Selva Book Club: Outlive by Peter Attia, MD
The below is taken from Selva Ventures’ Q4 2023 Quarterly Investor Letter
For the 11th installment we read a book that we believe will be the most impactful health and wellness book of the decade. We have seen so many peers, journalists, brands and retailers change their behavior, messaging and assortment based directly on insights from Dr. Attia. In honor of its significance to our mission (and overall density of material) we’ve doubled the number of passages this quarter.
Healthspan: Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live — the quality of your years. This is called healthspan.
Peter Attia’s legacy, and the popularity of this book, will be credited to its emphasis on healthspan-focused longevity. We think living a higher quality life in our later years, NOT living longer, will be the new gold standard for healthier living. This goal is highly motivating and tangible, and it strikes a chord with people of all ages, much more so than living to 130 years old or having 6-pack abs.
Medicine 3.0: When did Noah build the ark? Long before it began to rain. Medicine 2.0 tries to figure out how to get dry after it starts raining. Medicine 3.0 studies meteorology and tries to determine whether we need to build a better roof, or a boat. (…) Medicine 2.0 relies on two types of tactics, broadly speaking: procedures (e.g., surgery) and medications. Our tactics in Medicine 3.0 fall into five broad domains: exercise, nutrition, sleep, emotional health, and exogenous molecules, meaning drugs, hormones, or supplements..
The concept of Medicine 3.0 seems like a catchy way of saying “preventative medicine”, but Dr. Attia gives a compelling rundown of why this is an entirely different philosophy. Where it starts to feel radical is in its approach to risk — aggressive and proactive screening, diet and exercise not based on visible symptoms but rather genetics, demographics and probabilities. This would be overkill to Medicine 2.0 but appears to be the key to longevity.
Metabolic Health: Today over 11 percent of the US adult population, one in nine, has clinical type 2 diabetes, according to a 2022 CDC report, including more than 29 percent of adults over age sixty-five. Another 38 percent of US adults — more than one in three — meet at least one of the criteria for prediabetes. That means that nearly half of the population is either on the road to type 2 diabetes or already there. (…) Patients with diabetes have a much greater risk of cardiovascular disease, as well as cancer and Alzheimer’s disease and other dementias; one could argue that diabetes with related metabolic dysfunction is one thing that all these conditions have in common. This is why I place such emphasis on metabolic health, and why I have long been concerned about the epidemic of metabolic disease not only in the United States but around the world.
The takeaways on metabolic health are terrifying: first, the stats on Americans suffering from poor metabolic health are staggering, and frankly much worse than I would have expected; and second, the impact of poor metabolic health extends far beyond diabetes and heart disease into cancer and neurodegeneration. This is our biggest opportunity for impact with the investments we make: educating consumers on the risk of their actions and easy, engaging solutions are critical to making exercise and nutrition more approachable and habit-forming.
Cancer: Until we learn how to prevent or “cure” cancer entirely, something I do not see happening in our lifetime, short of some miraculous breakthroughs, we need to focus far more energy on early detection of cancer, to enable better targeting of specific treatments at specific cancers while they are at their most vulnerable stages. If the first rule of cancer is “Don’t get cancer,” the second rule is “Catch it as soon as possible.” This is why I’m such an advocate for early screening.
Dr. Attia has some sobering insights on how far we’ve come in “curing” cancer, or even understanding it. He does, however, give some hope to our agency in the matter: with its links to metabolic health there are real behavioral measures we can take (beyond just not smoking) to lower our odds, and proactive screening we can do to materially reduce its impact on us if we do eventually have the disease.
Exercise: I used to prioritize nutrition over everything else, 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.
As a busy professional I have frequently gone through hectic periods where I would de-prioritize exercise but maintain my nutritional regimen. In those times I would feel like I am still making healthy decisions and taking care of myself, but I now view that as a false sense of security. Frequency and type of exercise is of MUCH greater priority to me after reading this book. I now focus much more on strength training to build lean muscle mass that I’ll need decades from now, and squeeze in quick body weight routines even when I can’t make it to the gym.
Centenarian Decathlon: The Centenarian Decathlon is a framework I use to organize my patients’ physical aspirations for the later decades of their lives, especially their Marginal Decade. (…) Think of the Centenarian Decathlon as the ten most important physical tasks you will want to be able to do for the rest of your life. Some of the items on the list resemble actual athletic events, while some are closer to activities of daily living, and still others might reflect your own personal interests. I find it useful because it helps us visualize, with great precision, exactly what kind of fitness we need to build and maintain as we get older.
This concept is my favorite in the book. Ever since I stopped playing competitive sports I have struggled to define my exercise goals — typically it’s some combination of aesthetic confidence and energy. The centenarian decathlon is far more motivating to me: what will I want to do between age 80–100 to make me happy and how do I make sure I can do it? This reframe of health goals has become a powerful motivator and behavior changer.
Protein: The first thing you need to know about protein is that the standard recommendations for daily consumption are a joke. Right now the US recommended dietary allowance (RDA) for protein is [0.36g / lb] of body weight. This may reflect how much protein we need to stay alive, but it is a far cry from what we need to thrive…. The ideal amount can vary from person to person, but the data suggest that for active people with normal kidney function, one gram per pound of body weight per day is a good place to start — nearly triple the minimal recommendation…. Protein is actually the most important macronutrient, the one macro that should not be compromised. Remember, most people will be overnourished — but also undermuscled. It is counterproductive for them to limit calories at the expense of protein and hence muscle mass.
Dozens of people in the past few months have told me they have adopted this dietary goal. I have done it myself since December, and boy is it ever difficult. 1g / lb / day is A LOT of protein — pursuing this goal has forced me to change every single dietary habit in my life: I no longer intermittent fast (can’t fit that much protein into 8 hours) and now instead eat a high protein breakfast daily, I eat a completely different lunch and snacks, and I now look at protein content even before sugar on every nutritional label that I read. Growing adoption of this diet is going to fundamentally shift consumption towards brands that make this more convenient — we’ve already seen it this year, with the protein focus at last week’s Expo West, and the reported explosive growth of brands like Chomps and Oats Over Night. I wrote about this earlier this year on Medium if you’re interested in learning more.
Emotional Health: Even just living alone, or feeling lonely, is linked to a much higher risk of mortality. While most issues around emotional health are not age dependent, this is the one emotional health “risk factor” that does seem to grow worse with increasing age.
It’s easy to dismiss mental and emotional health when discussing longevity, but a positive and vibrant social life is an incredible form of medicine just like exercise, nutrition and sleep. I’m encouraged by the growing priority of mental health in our society. I am fortunate to have four living grandparents who continue to defy their age with a powerful thing in common: an active, loving group of friends and family who ensure they are never lonely.
