Outlive: The Science & Art of Longevity

The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge. —Daniel J. Boorstin

Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.

One macronutrient, in particular, demands more of our attention than most people realize: not carbs, not fat, but protein becomes critically important as we age.

Unfortunately, in today’s unhealthy society, “normal” or “average” is not the same as “optimal.

I am increasingly persuaded that our 24-7 addiction to screens and social media is perhaps our most destructive habit, not only to our ability to sleep but to our mental health in general. So I banish those from my evenings (or at least, I try to). Turn off the computer and put away your phone at least an hour before bedtime. Do NOT bring your laptop or phone into bed with you.

Another, related issue is that longevity itself, and healthspan in particular, doesn’t really fit into the business model of our current healthcare system. There are few insurance reimbursement codes for most of the largely preventive interventions that I believe are necessary to extend lifespan and healthspan. Health insurance companies won’t pay a doctor very much to tell a patient to change the way he eats, or to monitor his blood glucose levels in order to help prevent him from developing type 2 diabetes. Yet insurance will pay for this same patient’s (very expensive) insulin after he has been diagnosed. Similarly, there’s no billing code for putting a patient on a comprehensive exercise program designed to maintain her muscle mass and sense of balance while building her resistance to injury. But if she falls and breaks her hip, then her surgery and physical therapy will be covered. Nearly all the money flows to treatment rather than prevention—and when I say “prevention,” I mean prevention of human suffering.

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 never won a fight in the ring; I always won in preparation. —MUHAMMAD ALI

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.

Each night, when I go to sleep, I die. And the next morning, when I wake up, I am reborn. —Mahatma Gandhi

The study reported a 24 percent relative increase in the risk of breast cancer among a subset of women taking HRT, and headlines all over the world condemned HRT as a dangerous, cancer-causing therapy. All of a sudden, on the basis of this one study, hormone replacement treatment became virtually taboo. This reported 24 percent risk increase sounded scary indeed. But nobody seemed to care that the absolute risk increase of breast cancer for women in the study remained minuscule. Roughly five out of every one thousand women in the HRT group developed breast cancer, versus four out of every one thousand in the control group, who received no hormones.

The single most powerful item in our preventive tool kit is exercise, which has a two-pronged impact on Alzheimer’s disease risk: it helps maintain glucose homeostasis, and it improves the health of our vasculature

Our tactics in Medicine 3.0 fall into five broad domains: exercise, nutrition, sleep, emotional health, and exogenous molecules, meaning drugs, hormones, or supplements.

but I now consider exercise to be the most potent longevity “drug” in our arsenal, in terms of lifespan and healthspan. The data are unambiguous: exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention.

But if you really want to raise your VO2 max, you need to train this zone more specifically. Typically, for patients who are new to exercising, we introduce VO2 max training after about five or six months of steady zone 2 work.

found that grip strength, an excellent proxy for overall strength, was strongly and inversely associated with the incidence of dementia (see figure 8). People in the lowest quartile of grip strength (i.e., the weakest) had a 72 percent higher incidence of dementia, compared to those in the top quartile.

The overarching point here is that a good night of sleep may depend in part on a good day of wakefulness: one that includes exercise, some outdoor time, sensible eating (no late-night snacking), minimal to no alcohol, proper management of stress, and knowing where to set boundaries around work and other life stressors.

We spend so much of our time in car seats, in desk chairs, at computers, and peering at our various devices that modern life sometimes seems like an all-out assault on the integrity of our spine. The spine has three parts: lumbar (lower back), thoracic (midback), and cervical (neck) spine. Radiologists see so much degeneration in the cervical spine, brought on by years of hunching forward to look at phones, that they have a name for it: “tech neck.

How much protein do we actually need? It varies from person to person. In my patients I typically set 1.6 g/kg/day as the minimum, which is twice the RDA.

the great philosopher Mike Tyson once put it, “Everyone has a plan until they get punched in the mouth.

As Terry had written: “Family pathology rolls from generation to generation like a fire in the woods taking down everything in its path until one person, in one generation, has the courage to turn and face the flames. That person brings peace to his ancestors and spares the children that follow.” I wanted to be that person.

Exercise is by far the most potent longevity “drug.” No other intervention does nearly as much to prolong our lifespan and preserve our cognitive and physical function. But most people don’t do nearly enough—and exercising the wrong way can do as much harm as good.

Poor or disordered breathing can affect our motor control and make us susceptible to injury, studies have found. In one experiment, researchers found that combining a breathing challenge (reducing the amount of oxygen available to study subjects) with a weight challenge reduced the subjects’ ability to stabilize their spine. In real-world terms, this means that someone who is breathing hard (and poorly) while shoveling snow is putting themselves at increased risk of a back injury. It’s extremely subtle, but the way in which someone breathes gives tremendous insight to how they move their body and, more importantly, how they stabilize their movements.

Next is diet or nutrition—or as I prefer to call it, nutritional biochemistry. The third domain is sleep, which has gone underappreciated by Medicine 2.0 until relatively recently. The fourth domain encompasses a set of tools and techniques to manage and improve emotional health. Our fifth and final domain consists of the various drugs, supplements, and hormones that doctors learn about in medical school and beyond. I lump these into one bucket called exogenous molecules, meaning molecules we ingest that come from outside the body.

Of course, exercise is not just one thing, so I break it down into its components of aerobic efficiency, maximum aerobic output (VO2 max), strength, and stability, all of which we’ll discuss in more detail.

WHAT’S GOOD FOR THE HEART IS GOOD FOR THE BRAIN. That is, vascular health (meaning low apoB, low inflammation, and low oxidative stress) is crucial to brain health. WHAT’S GOOD FOR THE LIVER (AND PANCREAS) IS GOOD FOR THE BRAIN. Metabolic health is crucial to brain health. TIME IS KEY. We need to think about prevention early, and the more the deck is stacked against you genetically, the harder you need to work and the sooner you need to start. As with cardiovascular disease, we need to play a very long game. OUR MOST POWERFUL TOOL FOR PREVENTING COGNITIVE DECLINE IS EXERCISE. We’ve talked a lot about diet and metabolism, but exercise appears to act in multiple ways (vascular, metabolic) to preserve brain health; we’ll get into more detail in Part III, but exercise—lots of it—is a foundation of our Alzheimer’s-prevention program.

But Kirk stopped me short with a simple, Socratic question. If sleep is so unimportant, he asked, then why hasn’t evolution gotten rid of it?

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.

This study found that someone of below-average VO2 max for their age and sex (that is, between the 25th and 50th percentiles) is at double the risk of all-cause mortality compared to someone in the top quartile (75th to 97.6th percentiles). Thus, poor cardiorespiratory fitness carries a greater relative risk of death than smoking.

ketogenic diet means restricting carbohydrates to such an extent that the body begins metabolizing fat into “ketone bodies” that the muscles and brain can utilize as fuel.