Outlive: The Science and Art of Longevity

In this chapter, Attia underscores how exercise is the most powerful tool for extending both lifespan and healthspan. Despite this, over three-quarters of Americans do not exercise. Attia emphasizes that now is the time to change this. There are health benefits to adding even just a small amount of exercise to one’s daily routine.

Attia turns to describing “why exercise is so important” (219). He begins with cardiorespiratory or aerobic fitness, which refers to the capacity of the body to deliver oxygen to muscles for energy production during fitness activities. VO₂ max is the number which describes a person’s cardiovascular fitness (or the maximum rate of oxygen consumption) and “represents the single most powerful marker for longevity” (220). VO₂ max is measured in milliliters of oxygen consumed per minute per kilogram of body weight (ml/kg/min). A person has a higher VO₂ number if they can utilize higher oxygen levels, meaning they can also make more adenosine triphosphate (ATP), which is the chemical fuel that fuels all living cells. VO₂ max is correlated with longevity.

Attia next examines muscle strength, or the ability of muscles to generate force. A decade-long study found that individuals with lower muscle strength had greater mortality rates than those with higher muscle strength. Muscle strength is thus correlated with longevity, which is why Attia emphasizes the importance of strength training (Chapter 12).

Attia ends by encouraging readers to train for their own Centenarian Decathlon, or their physical aspirations for their later years. Doing so helps change mindsets that we will be weak and incapacitated in our later decades. However, it involves hard work, preparation, and training.

Attia begins this chapter by noting that there are three dimensions of exercise to optimize to maintain health and strength and avoid injury in our later years: aerobic efficiency and endurance (zone 2 training and VO₂ max), strength, and stability. He discusses the first two in Chapter 12 and the final one in Chapter 13.

Attia turns first to aerobic training or zone 2 training, which is an activity between an easy and moderate pace. Zone 2 training is important for two reasons. The first is because it increases mitochondrial quantity and function. A significant sign of aging is the decline in the quantity and quality of mitochondria, which is troublesome since mitochondria acts as a “powerful mediator of metabolic health and glucose homeostasis” (242). Mitochondria convert fatty acids and glucose to energy (which is why they are known as the powerhouse of cells). If our metabolic health is in check, we can use both types of fuels (known as metabolic flexibility). If we have metabolic dysfunction, then often we can only use glucose as fuel. Mitochondria, thus, helps keep fat accumulation and blood glucose levels in check. For this reason, zone 2 training serves as an effective management plan for type 1 and type 2 diabetes.

The second reason is that it increases endurance. Having a strong endurance base allows people to do most types of physical activity, from walking to riding a bike to playing with kids or grandkids. Mitochondria helps us maintain maximum effort during endurance training, since it removes lactate (if you feel the burn in your muscles, then you are exercising too hard and no longer in zone 2). High resting lactate levels point to mitochondria functioning sub-optimally. Attia underscores that “healthy mitochondria are key to both athletic performance and metabolic health” (238).

Attia next examines VO₂ max, which is a “higher level of intensity—a hard, minutes-long effort, but still well short of an all-out sprint” (244). People need to train the VO₂ zone specifically. Attia believes everyone should know their VO₂ max number since it is a good proxy for our physical capability. VO₂ max declines sharply with age, which represents a profound decrease in our physical capabilities.

Attia then focuses on strength training, noting, “we lose muscle strength about two to three times more quickly than we lose muscle mass. And we lose power (strength x speed) two to three times faster than we lose strength” (253). Inactivity is dangerous because it takes less time to lose muscle mass and strength compared to gaining both. Bone density also declines with age, which might result in osteopenia or osteoporosis. Mortality rates from hip or femur fractures due to low bone density are staggering starting around the age of 65 years old. Starting strength training at a younger age helps people build up a reserve of muscle mass, strength, and bone density for their later years. Attia focuses his strength training on grip strength, concentric (shortening) and eccentric (lengthening) movements, pulling motions, and hip-hinging movements.

In Chapter 13, Attia argues that people stop exercising later in life due to injury, which, in turn, continues their physical, emotional, and metabolic health declines. Chronic pain is surprisingly widespread. The Center for Disease Control (CDC) found that over 25% of Americans who are at least 45 years of age experience chronic pain, with between 10-12% saying this pain limits their physical activity. While aerobic fitness and strength training are important, they will not help someone with an injury. Attia’s goal in this chapter is to help readers exercise without injury. Stability training, or conducting strength exercises while on an unstable surface to build a solid foundation of underlying stabilizer (e.g., gluteus maximum and abdominals) and trunk (e.g., muscles that move the vertebral column) muscles, is how people prevent injury.

Attia first explores the concept of dynamic neuromuscular stabilization (DNS), which is our motor control (e.g., human gait, movement, and posture). Young children establish DNS through the series of movements they undergo while learning to walk. Unfortunately, our modern environment, specifically our sedentary lifestyle, erases our ability to perform these natural movements. For example, most adults cannot squat properly. People are using DNS today to help “retrain our bodies—and our brains—in those patterns of perfect movement that we learned as little kids” (271).

Attia turns to exploring stability training’s basic principles. At his practice, his staff does not encourage strength training until patients master their stability. They worry people will injure themselves if they do not have a solid foundation. The most basic level of stability training is breathing. Poor breath control negatively impacts motor control, increasing our susceptibility to injury. There are three types of poor breath control, each of which comes with injury risks: “Mr. Stay Put” (chest breather, which is associated with lower back pain and calf and hip tightness), “Sad Guy” (compressed breather), and “Yogini” (uncontrolled breathing which makes them susceptible to joint injury). Breath training helps to correct poor breath control, which also strengthens intra-abdominal pressure (IAP), or the steady pressure found within the abdominal cavity. IAP stabilizes the spine.

Attia also discusses moves and drills to help strengthen the feet (including toe strength), the spine, shoulders, hands (including finger strength). While these examples represent foundational principles of stability work, they are far from easy. Attia notes that at his practice they “don’t allow our patients to work out with heavy loads until they work on these basic principles for at least six months” (283).

Trainers can help people learn these basic principles and encourage motivation and excitement around stability training. However, Attia and his staff also discourage their patients from becoming overly reliant on trainers. They want their patients to do the principles on their own to learn their ideal movement patterns.