Outlive: The Science and Art of Longevity

Attia explains his interest in longevity arose through his experiences watching people die both fast and slow deaths in medical school and while he was a surgical resident at Johns Hopkins Hospital. Fast deaths are often the result of infectious diseases, accidents (e.g., speeding cars), and injuries (e.g., gunshot and knife wounds). Humans primarily died from fast deaths until the early 1900s. Slow deaths from “chronic diseases of aging” (10) have since overtaken fast deaths.

Attia calls these “chronic diseases of aging” the Four Horsemen. The Four Horsemen are metabolic dysfunction like type 2 diabetes (Chapter 6), heart disease (Chapter 7), cancer (Chapter 8), and neurogenerative diseases like Alzheimer’s (Chapter 9). Slow deaths might seem sudden, but they are the result of “slow-growing, long-undetected” (9) issues within the human body, such as tumors.

Attia underscores that modern medicine, which focuses on preventing death, is ill-equipped to help with longevity. Through Outlive, Attia hopes to provide people with a mindset change and toolkit that will help us delay or prevent the Four Horsemen “so that we can live longer without disease, rather than lingering with disease” (14). In sum, Attia believes we need to alter our approach to modern medicine. Rather than trying to catch the falling eggs (going back to his dream in the Introduction), we need to get to the rooftop and prevent the eggs from falling in the first place.

In Chapter 2, Attia focuses on how understanding risk is a huge “blind spot” in modern medicine. He reached this conclusion after he quit his residency at Johns Hopkins Hospital, where he had grown disillusioned with modern medicine, and worked in credit risk at McKinsey & Company during the runup to the global financial crisis. At McKinsey, Attia found that “the study of credit risk is a science, albeit an imperfect one” (23). He believes that medical professionals, in contrast, approach risk through an emotional rather than analytical lens. They often fail to act early enough as a result.

Attia turns to describing the three eras of medicine (See: Background). The first era, which Attia calls Medicine 1.0, begins with Hippocrates and lasted until the late 1800s. Medicine 1.0 represents pre-modern medicine. New technologies and a new way of thinking which focused on experimentation and hypothesis-testing paved the way for Medicine 2.0. Medicine 2.0 is the defining hallmark of modern society. The treatment of disease has been its focus. Infectious diseases have been almost eradicated and human life expectancy has nearly doubled. However, Medicine 2.0 has been less successful at eradicating the Four Horsemen because it treats the conditions of these diseases at the wrong end of time.

Attia believes we need a new way of thinking about chronic diseases and their treatment and healthspan. He proposes Medicine 3.0. Medicine 3.0 focuses on four parts: prevention over treatment; the individual patient’s unique symptoms, experiences, and risk factors; the importance of understanding risk; and maximizing both healthspan and lifespan. The patient also plays a much more active role in Medicine 3.0: They are the captain of the ship rather than just a passenger. 

In this chapter, Attia introduces the concept of the “Marginal Decade.” The marginal decade is when we live longer because of Medicine 2.0 but with compromised healthspans. Attia believes there is another option. By planning for our later years, we can “live longer, and we can live better for longer” (40). We can achieve “Bonus Decades” where we continue to thrive even in our later years.

To achieve longevity, Attia applies a three-part approach. The first part is our objective. The overall objective is that we maintain quality of life in our later years, delaying death and pain. Each person defines their own quality of life.

The second part is strategy. Strategy needs to account for both lifespan and healthspan, which are intertwined. Improving one improves the other. Regarding healthspan, strategies need to minimize cognitive decline, physical decline, and emotional decline, which represent the three major vectors of deterioration. Strategies must be based on evidence. While randomized clinical trials are the foundation of Medicine 2.0, their short time frame makes them ill-equipped to help people achieve longevity. Instead, Attia advocates for using five different types of data: studies of centenarians, or people who have lived to age one hundred and older; studies that use animal models, such as mice, to test lifespan- or healthspan-altering tactics; human studies that focus on the origins, progression, and treatment of the Horsemen diseases; studies that examine the physical, emotional, and molecular changes associated with aging in humans and animals; and clinical trials which help identify causal relationships between modified behaviors and outcomes.

The third part is tactics. Medicine 2.0 focuses on two tactics: procedures and medications. In contrast, Medicine 3.0 relies on five domains: exercise (Chapters 11-13); nutrition (Chapters 14 and 15); sleep (Chapter 16); emotional health (Chapter 17); and exogenous molecules such as supplements, hormones, and drugs (discussed throughout the book). While we must “eat, breathe, and sleep” (47) our tactics within these five domains, Attia believes exercise is “the most potent longevity ‘drug’ in our arsenal, in terms of lifespan and healthspan” (48).