Link to podcast + transcript.

Sajith: Peter Attia is a well-known longevity and wellness guru; has a popular podcast The Drive, covering these topics. Recently, he published Outlive, a how to book giving advice on living to 100+ years. The podcast gives you a quick overview of his thinking and perspectives on this topic. Some excellent advice here that can be readily implemented including 1) the importance of primary prevention, especially that of diabetes which accentuates the popular killers such as heart attack, strokes, cancer etc. 2) why exercise is disproportionately important of all of the steps you can take to enhance your life and health span and in particular the importance of VO2 3) why we overthink nutrition and nutrition advice too much – much of the advice around nutrition comes down to a balanced diet and not eating too much (and he gives a good hack for managing this). Far more attention gets paid to nutrition than it deserves he says.

All text below is as spoken by Peter Attia.

Fast death vs slow death

Peter: ….fast death was primarily that of infections, communicable diseases and trauma. That’s how people die. That’s how we died for millennia. And our life expectancy was relatively short, probably on the order of 30 to 40 years. 

….slow deaths.” And these are the chronic diseases that virtually everybody listening to us talk today is thinking about.

So Medicine 2.0 was and remains an amazing tool or paradigm for how we deal with fast death. The problem is it has not been very successful at treating slow death. And its strategy has been the way you treat slow death is the way you treat fast death.

The way you treat fast death is you intervene when the disease is visible. We don’t go around treating people prophylactically for infections. I mean, I guess you could say we do that with vaccines. But we don’t go around treating people for car accidents before they have them. We wait until they have a car accident, then we treat them. And so when you try to apply that approach to diseases of slow death, it doesn’t seem to work that well. We ought to be doing more of the vaccine thing, which is a preventative thing. We’re not.”

Primary treatment / prevention

Peter: “The model today for treating cardiovascular disease is, okay, we treat everybody for secondary prevention. Secondary prevention means you’ve already had a heart attack or a stroke. Is there anybody who thinks we shouldn’t be aggressively treating those people to prevent the second one, the fatal one? No. Okay, we all agree with that.

The real rub comes in what we think about for primary prevention. How do you treat a person who has not yet had a heart attack or stroke. And the mainstream view on that is, well, we use models that predict risk. We have decent actuary models that predict risk based on lipids, smoking history, blood pressure, family history, et cetera. And we wait until there’s a threshold that’s crossed to begin treating.

So in the cardiovascular literature, it’s typically viewed as about a 5% 10-year risk for a major adverse cardiac event. So if I plug your numbers in, Patrick, and your 10-year risk comes back at 3%, it is not deemed necessary to put any treatment preventive protocols in place. I think that’s fundamentally wrong.”

if they do smoke, we tell them to stop immediately, not waiting until their risk of lung cancer is high or waiting until they develop a small lung cancer and then telling them, okay, now it’s time to stop. So we clearly have it dialed in, in that area. And yet when it comes to managing diabetes or cardiovascular disease or other forms of cancer that are not related to smoking or that have other risk factors, we completely fail in that same line of thinking. We don’t treat the causal agents, and we don’t take an aggressive enough lifetime risk posture.”

The four horsemen of death

Peter: “And so in the book, I talk about these four horsemen of death. And they’re loosely the diseases that kill us, but if you read the fine print, you’ll realize that we’re mostly just dying from three of the horsemen directly, but the fourth horseman is probably the one that has the biggest overall effect. Even though it doesn’t show up on the death certificate as the cause of death, it’s the gasoline that’s being poured on the fire of the other three.

So the three are cardiovascular and cerebrovascular disease at #1 leading cause of death; cancer, #2; and neurodegenerative disease, #3, at least in a nonsmoking population because I’m stripping out COPD, chronic obstructive pulmonary disease. But the fourth one is kind of a category I’ve created from a disease such as type 2 diabetes at one end of the spectrum, but also all the things that are leading up to that.

So insulin resistance hyperinsulinemia, nonalcoholic fatty liver disease, which progresses to nonalcoholic steatohepatitis, all the way to type 2 diabetes. Again, if you added up all the death certificates in the country and said how many times does insulin resistance appear on it? The answer is never. No cause of death is insulin resistance. NAFLD is not a cause of death.

You’re not going to die from NAFLD(Non Alcoholic Fatty Liver Disease), but if it progresses to NASH and cirrhosis, you’ll die. Very few people are dying directly as a consequence of type 2 diabetes. It does show up on the death certificate. I should know those numbers, but they’re not that big. But if you have type 2 diabetes, your risk of heart disease, cancer and Alzheimer’s disease is approximately 2x that of someone who does not.”

5 areas of proactive intervention, and the importance of Exercise

Peter: “There are five things that I talk about is the areas that we have agency over in terms of how we impact our health span and lifespan, nutrition, exercise, sleep, pharmacology, including supplements, drugs, et cetera, hormones and all the tools around emotional health. If you assume that each of those is responsible for roughly one-fifth of the output, and it’s not. Clearly, it’s not. Exercise is actually disproportionately responsible for benefit. So conservatively, 80% of what can impact the length and quality of your life, you don’t need a doctor for. It’s interesting that 20% of that equation is all we learned in medical school and beyond (pharmacology / meds). 

Well, the three best ones for exercise targeting are VO2 max, muscle mass and strength because you can’t have a high VO2 max without doing a lot of hard exercise. And that (VO2) number is more predictive of how long you live than any other number we have.“


Peter: “Sleep is an area where you can really get punished if you’re outside of optimal. But once you’re optimal, there’s no super optimal. I think the data would really suggest the same is true for nutrition. If you’re really under nourished or over nourished, those things should be corrected. Probably, the over nourished is a bigger problem.

Most people are over nourished, and I don’t think there’s some magic around how you fix that. The operationalizing of it is hard, but the strategy is really simple. You can calorie restrict, dietary restrict or time restrict, each one has advantages, each one has disadvantages. They’re not mutually exclusive, but they are collectively exhaustive. Try the one that works for you, if you fail, go try another one. What I’m trying to get away from is kind of the dogmatic view that there is a right way.

Are you in energy balance? Are you metabolically healthy? Are you getting enough protein? After that, I almost joke that I didn’t want to write the 2 chapters on nutrition because it creates so much substrate for people to argue about things. And what I really want to say is like those are the 3 questions that matter most.

There’s very little doubt that food grown today doesn’t have nearly maybe even half the nutritional value that it could have or should have if the soil it grew in were healthier. So there’s no doubt that we could be eating better food, but I also think most people tend to over index that at the expense of exercise. If you look at the absolute battles that people have over social media with respect to this diet versus that diet and what about being vegan, what about being paleo, and it’s like, it might not actually matter as much as you guys think.”


Peter: “Anybody who’s ever played around with mindfulness based medication, which I have quite a bit is sobered to realize how noisy the mind is. That type of meditation for folks who haven’t done it is a meditation where you focus on an object, usually the breath, it’s an easy one to focus on. And the whole goal of the meditation is just to be as aware of the breath as possible and to notice every time your mind wanders off the breath onto a thought. And the exercise is making that realization and bringing the mind back to the Breath.

So contrary to maybe what people might think who haven’t done this meditation, the goal is not to stop thought because that’s not actually possible. It’s not possible for more than — in my case, a few seconds. The goal of that exercise, Dan Harris, I think, says this so well. He’s like, “The muscle, the bicep curl of meditation is the exercise of noticing that the mind wanders and bringing it back to the breadth or the object of meditation.” And if that happens 100 times in a 10-minute meditation session, that’s not a failure. It’s not that you failed 100 times, that you got 100 reps in.

I think that’s one of the most compelling arguments I ever heard for meditation, the very first time I heard Dan say that. So what does a calm mind mean? Well, it doesn’t mean a mind of no thoughts. For me, that’s been learning to develop an emotional awareness. So that means recognizing visceral sensations. So for example, yesterday, my wife got upset at me for something, and it was actually being able to stop and notice the physical feeling in my stomach as I was getting angry.  And so the difference is 5 years ago, I would have barked right back, and I would have escalated. And yesterday, instead, I was able to pause, notice the sensation, understand that I was getting irritated and simply not react and just say, you know what, how about I apologize again.”