Elon Musk and Gwyneth Paltrow swear by Peter Attia, the doctor who says he knows what we can do to live longer and healthier.
As published in The Times.
Starting this weekend, I will be making a regular habit of an activity called “rucking”. You take a backpack, fill it with weights and then spend an hour or so briskly walking up and down hilly terrain. As well as providing a good workout, doing this a few times a week will improve your spatial awareness and your eccentric strength, both of which you need in order to walk down things like stairs, kerbs, slopes etc with stability and control. I do not currently have a problem walking down stairs or stepping off pavements — I am 41 years old and in decent, if not exactly Olympian, shape — but I am thinking of the future. For reasons we will explore, I have started thinking a lot more about the future, and how best to ensure my later years are as healthy as they can be. And one of the things I absolutely do not want to do when I’m older is have a fall. As such, I am going to minimise that possibility with some dumb-bells in a bag and a big hill.
That is not all. I am going to make a concerted effort to increase both the quantity and quality of my sleep. So no more phone by the bed, no more waking up groggy after three weeknight pints, no more cheapo blinds that let the early dawn light strafe my face at 5am. I’m not going to worry too much about my weight, provided that I am adequately muscled. In fact, I now know that it is better to have a solid musculature and to be carrying a bit more subcutaneous fat than you would like — which is to say, the fat beneath your skin — than to be perfectly slim but basically scrawny. Visceral fat, on the other hand? The fat that can form between and around your internal organs, and which is linked to increased risk of cancer and cardiovascular disease? I’m going to do everything I can to stem that stuff. I’m going to lift more weights and do more cardio but, in terms of diet and dieting, I’m not going to put myself through anything that’s going to reduce my ability to go out and exercise on any given day. So no long periods of fasting, no crash diets, nothing that’s going to leave me feeling too pooped to get my trainers on. Also, if I had a sauna, I would use it at least four times a week for a minimum of 20 minutes per session with the temperature set to 82C — studies have suggested this may reduce the risk of Alzheimer’s by about 65 per cent. Only, I don’t have a sauna. But now I wish I did.
I have been inflicting this information and more — so much more — on everyone in my life over the past few days. This is because I have just read Outlive: The Science and Art of Longevity, written by a Canadian-American doctor called Peter Attia who specialises in the field of longer living. It is a dense book, almost 500 pages, low on silver-bullet solutions — no claims about “hacking mortality” or how to extend your life with this “one weird trick!” — but high on stats and studies and stuff about experiments involving groups of chimps being put on different diets etc. But at Outlive’s heart, Attia makes a straightforward proposition: almost all of us, regardless of genes, can systematically do things to extend our lifespan. Better still, we can systematically do things to extend our “healthspan”, to retain as many of our physical and cognitive faculties as possible as we enter the final furlong of life.
A quick example: Attia describes how, once you’re beyond the age of 65, breaking a hip can trigger a terminal decline in your health. “There’s a 15 to 30 per cent chance of death in the next 12 months,” he says, frowning. “And of those who don’t die, 50 per cent will never regain full function. It’s an awful statistic.” Which is why Attia goes rucking three times a week and why he has persuaded me to do the same. Because if you can build and maintain good eccentric strength, your chances of falling and breaking a hip in your later years diminish. What you don’t want is to start thinking only about how much you don’t want to break a hip when you’re flying through the air and the ground is rushing up to meet you. Because by then, well, it’s really too late.
Attia is 50, with a shaved head, a sonorous voice and a manner that tends towards seriousness. He has the trim, aggressively good posture of a personal trainer, but the fitted white shirt and reflexive hand gestures of an entrepreneur. Which, to a large extent, is what he is. For the past decade, Attia has run a private clinic with offices in New York and California, which specialises in helping patients extend their healthspan. (The cost? “Not cheap.”) He hosts his own podcast, The Drive, which focuses on questions surrounding longevity and, with more than one million followers on social media, it would not be dismissive to describe him as a “health influencer”. He is big in the overlapping and occasionally nebulous online fields of wellness, performance and self-improvement. He has celebrity followers: the actors Hugh Jackman and Chris Hemsworth are friends. Elon Musk recommends his articles on Twitter. Gwyneth Paltrow, Arnold Schwarzenegger and Oprah Winfrey have all recommended Outlive, which is, perhaps unsurprisingly, a US bestseller.
He lives in Austin, Texas, with his wife and three children. In his office, he has various items of Formula One racing memorabilia — a self-confessed perfectionist, he is entranced by the precision required to drive incredibly fast — and, on a wall, there is a calendar titled “My Life in Weeks”, composed of hundreds of tiny rectangles. “I colour in one of the boxes every week,” he says. “And I’m marching through the weeks of my life, and I can see I have fewer weeks left than I had. And that’s assuming I live for a long time.”
He smiles. Everybody wants more time on Earth. So how did he become the world’s go-to guy for that very thing? To answer this, we have to understand that for a very long while, Attia didn’t even want to become a doctor. The child of Coptic Christian immigrants from Egypt, he grew up in Toronto where, during his adolescence and teenage years, he hoped to become a boxer. Instead, he ended up studying applied mathematics and mechanical engineering at Stanford, and was all set to start a PhD in aerospace engineering. During this time Attia was volunteering at a shelter for teenagers who had been sexually abused. “One day, I was visiting one of the young women who was part of this group in hospital. And I had a really profound epiphany.”
Something about the visit made him abandon his aerospace ambitions and instead throw himself into medicine. He chose to specialise in surgery, and eventually found himself pulling 110-hour weeks at the prestigious Johns Hopkins hospital in Baltimore as a young resident physician. It meant he was living and working in constant and intimate proximity to death and, he came to observe, it tended to come in one of two forms. There was “fast death”, which was sudden and violent. “Most of it was gang-related — you know, gunshot wounds, stab wounds — but obviously motor vehicle accidents as well,” he says. “Meaning these are people who yesterday were in perfect health, usually young people, and today they’re dead.”
“Slow death”, on the other hand, involved caring for people suffering from chronic illnesses and conditions, from heart disease to cancer to diabetes. “You would take care of patients for a long period and get to know them and meet their family. And then ultimately realise that you had nothing left to offer them, that their disease was going to take their life and nothing you could do surgically or medically was going to change that.”
There was, it seemed to Attia, a “futility” to this approach. He developed a frustration with how contemporary medicine — which he terms “Medicine 2.0” — worked on a systemic level. The way he saw it, a great deal of time and money was being spent on attempting to fix a serious condition at the “wrong end of the timescale”, which is to say, once that condition is a problem, often very advanced and often terminal. “Most doctors get paid by a health insurance company, and the health insurance company is paying you to take care of somebody once they are sick, to make a diagnosis and to apply a treatment to a sick person. That’s the hallmark of Medicine 2.0.”
What’s more, he continues, the efficacy of Medicine 2.0 itself has plateaued. While average lifespans may have doubled over the course of the 20th century, it was antibiotics and sanitation doing most of the heavy lifting. And while it has been effective against many acute illnesses, the odds are still that we will die of one of the “chronic diseases of ageing”, which Attia lists as heart disease, cancer, neurodegenerative disease (such as Alzheimer’s) and type 2 diabetes and related complications. Against these “four horsemen”, he says, the passive, back-foot approach of Medicine 2.0 alone is making little progress.
Attia left medicine in 2006. He took a job at management consultancy firm McKinsey where, thanks to his background in maths, he ended up analysing credit risk for US banks. This sabbatical in a world of risk and data and metrics, however, got Attia thinking about how a more personalised, analytical and long-term approach to health might be applied. The birth of his first child in 2009 drew him deeper into the study of longevity. “I wanted to maximise our time together,” he says. By 2012 he had returned to medicine, setting up his practice and starting in earnest down the path that would lead him to where he is today.
But what, exactly, do we have to do to live longer? Much of Outlive serves as a manifesto for what Attia calls “Medicine 3.0”, which is, in essence, the aggressive prevention or delaying of the “four horsemen”. The complicated part is that, to get the best out of this approach, Attia believes we should discover and monitor a raft of very specific things about our bodies and health: everything from your daily blood glucose levels to your visceral fat range to your lipid profiles to your apolipoprotein E (APOE) genome type. It was Attia who broke the news to Chris Hemsworth, during a National Geographic TV series in which the Thor actor learnt about aspects of longevity, that he was genetically predisposed to Alzheimer’s and around eight to ten times more likely to develop the disease than the average person. “If you look at Alzheimer’s prevention,” Hemsworth said afterwards, “the benefit of preventative steps is that it affects the rest of your life. When you have a predisposition to cardiovascular heart disease, cancer, anything, it’s all about sleep management, stress management, nutrition, movement, fitness. It’s the same kind of tools that need to be applied in a consistent way.”
Even if you’re not in a position — or don’t have the inclination — to undergo rafts of tests, Attia says there are still changes you can start making today. And perhaps the biggest one is psychological. Because if you want to extend your healthspan, the first thing you need to do is accept that, even if you are healthy now, you will inevitably decline and die. This is not something most of us want to dwell on. I tell Attia that while I found Outlive interesting and informative, I also found myself feeling increasingly maudlin as I read it. Forcing myself to acknowledge this reality felt uncomfortable.
“It’s uncomfortable for me as well,” he says. “But I do think, unfortunately, as the stoics teach us, a good life is a life that has a very clear acknowledgment of death.”
Besides, once you accept that decline and death are inevitable, you can start to really motivate yourself to keep them at arm’s length for as long as possible. This requires some strategic thinking. At his clinic, Attia will ask his patients to make a list of the things they would like to be able to do in the final decade of their life, a period he calls the “marginal decade” (a term he has trademarked). This can be anything from “stand up from a sitting position on the floor unaided” to “have sex”. It’s then a case of working backwards and figuring out what you need to be doing now in order to do those things then.
And Attia is very clear that, above all else, exercise is the thing most likely to extend your healthspan. Building and maintaining muscle strength via resistance training — weights, squats, push-ups etc — is likely to help you hit more of your marginal decade goals than anything else. Some people, he says, will hand-wave this away and tell him that as long as they’re with it cognitively during their marginal decade, they’ll be happy. But this physical/cognitive distinction is a false binary. For one thing, he says, what tends to be good for your heart tends to be good for your brain. Exercise appears to preserve brain health in multiple ways, plus, well… Think about it: you get to old age with all your mental faculties, but you skipped squats and now you’re frailer than you’d care to be. You can’t get out and about easily. You see fewer and fewer people. This, obviously, is not good for your cognitive health.
‘If you ask me what I’ve changed most, it’s not nutrition. It’s not sleep. It’s the emotional health’
Diet, he says, is important. But really not as important as exercise. Attia tends to maximise protein and minimise carbs, based on what he’s found works for him. “But most people who are very, very health-conscious I think are spending too much of their mental energy on nutrition and not enough on exercise. If you’re going to read my book and nitpick some detail about the ratio of polyunsaturated fat, I have some advice for you: get outside and exercise.”
What about booze? It’s possible, if you read enough cheerful interviews with the very long-lived, to come away with the impression that they all enjoy regular glasses of wine, Scotch, whatever they fancy. And perhaps, therefore, drinking regularly isn’t such a bad thing? Attia shakes his head. “I don’t think anybody disputes that ethanol is harmful,” although it’s possible that, in small amounts, there are nutritional and stress-busting benefits to, say, a glass of red wine that outweigh the harm. Attia says if he opens a bottle at home and doesn’t love the first sip, “I dump it down the sink and get another bottle. I’m not going to waste my drinks on crap. That’s why I don’t drink on planes. The alcohol is garbage.”
Attia writes at great length about the importance of sleep. Suffice to say, it’s just really, really important to pretty much every aspect of our health. Today, Attia makes sure he has eight hours of sleep, having previously been guilty of the classic entrepreneurial “rise and grind” mindset. “And I think that was only heightened by my medical training,” he says. “The mantra was, ‘I’ll sleep when I’m dead.’ I don’t need to waste any of my alive time doing it. Which, of course, was foolhardy. Because the more you short-change sleep, the more your health deteriorates.”
In fact, for a very long time, Attia was relentless. His ambition and drive seemed remarkable, from engineering at Stanford to training as a surgeon to working for McKinsey to setting up his longevity practice, being tweeted by Elon Musk and writing bestsellers while, for hobbies, racing cars and completing endurance swimming events. But he was also prone to anger and rage — at himself and at others — and liable to coldness to those around him. In Outlive, he describes an incident in 2017 when, while he was away from home on a business trip to New York, his infant son almost died as a result of sudden cardiac arrest and had to be resuscitated by the family nanny. But rather than rush to the hospital where his son and traumatised wife were, he remained in New York, liaising with the doctors by phone but not curtailing his work trip. In fact, he did not come home for another ten days. The memory of this decision still leaves him feeling “nauseous” today.
Despite being an almost perfect physical specimen, he was miserable and beset by a deep self-hatred. “As was put to me by one of my therapists, what’s the point in living longer if you’re not happy? It doesn’t make sense.”
Eventually, at the encouragement of a friend and the insistence of his wife, Attia checked into a residential treatment centre. And it was here that he told a roomful of strangers about how, as a young child, he had suffered sexual and physical abuse. This admission marked the start of a profound change in how he understood himself. “I assumed my flaws were immutable. That they were coded into my DNA. Detachment. Resentment. Selfishness. Anger. Workaholism. Perfectionism. I assumed this was just who I was,” he says. “Especially when these are traits that go back to being a child. I just didn’t assume they could be changed.”
Attia is sharing all this because he now understands that, if we want to live well for as long as we’re able, we cannot afford to ignore our “emotional health”, and particularly the quality of relationships we have with others and ourselves. “I think many of us accept misery as a human condition that we have no control over. And I don’t think that’s true. We actually do have a lot of control over it.”
One therapist explained to him that men often attempt to replace feelings of shame with feelings of grandiosity: to replace helplessness with heroism. I suppose it’s possible that offering people the means to a longer, healthier life could fall under this dynamic. Now, though, he is more balanced in his outlook. It used to be that if his kids baked cookies, he wouldn’t eat them on health grounds. Now he eats them, because eating cookies with your kids once in a while is, in the grand scheme of things, more important. “If you were to ask me, ‘Peter, in the process of writing this book, what has changed most in your life?’ It’s not exercise. It’s not nutrition. It’s not sleep. It’s the emotional health.”
He says he hopes that, in time, his Medicine 3.0 ideas can be put into wider practice. “I hear a lot from physicians who are on the front lines who say, I love the way you’re talking about this. I wish I understood how to apply this within the current system that I must function in.” He hopes his own final years will be spent “living a very simple life in remarkable obscurity” somewhere quiet, with family and friends nearby, enjoying many of the things he does today. “But obviously, at a different level. I don’t have any delusions.”
Before we finish, I ask him if he’s happy. He frowns. “I think ‘happiness’ is a complicated word. I still struggle every day with the things I’ve always struggled with. But I have my priorities straight. I’m definitely living better today than I ever lived,” he says. “But I hope to be living even better tomorrow.”
9 easy ways to avoid decline in later life
Take up rucking — hiking with a weighted backpack
This will build up your eccentric strength — working your muscles when they are extended, such as stepping downwards and off things — and improve stability and control around your joints such as your knees, hip, and spine. This will hugely diminish your chance of having a fall when you are older. If you break a hip in later life, beyond the age of 65, there is a 15 to 30 per cent chance of death in the following 12 months. And 50 per cent of those who don’t die will never regain full function.
Don’t get fixated on your diet
A high-protein, relatively low-carb diet is good to aim for, but if you are focusing too much on what you are eating it risks detracting from the importance of exercise and maintaining muscle mass. Never compromise on this because the older you get, the more you need to keep your muscles stable and strong so they keep working when you are 80 or 90. Be very careful with any kind of extreme restrictive eating like fasting because it will wash you out and prevent you from exercising properly. It’s better to be somewhat over-nourished, and have strong muscles.
Look on exercise as training for later life
Think about the things you want to be able to do in your eighties and nineties: picking up grandchildren, getting out of a chair unaided, putting your own luggage into an overhead locker on a plane, hiking, sex. Look on exercise as a way to hit those goals — this will make it feel purposeful and give you incentive.
Do resistance training
Walking and jogging isn’t enough; you need to keep up your muscle strength with exercises like squats, push-ups and by using weights. Muscle strength rapidly declines as we age so it is vital to keep building it.
Get at least eight hours’ sleep a night
There is no part of your mental and physical health that isn’t negatively impacted by poor sleep. Good sleep is crucial for every aspect of your life. Do anything to improve your sleep quality, such as banning your phone from your bedroom or getting proper blackout blinds.
Our most powerful tool for preventing cognitive decline is exercise
Some people have the attitude that as long as they are mentally sound when they are older, they care less about fitness. But the two are directly linked. What tends to be good for your heart is good for your brain. That’s because good cardiovascular health will make sure your brain is getting the oxygen and nutrients it needs. Getting out and about and having social contact has also been shown to improve cognitive health. You won’t be able to do that if you are unable to move properly.
Pay attention to your mental health
Do everything you can to avoid being miserable. Having good relationships with people is as important to your lifespan as any number of diagnostic tests and squats. If you are old and don’t have friends or your kids and family around, then there is not much point in living longer.
If you are going to drink, drink something decent
Ethanol is harmful but in small amounts there may be nutritional and stress-busting benefits of enjoying, say, a glass of wine. That said, don’t get misled by surveys that report that healthy people drink in old age — they are drinking because they are healthy, not because it has made them healthy. If you are going to drink, keep it to three to four drinks a week, and make sure you savour every mouthful by drinking the nicest stuff you can find.
Get testing
The more you know about your personal physiology the more you can take preventive measures to stay healthy. That includes, testing what kind of cholesterol you have, or a DNA test to see your propensity for Alzheimer’s.
Outlive: The Science and Art of Longevity by Dr Peter Attia and Bill Gifford is published by Vermilion at £22. To order a copy go to timesbookshop.co.uk or call 020 3176 2935. Free UK standard P&P on orders over £25. Special discount available for Times+ members