kortina.nyc / notes
21 Apr 2024 | by kortina

Attia // Outlive: The Science and Art of Longevity

I heard an interview with Peter Attia on a podcast this past fall, queued up his book on Libby, and it finally came around: Outlive: The Science and Art of Longevity.

He’s much more of a fan of pharmaceuticals than I am, but I nonetheless appreciated all the heterodox thinking in this book.

Notes and quotes…

Cholesterol is not a nutrient of concern (according to Dietary Guidelines Advisory Committee 2015) when it comes to diet:

1298 Even Ancel Keys, the famed nutrition scientist who was one of the founding fathers of the notion that saturated fat causes heart disease, knew this was nonsense. The problem he recognized was that much of the basic research into cholesterol and atherosclerosis had been conducted in rabbits, which have a unique ability to absorb cholesterol into their blood from their food and form atherosclerotic plaques from it; the mistake was to assume that humans also absorb dietary cholesterol as readily. “There’s no connection whatsoever between cholesterol in food and cholesterol in blood,” Keys said in a 1997 interview. “None. And we’ve known that all along. Cholesterol in the diet doesn’t matter at all unless you happen to be a chicken or a rabbit.”

It took nearly two more decades before the advisory committee responsible for the US government dietary guidelines finally conceded (in 2015) that “cholesterol is not a nutrient of concern for overconsumption.” Glad we settled that.

I love this idea of the centenarian decathlon (and the related idea of being an “athlete of life”) – the idea that if you want to be able to do some subset of activities like these when you are 100 years old, you need to be anticipating your loss in things like your decreases in muscle mass and training beyond the ability to do them tody:

Notes and quotes…

Shocking: 77% of the US adult population does not exercise regularly!

2296 More than any other tactical domain we discuss in this book, exercise has the greatest power to determine how you will live out the rest of your life. There are reams of data supporting the notion that even a fairly minimal amount of exercise can lengthen your life by several years. It delays the onset of chronic diseases, pretty much across the board, but it is also amazingly effective at extending and improving healthspan. Not only does it reverse physical decline, which I suppose is somewhat obvious, but it can slow or reverse cognitive decline as well. (It also has benefits in terms of emotional health, although those are harder to quantify.)

So if you adopt only one new set of habits based on reading this book, it must be in the realm of exercise. If you currently exercise, you will likely want to rethink and modify your program. And if exercise is not a part of your life at the moment, you are not alone—77 percent of the US population is like you. Now is the time to change that. Right now. Even a little bit of daily activity is much better than nothing. Going from zero weekly exercise to just ninety minutes per week can reduce your risk of dying from all causes by 14 percent. It’s very hard to find a drug that can do that.

Various forms of poor breathing:

2942 Beth identifies three types of breathing styles and associated phenotypes, which she jokingly calls “Mr. Stay Puft,” the “Sad Guy,” and the “Yogini”—each corresponding to a different set of stability strategies:

Mr. Stay Puft

HYPERINFLATED. This person is an upper-chest breather who tends to pull up into spinal extension for both respiration and stability. Their lumbar spine is in hyperextension, while their pelvis lives in anterior (forward) tilt, meaning their butt sticks out. They are always pulling up into themselves, trying to look like they are in charge. They have a limited sense of grounding in the feet, and limited ability to pronate to absorb shock (the feet turn outward, or supinate). All of the above makes them quite susceptible to lower back pain, as well as tightness in their calves and hips.

Sad Guy

COMPRESSED. Everything about them is sort of scrunched down and tight. Their head juts forward, and so do their shoulders, which kind of roll to the front because they are always pulling forward to try and take in more air. Their midback rolls in an overly flexed or hyperkyphotic posture, and they have limited neck and upper limb motion. Sometimes their lower legs externally rotate, and the feet overpronate. Gravity is weighing them down.


UNCONTROLLED. These folks have extreme passive range of motion (i.e., flexibility)—and extremely limited ability to control it. They can often do a toe touch and put their palms flat on the floor, but because of their lack of control, these people are quite prone to joint injuries. They are always trying to find themselves in space, fidgeting and twitching; they compensate for their excessive flexibility by trying to stabilize primarily with their neck and jaw. It is very hard for them to put on lean mass (muscle). Sometimes they have very high anxiety, and possibly also a breathing pattern disorder.

Breathing hack to make your hips feel OK after a long flight:

3134 Back when I used to fly every week, I tried a clever trick that Michael Rintala showed me: put two tennis balls in an athletic sock about four to six inches apart, and position them just about at the level of my kidneys, or where my thoracic spine meets my lumbar spine. Then, with every breath I try to make sure I expand fully enough to feel the tennis balls on both sides. The idea is that it cues your breathing. When I did this, I could get off a five-hour flight and feel as if I had not been sitting for longer than about five minutes. (It also kept my seatmates from talking to me when I was trying to work.) It’s worth trying on a long flight or drive.

DETAILED walk through of the step-up (see also the videos):

3060 Rather than try to describe multiple exercises, I think it’s more instructive to provide a deeper explanation of one exercise. I’ve chosen a step-up, simply stepping up onto a box or a chair, for three reasons. First, it’s a hip-hinging movement, one of our core elements of strength training. Second, it’s a single-leg exercise that does not require much axial (spine) loading, even with weights in your hands, which means it’s very safe, even for beginners (you’ll start with just your body weight). Third, it’s one of the best exercises to target the eccentric phase of the movement as well as the concentric phase. I also like it because it demonstrates some of the key stability concepts we have been learning in this chapter.

First, find a box or a sturdy chair such that when your foot is on the step your thigh will be parallel to the floor. For most people this is about sixteen to twenty inches, but if that is too difficult start with twelve inches. Place one foot on the box, making sure that the big toe and pinky toe mounds and the entire heel are connected firmly to its surface (I like to do these barefoot). The back foot remains on the floor, roughly twelve inches behind the box, with roughly 40 percent of your weight on the back leg and 60 percent on the front leg. Keep your front hip flexed, spine tall, chest heavy (ribs down), arms relaxed by your sides, and eyes forward.

Now, slightly shift your head, ribs, and pelvis forward at the same time as you quietly but fully inhale through your nose, allowing the diaphragm to descend and creating intra-abdominal pressure. You should feel pressure in the center of the front foot, toward the heel, but keep your toes connected to the box. Glide your front femur back slightly, so that you feel a stretch in both the hamstring and the glute max; they should be very slightly loaded. This sensation is the essence of the hip-hinge. You want to lead with your glutes and hamstrings, not pelvis or ribs. All of your power will come from these muscles working together, and not your back. Keep your knee behind your toes, and your pelvis and ribs in alignment, and load your front foot evenly, not favoring either the toes/forefoot or heel.

With your front foot, push down on the box with intent and with

minimal push-off assistance from the back foot.

Lift yourself off the floor, exhaling as you initiate the movement, extend the hip, and stand up straight on top of the box. Your head and ribs should finish directly over the pelvis. Bring your rear leg through to finish beside and a little in front of the working leg. Everything should arrive at the same time, as you complete the exhale (feeling the compression in the ribs). Hold this position for a second or two.

On the way down, step the nonworking (now front) foot off the back of the box as your head, ribs, and shoulders shift slightly forward and the hip flexes to (once again) prepare the hamstring and glute to lower your weight. Load the front of the stationary foot, the toes actively flexed into the box. As you lower your body down and back through space, feel the weight shifting from the forefoot into the midfoot, and finally to the heel, in a smooth, coordinated fashion that is controlled by the hamstring (think: slowly rocking backward).

Keep the tempo as slow and even as possible; aim for three seconds from step-off to landing (difficult; two seconds is good). As the back foot lowers, your weight continues to shift back until you “land.” Avoid shifting more than 40 percent of your weight to the back foot, to reduce the temptation to use forward momentum to start the next rep. Repeat.

Do five to six reps on each side. Start with body weight only, but once you have the movement and sensation down, you can add weights, ideally a dumbbell or kettlebell in each hand. (Bonus points: Now you are training grip strength as well as hip-hinging.)

3 basic forms of diet:

3358 CALORIC RESTRICTION, or CR: eating less in total, but without attention to what is being eaten or when it’s being eaten

DIETARY RESTRICTION, or DR: eating less of some particular element(s) within the diet (e.g., meat, sugar, fats)

TIME RESTRICTION, or TR: restricting eating to certain times, up to and including multiday fasting

Alcohol: no more than 7 servings per week, no more than 2 in one day:

3474 Nevertheless, for many of my patients, the lifestyle around moderate drinking (e.g., a nice glass of wine with a non-SAD dinner) helps them dissipate stress. My personal bottom line: if you drink, try to be mindful about it. You’ll enjoy it more and suffer fewer consequences. Don’t just keep drinking because they’re serving it on the plane. I strongly urge my patients to limit alcohol to fewer than seven servings per week, and ideally no more than two on any given day, and I manage to do a pretty good job adhering to this rule myself.

Insights from CGM (continuous glucose monitoring):

3522 Lessons from Continuous Glucose Monitoring

In the years that I have used CGM, I have gleaned the following insights—some of which may seem obvious, but the power of confirmation cannot be ignored:

Stacking the above insights—in both directions, positive or negative—is very powerful. So if you’re stressed out, sleeping poorly, and unable to make time to exercise, be as careful as possible with what you eat.

The complexities of plant protein:

3566 Now, a word on plant protein. Do you need to eat meat, fish, and dairy to get sufficient protein? No. But if you choose to get all your protein from plants, you need to understand two things. First, the protein found in plants is there for the benefit of the plant, which means it is largely tied up in indigestible fiber, and therefore less bioavailable to the person eating it. Because much of the plant’s protein is tied to its roots, leaves, and other structures, only about 60 to 70 percent of what you consume is contributing to your needs, according to Don Layman, professor emeritus of food science and human nutrition at the University of Illinois Urbana-Champaign, and an expert on protein.

Some of this can be overcome by cooking the plants, but that still leaves us with the second issue. The distribution of amino acids is not the same as in animal protein. In particular, plant protein has less of the essential amino acids methionine, lysine, and tryptophan, potentially leading to reduced protein synthesis. Taken together, these two factors tell us that the overall quality of protein derived from plants is significantly lower than that from animal products.

The same is true of protein supplements. Whey protein isolate (from dairy) is richer in available amino acids than soy protein isolate. So if you forgo protein from animal sources, you need to do the math on your protein quality score. In truth, this can get pretty complicated pretty quick, because you get wrapped around the axle of something called the Digestible Indispensable Amino Acid Score (DIAAS) and the Protein Digestibility-Corrected Amino Acid Score (PDCAAS). These are great if you have the time to comb through databases all day, but for those of us with day jobs, Layman suggests focusing on a handful of important amino acids, such as leucine, lycine, and methionine. Focus on the absolute amount of these amino acids found in each meal, and be sure to get about three to four grams per day of leucine and lycine and at least one gram per day of methionine for maintenance of lean mass. If you are trying to increase lean mass, you’ll need even more leucine, closer to two to three grams per serving, four times per day.

Sleep 7.5 - 8.5 hours per night (not less, not more):

3816 How long do we need to sleep? This question is tricky, because our sleep cycles are powerfully influenced by external cues such as sunlight, noise, and artificial lighting, not to mention our own emotions and stresses. Also, we are quite good at adapting to inadequate sleep, at least for a while. But many, many studies have confirmed what your mother told you: We need to sleep about seven and a half to eight and a half hours a night. There is even some evidence, from studies conducted in dark caves, that our eight-ish-hour sleep cycle may be hard-wired to some extent, suggesting that this requirement is non-negotiable. Getting significantly less sleep than this, or significantly more, will almost inevitably cause problems in the long run.

Change the behavior, change the mood:

4410 This is an easy example, obviously. Who wouldn’t want to play with their kids instead of working? But for Old Peter, it would have been impossible. This small lesson, which I have implemented countless times since, taught me something very important: changing the behavior can change the mood. You do not need to wait for your mood to improve to make a behavior change. This is also why cognitive therapies alone sometimes come up short; simply thinking about problems might not help if our thinking itself is disordered.

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