# Outlive  ## Metadata - Author: [[Peter Attia, MD & Bill Gifford]] - Full Title: Outlive - Category: #books ## Highlights - Instead of a lousy Marginal Decade, we get to enjoy what feels more like a “Bonus Decade - Take another look at the Sun Tzu quote that opens this chapter: “Tactics without strategy is the noise before defeat.” - In this book, we will apply this three-part approach to longevity: objective → strategy → tactics. - So your choices are (a) surrender to the decline, or (b) come up with a plan, starting now. - break down this thing called exercise into its most important components: strength, stability, aerobic efficiency, and peak aerobic capacity - not too much, not too little, but just right - For MR to work properly, certain conditions must be met. First, the genetic variant(s) being considered must associate with the risk factor of interest (this is called the relevance assumption); second, the genetic variant does not share a common cause with the outcome (this is called the independence assumption); and third, the genetic variant does not affect the outcome except through the risk factor (this is called the exclusion restriction assumption) - As Perls and his colleagues put it in a paper title, “The Older You Get, the Healthier You Have Been.” - compression of morbidity, and it basically means shrinking or shortening the period of decline at the end of life and lengthening the period of healthy life, or healthspan. - I think that the centenarians’ secret comes down to one word: resilience - a reasonable person could conclude that there was something good about turning down mTOR, at least temporarily—and that rapamycin may have potential as a longevity-enhancing drug. - obesity is merely one symptom of an underlying metabolic derangement, such as hyperinsulinemia, that also happens to cause us to gain weight. But not everyone who is obese is metabolically unhealthy, and not everyone who is metabolically unhealthy is obese. There’s more to metabolic health than meets the eye. - our metabolism, as it has evolved over millennia, is not equipped to cope with our ultramodern diet, which has appeared only within the last century - takes a much longer view—and more importantly seeks to identify and eliminate the primary causative agent in the disease process: apoB. This changes our approach to treatment completely. For example, a forty-five-year-old with elevated apoB has a lower ten-year risk than a seventy-five-year-old with low apoB. - The sooner you cut the head off the snake, the lower the risk that it will bite you. - But it’s difficult to disentangle cognitive reserve from other factors, such as socioeconomic status and education, which are in turn linked to better metabolic health and other factors (also known as “healthy user bias”). Thus, the evidence on whether cognitive reserve can be “trained” or used as a preventive strategy, such as by learning to play a musical instrument or other forms of “brain training,” is highly conflicted and not conclusive—although neither of these can hurt, so why not? - The dementia symptoms that we see result from a gradual reduction in blood flow, which eventually creates what he calls a “neuronal energy crisis,” which in turn triggers a cascade of unfortunate events that harms the neurons and ultimately causes neurodegeneration. The amyloid plaques and tangles come later, as a consequence rather than a cause. “We believed, and still do, that amyloid-beta is an important pathological product of neurodegeneration,” de la Torre wrote recently, “…[but] it is not the cause of Alzheimer’s disease.” - All this suggests that metabolic and vascular causes of dementia may be somewhat overlapping, just as patients with insulin resistance are also prone to vascular disease. And it tells us that with high-risk patients like Stephanie, we need to pay special attention to their metabolic health. - Our genes no longer match our environment. Thus, we must be cunning in our tactics if we are to adapt and thrive in this new and hazardous world. - At busy intersections, it makes sense to look left, then right, then left again, in case we missed something the first time. - We use data and intuition to figure out where to focus our efforts, and feedback to determine what is and isn’t working. And seemingly small tweaks can yield a significant advantage if compounded over time. - I never won a fight in the ring; I always won in preparation. —Muhammad Ali - Our human body has an amazing ability to respond to the demands placed on it. - But I can say with a very high degree of certainty that having a higher VO2 max is better for your overall health and longevity than having a lower VO2 max. - numerous randomized clinical trials, exercise-based interventions performed as well as or better than multiple classes of pharmaceutical drugs at reducing mortality from coronary heart disease,[*5] prediabetes or diabetes, and stroke - I suspect it’s probably both ways: people are less active because they are weaker, and they are weaker because they are less active. - There are dozens of studies showing that strength training programs can significantly improve the mobility and physical function of subjects who are obese, or recovering from cancer treatment, even those who are already elderly and frail. - Religion is a culture of faith; science is a culture of doubt. —Richard Feynman I - through the lens of efficacy versus effectiveness. Efficacy tests how well the intervention works under perfect conditions and adherence (i.e., if one does everything exactly as prescribed). Effectiveness tests how well the intervention works under real-world conditions, in real people - perhaps the most vexing issue with diet and nutrition studies is the degree of variation between individuals that is found but often obscured - recent study in JAMA, using the tool of Mendelian randomization we discussed back in chapter 3, suggests that this might not be true. This study found that once you remove the effects of other factors that may accompany moderate drinking—such as lower BMI, affluence, and not smoking—any observed benefit of alcohol consumption completely disappears. The authors concluded that there is no dose of alcohol that is “healthy.” - we might conclude that eating more calories causes all mice to live longer, which we are pretty certain is not the case. This experiment demonstrates how easy it is to be misled by epidemiology. One reason is because general health is a massive confounder in these kinds of studies - another problem in the world of nutrition: too many people are majoring in the minor and minoring in the major, focusing too much attention on small questions while all but ignoring the bigger issues. Small variations in what we eat probably matter a lot less than most people assume - if your diet is high quality to begin with, and you are metabolically healthy, then only a slight degree of caloric restriction—or simply not eating to excess—can still be beneficial. - The advantage of DR is that it is highly individualized; you can impose varying degrees of restriction, depending on your needs. - Steve Rosenberg used to say when a patient’s cancer progressed despite treatment: The patient has not failed the treatment; the treatment has failed the patient. - most people can’t safely lose muscle mass, so fasting is a tool that we can only really use in extremis, when there are no other viable options. - explored the impact of what we eat—and sometimes what we do not eat—on our health, and the importance of moving our thinking toward a Nutrition 3.0 mindset, based on feedback and data rather than labels and trends and ideology. - the best nutrition plan is the one that we can sustain - Stop overthinking nutrition so much. Put the book down. Go outside and exercise. - fixing their sleep issues makes our other tactics more effective. - Good sleep is like a performance-enhancing drug. - There is still no pharmacological magic bullet for sleep - The first requirement for good sleep is darkness - try to keep your bedroom cool—around sixty-five degrees Fahrenheit seems to be optimal - Everyone differs in their caffeine tolerance - This concept of sleep pressure, our need or desire for sleep, is key to many of our sleep tactics. We want to cultivate sleep pressure, but in the right amounts, at the right times - Another way to help cultivate sleep pressure is via exercise - It is also important to mentally prepare ourselves for sleeping. For me, this means avoiding anything that might create stress or anxiety, such as reading work emails or especially checking the news - a good night of sleep may depend in part on a good day of wakefulness: one that includes exercise, some outdoor time, sensible eating - Tags: [[blue]] - The substance-abuse crisis has created a longevity crisis, because it is really a mental health crisis in disguise. - Tags: [[purple]] - Trauma generally falls into five categories: (1) abuse (physical or sexual, but also emotional or spiritual); (2) neglect; (3) abandonment; (4) enmeshment (the blurring of boundaries between adults and children); and (5) witnessing tragic events. - The problems begin when these adaptive children grow up to become maladaptive, dysfunctional adults - This dysfunction is represented by the four branches of the trauma tree: (1) addiction, not only to vices such as drugs, alcohol, and gambling, but also to socially acceptable things such as work, exercise, and perfectionism (check); (2) codependency, or excessive psychological reliance on another person; (3) habituated survival strategies, such as a propensity to anger and rage (check); (4) attachment disorders, difficulty forming and maintaining connections or meaningful relationships with others (check). - Medicine 3.0 places a far greater emphasis on prevention than treatment. - Medicine 3.0 considers the patient as a unique individual. - In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing. - One reason this approach has proved less effective in the psychological realm is that mental health and emotional health are not the same thing - Taking care of our emotional health requires a paradigm shift similar to the shift from Medicine 2.0 to Medicine 3.0. It’s about long-term prevention, just like our approach to preventing cardiovascular disease. We have to be able to recognize potential problems early and be willing to put in hard work to address these problems over a long period of time. And our approach must be tailored to each individual, with their unique history and set of issues. - Tags: [[pink]] - Addressing emotional health takes just as much constant effort and daily practice as maintaining other aspects of our physical health by creating an exercise routine, following a nutritional program, adhering to sleep rituals, and so on - this observation by Jacob Riis, the great Danish American journalist and social reformer: “When nothing seems to help, I go back and look at a stonecutter hammering away at his rock perhaps a hundred times without as much as a crack showing in it. Yet at the hundred-and-first blow it will split in two, and I know it was not the last blow that did it, but all that had gone before.” - Many behaviors expand this window: exercise, sound sleep, good nutrition, time with my family, medications such as antidepressants or mood stabilizers, deep social connections, spending time in nature, and recreational activities that do not emphasize self-judgment. - DBT consists of four pillars joined by one overarching theme. The overarching theme is mindfulness, which gives you the ability to work through the other four: emotional regulation (getting control over our emotions), distress tolerance (our ability to handle emotional stressors), interpersonal effectiveness (how well we make our needs and feelings known to others), and self-management (taking care of ourselves, beginning with basic tasks like getting up in time to go to work or school). - dialectical behavior therapy, or DBT, developed in the 1990s by Marsha Linehan. - Tags: [[pink]] - What I eventually realized, after this long and very painful journey, is that longevity is meaningless if your life sucks. Or if your relationships suck. - Tags: [[purple]] - “I think people get old when they stop thinking about the future,” Ric told me. “If you want to find someone’s true age, listen to them. If they talk about the past and they talk about all the things that happened that they did, they’ve gotten old. If they think about their dreams, their aspirations, what they’re still looking forward to—they’re young.” - Tags: [[purple]]