By David Marchese
Modern medicine has been a miracle for healthy aging. But what if we’re still thinking about the subject of living better for longer all wrong? That’s the premise of Dr. Peter Attia’s book, “Outlive: The Science & Art of Longevity,” which he wrote with Bill Gifford and has been a runaway best seller since it was published this spring. In the book, Attia distinguishes between standard medical thinking, what he calls Medicine 2.0, and his approach, Medicine 3.0. In his telling, Medicine 2.0 is oriented toward addressing the four chronic diseases of aging that will probably be the cause of most of our deaths, but only after they become problems. (Those chronic diseases are heart disease, cancer, Alzheimer’s and related neurodegenerative diseases and Type 2 diabetes and related metabolic dysfunction.) Medicine 3.0, though, aims to proactively prevent those things for as long as possible and allow us to maintain better health deeper into old age. How exactly? Not through any techno-fantasies of biohacking or wonder-drug supplements but largely with highly rigorous, detailed and personalized monitoring and treatment of our nutrition, sleep, exercise and mental health. “When you’re at the end of your life, if your health has failed you, no amount of money is going to buy that back,” says Attia, who is 50. “Health is everything to us. As such, we have to accept the fact that it might take work to get it right.”
Let’s say someone reads your book and decides that they want to pursue a Medicine 3.0 approach to health. Then they go to their general practitioner, and their G.P. says, contrary to you, “Nah, we don’t need to get into the weeds of your glucose levels and lipids.” Then what? How do people operationalize Medicine 3.0 in a world of Medicine 2.0 doctors? Some of the work you can do on your own. The exercise — you don’t need a doctor for that. Nutrition, sleep, the emotional-health stuff — you don’t need an M.D. to help with that. But there is a big chunk of this that does require a physician. You need someone to order and check those labs, and you may need prescriptions as a result. But imagine you’re trying to sue a company that has wronged you. You’re going to talk to a bunch of attorneys until you find the person whose strategy makes sense to you. It’s the same with finding the right doctor. When you’re talking about who’s your attorney, who’s going to be your doctor, these are important decisions, and the exception is finding that person on the first chance, not the rule.
In my experience, and I think this applies to a lot of people, the doctor-patient dynamic is basically a parent-child one. The doctor gives information and guidance, and the patient obeys. But you’re implicitly calling for people to be much more hands-on in directing their medical care. Do you have a sense of what physicians might think about having that traditional doctor-patient dynamic upended? I can certainly tell you every time it annoyed a physician, because I hear about it! You’ve probably heard me harp on the importance of knowing your ApoE genome type. I get a lot of pushback on that from physicians saying, “Why would you want to burden a patient with that knowledge?” I welcome that debate because it opens a discussion: Do you or do you not believe that this a deterministic gene? If it’s not deterministic, the next most important question is: Is there a manner in which you can alter the outcome? I believe the answer is emphatically yes: It’s not deterministic, but it’s risk-associated, and you can alter your trajectory. Therefore, how would you not want to know this? Another area where I hear about a lot of pushback is on lipid stuff. I’m adamant about everybody knowing their Lp(a) and their ApoB. Cardiovascular disease — you’ve got to prevent early, and you have to know those metrics. You’d be amazed at how many doctors are like, “LDL cholesterol is fine, and this Lp(a) thing — I don’t even know what it is.” I say to patients: “Let your doctor’s response be a litmus test to the caliber of their thinking. You don’t have to agree with me on everything, but you have to disagree with evidence.”
When I read your book, I was thinking, this guy is advising me to pursue a fair bit of medical testing, which I doubt my insurance covers. There’s equipment he thinks I should probably buy. He’s suggesting psychotherapy. This stuff all costs money. So to put it crassly, is your method just for the rich? The biggest asset class a person needs is not financial; it’s time. It would be delusional of me to say that a single working mom with five kids in the inner city has the same amount of time that the wealthy mom in Beverly Hills has. Of course not. Unfortunately, the truth of it is that health is not fully democratized. There’s a certain income level and disposable time requirement that’s probably necessary. You don’t have to be wealthy, but you have to be above a certain threshold in terms of disposable time and income to spend on good food, gym memberships or exercise equipment at home and those things. I don’t know that dollar amount. I don’t think it’s that high. But it’s certainly higher than where many people are, unfortunately.
What would it run me to be one of your patients? I mean, it’s not cheap.
All right, we can leave it at that. If you were to say to someone, “If you don’t do anything else to increase your health span, at least start doing X,” what would X be? For most people, the answer is exercise more. Then within that, you can get into the weeds. Many people, I think, are underemphasizing strength training. There’s the sense that, Yep, I’m out there, I’m hiking, I’m walking. Those things are great, but the sine qua non of aging is the shrinkage or atrophy of Type 2 muscle fiber. That’s the thing we probably have to guard most against, and you can’t do that without resistance training. Count the number of times in human history when someone in the last decade of their lives said: “I wish I had less muscle mass. I wish I was less strong.” The answer is zero.
You’re asking people to pay a significant amount of attention to the specifics of their nutrition, physical activity and sleep. All of which are subjects that you say doctors typically don’t learn enough about nor pay enough attention to when it comes to patients’ long-term health. I’m sure that’s true, but don’t you think there’s a real danger of pathologizing these totally normal things by micromanaging them and linking them to potential risks? That’s possible. We also probably see extreme examples of excessive exercise. I’m aware of patients who, in the era of rampant sleep tracking, are overwhelmed by sleep data. The question is: What is the balance of benefit versus harm? We’re probably still in a world where a majority of people are not paying enough attention to those things, as opposed to too many people paying too much attention.
Sorry, I remain curious: What does it cost to get into your practice? I’m not looking to get any patients into the practice. I would like it if maybe there wasn’t much of a focus on my practice. It’s small, it’s bespoke, and the intention is to keep it that way.
Fair enough. I can’t help wondering if your methods have an element of robbing Peter to pay Paul. If I decide to exercise two hours a day, become hyperfocused on well-being, get very particular about what I eat, in the hope that I’ll be healthier and have more quality time to spend when I’m older — but I could be using that time now! Why give away all this time and energy when I’m still relatively young and healthy? Do you not see any tension or contradiction there? I see it as an optimization problem. I’ll give you a personal example that happened today: My son in kindergarten had a thing at school. Parents come in, and from 9 to 9:30 the kids are going to read you the story that they wrote. This poses a challenge for my schedule, because from 6 until 7:15, when my kids go to school, I’m with my wife and kids. Then the second my kids leave until about 8, I’m getting as much work done as I can before I jump in the gym — I usually work out until 10:30. Then my day runs scheduled, 11 to 5. Well, today, not only do I have my son’s thing at 9, but then I have my skin exam at 10:30. Once a year, you’ve got to get the dermatologist to look you over for moles. So I had a choice to make, which was I could have punted on going to my son’s thing and got my full workout in, or I could have squeaked in a 45-minute workout, then gone to the dermatologist. I thought about this for two nanoseconds, and it was clear what the right thing was: I’m not going to miss this school thing, because that’s not the dad I want to be. That’s costing me a little in terms of fitness. Today was supposed to be a killer day: squats and dead lifts. It didn’t happen. I didn’t do my blood-flow restrictions. I missed stuff that I wanted to do, but that’s the trade-off I wanted to make. We have to think about those things constantly. I could say, “I am going to spend this summer in Ibiza, partying with my friends, never lifting a finger, and boy, will I have fun.” But the price I will pay with my health is too great.
One summer would be that bad? I’m not 25 anymore. I don’t want to suggest that I’m an old man, but when I was 40 I had a superhuman ability to exercise and recover. I don’t have that anymore. When I do a crushing workout today, I feel it for the rest of the day. Let’s give you another example. Do you want to eat like a monk every minute of every day? No. I love food. My days of being a freak around food are over. Now, I don’t think I’m as healthy as I was from 2011 to 2014, when I had the most restrictive diet in the history of diets. I was a physical specimen. Seven percent body fat. My biomarkers were out of this world. But if my kids made cookies, I couldn’t eat them. I couldn’t go to Italy and eat a thing. Whereas now, I could go to Italy and eat anything. I pay a little price for a week, but I can get back in the zone. Same with alcohol. There is zero reason to consume one gram of ethanol. I still probably have five or six drinks a week, because I really, really like tequila and mezcal.
So more specifically, how would you suggest people think about balancing adherence to what strikes me as your pretty demanding health strategy and not letting that plan get in the way of the pleasures that make life worth living in the first place? You have to think about it the way you think about retirement. Let’s pretend you’re making $100,000 a year, and you’re 40 years old. At some point, you’re going to find yourself at an age where maybe you don’t want to work as hard. You’re going to have to put money away for that time. You can do the math that says: This is how old I am, this is how much I make, this is the standard of living I want, this is how long I want to work, this is my risk appetite for how I invest, and therefore this is approximately what I need to do. What I’m saying is no different from that type of analysis. For me, I’m tethered to the marginal decade. I think about that all the time because I’ve seen too many examples of what a bad marginal decade looks like, and that’s not what I want. The beauty of the marginal decade is: I’m not going to be working, I’m not going to have any nonsense that’s going to bug me anymore. The only thing that matters is spending time with people you care about and the state of your health to enjoy those relationships — not being in pain, being able to travel, to play in a park. If you can’t do that, I don’t care how much you partied in Ibiza; it’s not worth it.
But saving for retirement has metrics that we can apply to help us achieve our goals. What are the analogous metrics when it comes to healthful aging? That’s what we do with patients. I’ll use my example: I have a paper where I draw my lifeline. So I’m at 50. Then I go out by decade: at 60, 70, 80, 90. So what is the game between 80 and 90? I have a specific list of things — probably more than 25 — that I want to be able to do in that decade. It’s not just like I want to be able to walk. It’s like I want to be able to walk at this speed for this duration; I want to be able to pull myself out of a pool if there are no steps; I want to be able to pull back on a compound bow with a 50-pound draw weight. Then we deconstruct each of those from objective measurements. What VO2 max is required to do that? What amount of leg strength? What amount of lower-leg variability? What grip strength? Then we ask, given the inevitable decline of all those features, if you want to have those parameters at 90, what do they need to look like at age 50? What do they need to look like at age 70? At 80? Just as we use a discount rate on future cash flows to figure out retirement, we’re doing the same thing on physiologic parameters. All of my training is geared toward performance 40 years from now.
Does your wife have the same health regimen as you? I mean, my wife is a very healthy woman. She’s an amazingly fit human being, eats sensibly, sleeps well. Nobody meets her and thinks she’s a psycho.
Unlike you. [Laughs.] Yeah. People meet me and think I’m intense, and I keep telling them, I’m not actually that intense.
Do you think about your kids in terms of Medicine 3.0? I think about it. I’ll give you silly examples. My kids wear minimalist shoes and have standing desks at home. I know the damages of oversize running shoes, where basically they lose the proprioception of their feet. I know the damages of sitting. They have to sit at school. I can’t change that, but they’re not going to sit that much at home. If they’re watching TV, they’re going to do it standing. They’re going to wear minimalist shoes when they run around and play sports. We’re not crazy, but those are subtle things. They also come in the gym with me. They don’t really work out, but they see that Mom and Dad work out a lot. I bring them when I go for rucks. I think it’s mostly creating a mind-set around being healthy.
This is a somewhat random question, but in the book there’s an aside where you’re talking about trying to be more empathetic. And the scenario you give is being understanding about your wife being sharp with you because you realize, among other things, that maybe earlier in the day she was waiting in line at the deli counter to get your meat sliced a certain way. How exactly do you like your deli meat sliced? Oh, I am fanatical about it being microtomed. If you go up to the counter, you can get it really, really, really thin, but if you buy the prepackaged —
It’s too thick. And if the deli slices earlier in the day — you know how they’ll sometimes slice it earlier in the day? They do it too thick for my taste.
What does Esther Perel make of the work you do? I have never asked her that question. I understand why I initially got into this space. I got into this because I didn’t want to die. I wasn’t afraid of death; I was afraid of dying. I was afraid of not finishing what I knew I needed to do. I was afraid of being incomplete, not being a great fill-in-the-blank: father, husband, son, brother. Just thinking, I need more time to fix it. But I was never fixing it. I was just running. I don’t feel that way today. I don’t feel like I’m in this frenetic race to not die.
Can I share my theory about you? Of course.
I think as a young child, you had a deeply scarring, formative loss of control as a result of being abused, and you’ve since been compelled to carve out a life of total control, especially over your own body. It’s certainly possible. There’s no question that I was drawn at such a young age to boxing and training and exercising. It was like, there was nobody that was ever going to be able to harm me again. That to me is unmistakable. I’ve never really thought about the connection you’ve made, but I’m open to nonlinearity and orthogonal logic when it comes to that.
You do rationally understand that you probably won’t get to decide the terms of your decline and when and how you die, right? It’s all about controlling what I can control, which improves the odds that I will get the desired outcome. Look, there could be a cancer brewing inside me today that I’m unaware of that ends my life next year. I understand that. And if that’s the case and I’m on my death bed in a year, I won’t regret how hard I’ve worked to try to live a longer, better life. I’ll have given it my all.
This interview has been edited and condensed from two conversations.
David Marchese is a staff writer for the magazine and writes the Talk column. He recently interviewed Emma Chamberlain about leaving YouTube, Walter Mosley about a dumber America and Cal Newport about a new way to work.