Outlive, p.1
Outlive, page 1
The information and advice presented in this book are not meant to substitute for the advice of your family’s physician or other trained healthcare professionals. You are advised to consult with healthcare professionals with regard to all matters pertaining to you and your family’s health and well-being.
Copyright © 2023 by Peter Attia
All rights reserved.
Published in the United States by Harmony Books, an imprint of Random House, a division of Penguin Random House LLC, New York.
HarmonyBooks.com | RandomHouseBooks.com
Harmony Books is a registered trademark, and the Circle colophon is a trademark of Penguin Random House LLC.
Centenarian Decathlon is a trademark of PA IA, LLC.
Marginal Decade is a trademark of PA IP, LLC.
Library of Congress Cataloging-in-Publication Data has been applied for.
ISBN 9780593236598
Ebook ISBN 9780593236604
Book design by Andrea Lau
Cover design by Rodrigo Coral Studio
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AUTHOR’S NOTE
Writing about science and medicine for the public requires striking a balance between brevity and nuance, rigor and readability. I’ve done my best to find the sweet spot on that continuum, getting the substance right while keeping this book accessible to the lay reader. You’ll be the judge of whether or not I hit the target.
CONTENTS
Introduction
Part I
CHAPTER 1: The Long Game: From Fast Death to Slow Death
CHAPTER 2: Medicine 3.0: Rethinking Medicine for the Age of Chronic Disease
CHAPTER 3: Objective, Strategy, Tactics: A Road Map for Reading This Book
Part II
CHAPTER 4: Centenarians: The Older You Get, the Healthier You Have Been
CHAPTER 5: Eat Less, Live Longer: The Science of Hunger and Health
CHAPTER 6: The Crisis of Abundance: Can Our Ancient Genes Cope with Our Modern Diet?
CHAPTER 7: The Ticker: Confronting—and Preventing—Heart Disease, the Deadliest Killer on the Planet
CHAPTER 8: The Runaway Cell: New Ways to Address the Killer That Is Cancer
CHAPTER 9: Chasing Memory: Understanding Alzheimer’s Disease and Other Neurodegenerative Diseases
Part III
CHAPTER 10: Thinking Tactically: Building a Framework of Principles That Work for You
CHAPTER 11: Exercise: The Most Powerful Longevity Drug
CHAPTER 12: Training 101: How to Prepare for the Centenarian Decathlon
CHAPTER 13: The Gospel of Stability: Relearning How to Move to Prevent Injury
CHAPTER 14: Nutrition 3.0: You Say Potato, I Say “Nutritional Biochemistry”
CHAPTER 15: Putting Nutritional Biochemistry into Practice: How to Find the Right Eating Pattern for You
CHAPTER 16: The Awakening: How to Learn to Love Sleep, the Best Medicine for Your Brain
CHAPTER 17: Work in Progress: The High Price of Ignoring Emotional Health
Epilogue
Acknowledgments
Notes
References
Index
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INTRODUCTION
In the dream, I’m trying to catch the falling eggs.
I’m standing on a sidewalk in a big, dirty city that looks a lot like Baltimore, holding a padded basket and looking up. Every few seconds, I spot an egg whizzing down at me from above, and I run to try to catch it in the basket.
They’re coming at me fast, and I’m doing my best to catch them, running all over the place with my basket outstretched like an outfielder’s glove. But I can’t catch them all. Some of them—many of them—smack on the ground, splattering yellow yolk all over my shoes and medical scrubs. I’m desperate for this to stop.
Where are the eggs coming from? There must be a guy up there on top of the building, or on a balcony, just casually tossing them over the rail. But I can’t see him, and I’m so busy I barely even have time to think about him. I’m just running around trying to catch as many eggs as possible. And I’m failing miserably. Emotion wells up in my body as I realize that no matter how hard I try, I’ll never be able to catch all the eggs. I feel overwhelmed, and helpless.
And then I wake up, another chance at precious sleep ruined.
We forget nearly all our dreams, but two decades later, I can’t seem to get this one out of my head. It invaded my nights many times when I was a surgical resident at Johns Hopkins Hospital, in training to become a cancer surgeon. It was one of the best periods of my life, even if at times I felt like I was going crazy. It wasn’t uncommon for my colleagues and me to work for twenty-four hours straight. I craved sleep. The dream kept ruining it.
The attending surgeons at Hopkins specialized in serious cases like pancreatic cancer, which meant that very often we were the only people standing between the patient and death. Pancreatic cancer grows silently, without symptoms, and by the time it is discovered, it is often quite advanced. Surgery was an option for only about 20 to 30 percent of patients. We were their last hope.
Our weapon of choice was something called the Whipple Procedure, which involved removing the head of the patient’s pancreas and the upper part of the small intestine, called the duodenum. It’s a difficult, dangerous operation, and in the early days it was almost always fatal. Yet still surgeons attempted it; that’s how desperate pancreatic cancer is. By the time I was in training, more than 99 percent of patients survived for at least thirty days after this surgery. We had gotten pretty good at catching the eggs.
At that point in my life, I was determined to become the best cancer surgeon that I could possibly be. I had worked really hard to get where I was; most of my high school teachers, and even my parents, had not expected me to make it to college, much less graduate from Stanford Medical School. But more and more, I found myself torn. On the one hand, I loved the complexity of these surgeries, and I felt elated every time we finished a successful procedure. We had removed the tumor—we had caught the egg, or so we thought.
On the other hand, I was beginning to wonder how “success” was defined. The reality was that nearly all these patients would still die within a few years. The egg would inevitably hit the ground. What were we really accomplishing?
When I finally recognized the futility of this, I grew so frustrated that I quit medicine for an entirely different career. But then a confluence of events occurred that ended up radically changing the way I thought about health and disease. I made my way back into the medical profession with a fresh approach, and new hope.
The reason why goes back to my dream about the falling eggs. In short, it had finally dawned on me that the only way to solve the problem was not to get better at catching the eggs. Instead, we needed to try to stop the guy who was throwing them. We had to figure out how to get to the top of the building, find the guy, and take him out.
I’d have relished that job in real life; as a young boxer, I had a pretty mean left hook. But medicine is obviously a bit more complicated. Ultimately, I realized that we needed to approach the situation—the falling eggs—in an entirely different way, with a different mindset, and using a different set of tools.
That, very briefly, is what this book is about.
PART I
CHAPTER 1
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 from East Palo Alto, a 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 by 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, okay?”
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 surgical 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, poor, Black, 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 ask me that at a party, 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 been hopelessly tainted by 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 myself have 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 elders’ 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: 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. 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.
* * *
—
One of the main obstacles in anyone’s quest for longevity is the fact that the skills that my colleagues and I acquired during our medical training have proved to be far more effective against fast death than slow death. We learned to fix broken bones, wipe out infections with powerful antibiotics, support and even replace damaged organs, and decompress serious spine or brain injuries. We had an amazing ability to save lives and restore full function to broken bodies, even reviving patients who were nearly dead. But we were markedly less successful at helping our patients with chronic conditions, such as cancer, cardiovascular disease, or neurological disease, evade slow death. We could relieve their symptoms, and often delay the end slightly, but it didn’t seem as if we could reset the clock the way we could with acute problems. We had become better at catching the eggs, but we had little ability to stop them from falling off the building in the first place.
The problem was that we approached both sets of patients—trauma victims and chronic disease sufferers—with the same basic script. Our job was to stop the patient from dying, no matter what. I remember one case in particular, a fourteen-year-old boy who was brought into our ER one night, barely alive. He had been a passenger in a Honda that was T-boned by a driver who ran a red light at murderous speed. His vital signs were weak and his pupils were fixed and dilated, suggesting severe head trauma. He was close to death. As trauma chief, I immediately ran a code to try to revive him, but just as with the woman in the Stanford ER, nothing worked. My colleagues wanted me to call it, yet I stubbornly refused to declare him dead. Instead, I kept coding him, pouring bag after bag of blood and epinephrine into his lifeless body, because I couldn’t accept the fact that an innocent young boy’s life could end like this. Afterwards, I sobbed in the stairwell, wishing I could have saved him. But by the time he got to me, his fate was sealed.
