Want to Live Longer and Healthier? Peter Attia Has a Plan.

“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. [..]

[Marchese] 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?

[Attia] 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.”

[Marchese] 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?

[Attia] 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. [..]

[Marchese] 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?

[Attia] 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.

[Marchese] 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?

[Attia] 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. [..]

[Marchese] 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?

[Attia] [..] 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 reallyreally like tequila and mezcal.

[Marchese] [..] 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?

[Attia]  I’m tethered to the marginal decade [Attia’s term for the last decade of your life, when, typically because of declining physical and mental health, you can no longer participate in the activities that bring you pleasure]. 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.

[Marchese] 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?

[Attia] 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.”

Full article, D Marchese, New York Times Magazine, 2023.5.21