.
  • Bonus points eyes closed for fifteen seconds

7. Sex
8. climb for flights of stairs in 3 minutes

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Chapter 12: Training 101

Prepare for Centenarian Decathlon

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Civilization impacts human health, causing a mismatch between genes and the modern environment. Medicine 3.0 uses tactics like exercise, nutrition, sleep, emotional health, and exogenous molecules to improve health. Exercise is the most effective.