Dr. Peter Attia: This Is What You Need to Do to Live Longer

HARI SREENIVASAN, CNN INTERNATIONAL CORRESPONDENT: Bianna, thanks, Doctor Peter Attia, thanks so much for joining us. Now, in your new book, “Outlive: The Science and Art of Longevity,” you’re not just trying to help us live longer, but you’re trying to get us to be healthy as well. I mean, you, you have, you kind of make a distinction between lifespan and healthspan. Spell that out.

DR PETER ATTIA, AUTHOR “OUTLIVE”: Yeah. lifespan is probably the easier of those two things to explain, which is you know, obviously how long you live. And that in that sense is, is kind of binary. It’s all or none. You’re alive or you’re not alive. And unfortunately, I think our medical system mostly fixates on that metric. And obviously what gets measured gets managed. As the old saying goes, what I think we’re not paying nearly enough attention to is the quality of life. And that’s what’s captured in healthspan, right. So there’s a, there’s a cognitive component to that. There’s obviously a very physical component to that. And there’s an emotional component to that. And if you don’t really define metrics around those things, it’s probably not surprising that we’re not managing those things. And therefore most of the resources and attention go to simply prolonging life, even at the expense of quality.

SREENIVASAN: So when a patient approaches you in your practice, I mean, kind of what are the questions that you’re asking them so that you’re kind of on the same path together?

ATTIA: Well, obviously we want to talk about all of the medical things and all of the things that deal with prolonging life as well. So we certainly want to understand all the risks coming in with respect to, you know, what we talk about as the four horsemen of death, you know, cardiovascular disease, neurodegenerative disease, cancer, et cetera. But on the healthspan side, we spend just as much time and energy thinking about, for example, what do you want to be able to do in the last decade of your life? This becomes a very important framing, framing question. And the more detail that a person can provide sometimes with our prodding as to what they actually wanna be able to do. Right. Do you want to be able to pick up a grandchild? Do you want to be able to travel? These things require very deliberate planning, and most people can’t do these things in the last decade of their life mm-hmm. Unless they train for it.

SREENIVASAN: So, you know, you took a look and studied people who were a hundred years old and was there something that they had in common that we can apply in our lives?

ATTIA: So the one thing that is common to all centenarians is that from the standpoint of chronic disease, they’re about 20 to 25 years younger than their birth certificate age says. Wow. In other words, their first brush with cancer, their first brush with heart disease, their first brush with any sort of chronic ailment is about 20 to 30 years after you would expect based on their, you know, birth certificate age. So they have a superpower, and the superpower is they delay the onset of chronic disease. Now the question of course, the million dollar question is, are they doing something in order to get that superpower right? Is it, is it, you know, is there some magic diet or something like that?

SREENIVASAN: Yeah.

ATTIA: And unfortunately, I say unfortunately, for the rest of us who don’t have those genes, the answer is no. And, and, and it’s actually more likely your observation, which is on average, believe it or not, centenarians are more likely to smoke, more likely to drink, less likely to exercise, and less likely to eat well <laugh>. And yet, despite those things, they have this supernatural lifespan. But that doesn’t mean we can’t learn from them. What we learn is we have to apply to ourselves other tools to get their benefits. In other words, we have to use nutrition, exercise, sleep, stress, all those other things as tools to get what they get for free genetically, we have to create a phase shift of time in the onset of chronic disease.

SREENIVASAN: Let’s first talk about just exercise. I mean, you write a tremendous amount that that is one of the most beneficial things that we could be doing earlier in our lives to prevent a lot of ailments.

ATTIA: Yep. Exercise is hands down, the most potent tool slash intervention that we have to affect both of the metrics we care about lifespan and healthspan. So on the lifespan side of the equation, having a very high degree of cardiorespiratory fitness, having high muscle mass and high strength relative to your sex and age is a better predictor of longer life – meaning a greater reduction of all causes of mortality, death from any causes – than anything else we have positive or negative. The benefit bestowed on an individual from being very high in those categories is greater than the harm that comes from smoking, having high blood pressure, having type two diabetes, even having kidney disease, which would be the step right before needing a transplant.(16:05) So as much as we understand how harmful those things are, it’s even more beneficial to be incredibly fit and incredibly strong. So if you’re just thinking about how do I live longer, that’s the ticket. On the other side of the ledger, when we think about the quality of life, there simply is no greater tool to foster neurodegenerative, neuroprotection and ward off neurodegeneration than exercise. And of course, exercise is the most important piece in maintaining your physical body as you age. So you can do all those things you would wanna do in that last decade of your life.

SREENIVASAN: Is there a combination of things that will help your body prepare for aging better than anything else?

ATTIA: You know, if there’s one drawback to exercise, it’s that it takes more time than all of the other things that we might think of as being beneficial. Few things take as much time to reap the full benefit from as exercise. You need to be doing strength training, you need to be doing cardio respiratory training. And that cardio training needs to be at different levels of intensity. About 80% of it needs to be at relatively low intensity. The level of intensity at which you could still carry out a conversation, albeit a strained one, and about 20% of it needs to be at a higher level of intensity where you couldn’t carry out a conversation. And I think for the individual who says, look, Peter, I am not willing to spend more than 90 minutes a week exercising. Yes. I would rather have them, you know, focus on what’s not necessarily what I think the best approach to exercise is, but doing whatever they can to get some benefits. But the way I ask my patients is very different. I start in reverse. I say, tell me how many hours a week you’re willing to put into this. And I, I’ve already explained to them and shown them all the data that explained why this is gonna have a greater impact on the length and quality of their life than anything they will ever do.

SREENIVASAN: Let’s talk a little bit about nutrition you for a time being, were a big fan of keto diets and in the book you kind of walk through why and how you changed your mind about that. Explain to our audience how should we be thinking about nutrition in the context of aging?

ATTIA: I go to great lengths in the book to detach from diets and really just talk about nutrition as a biochemistry phenomenon. Let’s just talk about it through the lens of biochemistry and molecules. The most important component of your nutrition is basically the energy balance it creates in your body. In other words, is a person undernourished or overnourished? Now, for most of our existence, we have been undernourished, right? For, if you think about a thousand years ago, 500 years ago, 200 years ago, most of us were barely getting enough energy <laugh>, right? And, and our bodies of course evolved remarkable ways to store and hold onto energy. This is what basically allowed us to leapfrog ahead of all other species in terms of our remarkable brains because our brains are so energy hungry. Well, that worked really well until our, you know, modern environment, which basically created such an abundance of food that now most of us are on the other side of that we are overnourished. Strategy number one is you have to reduce energy intake. And there are basically three approaches to that, each of which can work, each of which has advantages and each of which has disadvantages. So broadly speaking, they are direct caloric restriction, dietary restriction, and time restriction. To say a bit more about them; Direct caloric restriction, as the name suggests, means you just deliberately go about eating less while paying attention to how much you are eating. Not necessarily paying attention to when you’re eating or what you’re eating, but just reducing the total caloric burden. Dietary restriction of which you mentioned an example, a ketogenic diet is a form of dietary restriction, but so are most quote unquote diets. This is when you just restrict certain elements within the diet. And what that results in is less overall consumption. So it’s an indirect way to go about calorie restriction. Finally, time restriction is also an indirect way to go about calorie restriction by creating a narrower and narrower window in which you eat. And if you create a narrow enough window, you will end up reducing intake. Now, you know, we don’t have to go into the details of how each of these has a benefit, and each of these has a risk, but none of these are, you know, things that you should do mindlessly. Each of these are things you have to be mindful of the blind spots and pitfalls and work around them.

SREENIVASAN: You spend a fair amount of time talking about sleep, Why is it as important? I mean, I’m somebody who doesn’t get enough sleep and I feel like it’s underrated, but at, you know, younger points in my life, I didn’t really think about how much I was getting. Maybe cuz I was obviously younger and I was fitter and I was able to rebound faster. But now if I don’t get a good night’s rest, it’s really difficult to perform at the same level every day.

ATTIA: In the book I talk about a thought experiment, which is effectively like, you know, evolution didn’t muck around, right? Evolution, <laugh>, everything about evolution is really laser focused. And if you think about it, no one disputes that we are optimized to forage for food, to reproduce, to fend for ourselves. I mean, these are the characteristics that evolution honed. Why would evolution have kept around this behavior that rendered us unconscious for eight hours a day? It just doesn’t make any sense. And the only way you could really justify this is if that eight hours ie one third of our life that is spent in unconsciousness must be doing something so important. We have never figured out a way to evolve it. We’ve never even figured out a way to reduce it by half. Like it’s basically just stuck there at about seven to eight hours. And I, that’s kind of what I think I talk a little bit about in the book, right? Is like, what are those features of sleep? Why is that important to brain health? Why is that important to memory consolidation? Why does that play a profound role in metabolism? Right? So many of the problems that I think we have with obesity, metabolic health, insulin resistance, type two diabetes can actually be attributed to poor sleep just as much as they can be attributed to poor diet.

SREENIVASAN: You know, a lot of the book also, it takes a critical look at our existing healthcare system you write, that both health insurance companies won’t pay a doctor very much to tell a patient to change the way he eats or to monitor his blood glucose levels in order to help prevent him from developing type two diabetes. Yet insurance will pay for this same patient’s very expensive insulin after he’s been diagnosed. So is there a way to turn what seems like the largest industry in the country around to think kind of proactively instead of reactively?

ATTIA: I mean, there clearly is from a conceptual standpoint, from a structural standpoint, I don’t want to be naive and suggest that it’s going to be easy. But that example that you, you read the quote from I, I think illustrates kind of the point, right? Which is everything follows the dollar. And I don’t say that as a skeptical guy, like, dollars are important, I’m a capitalist. It’s all about, you know, you have to set the right economic incentives. But right now the economic incentives in medicine are around diagnosis and pharmacologic treatment. And I’m not here to say pharmacologic treatments don’t matter. They’re very important and we do rely on them. But the point here is we were really only educated along one parameter of intervention, which is procedural and pharmacologic. And if the entire system of reimbursement is based on creating a diagnosis and developing a treatment plan along those metrics, and by the way, go back to what I said at the outset, the only metric of interest is length of life. You, you will create the machine we have called Medicine 2.0. And by the way, medicine 2.0 was very successful at treating some things, namely infectious diseases and acute problems such as trauma. This is what has effectively doubled the lifespan of humans in the last 150 years. It’s the success of that model Medicine 2.0 applied in that way, which is wait till the problem happens, treat it with pharmacologic intervention or procedural intervention. Yeah. What we’re seeing is that playbook is not working with chronic diseases, not even close. And the only way you’re gonna treat chronic diseases is moving on to an approach where you treat you, where you really enact prevention. And if you want to incentivize physicians to do that, they have to be educated in this way. And you have to be able to reimburse for these tools. You have to be able to reimburse physicians and you have to be able to incentivize patients to take care of themselves 30 years before they have that heart attack.

SREENIVASAN: If you were to advise a patient that’s heading to their doctor, what are the kinds of things that you would tell ’em to kind of perk their ears up on or listen close to this number that are good guides for healthfulness?

ATTIA: I want patients to understand there are some things that labs are really good at. There are a lot of things they’re not good at. Everybody should know their ApoB. ApoB is a number that measures the total concentration of the cholesterol carrying particles in the blood that drive atherosclerosis, which is the dominant force driving heart disease. Again, can’t say it enough, right? Heart disease is the leading killer globally. About 19 million people per year die of atherosclerotic cardiovascular disease, which dwarfs the number two killer, by the way, which is cancer at about 12 to 13 million. So you’ve gotta know this, ApoB concentration. Everybody at least once in their life needs to have their LPa measured, that’s a, that’s genetically determined. So once you’ve measured it once, you don’t really need to recheck it. And we think everybody needs to know their ApoE genotype. This is a gene that plays an important role in Alzheimer’s disease and also in cardiovascular disease. And knowing that can help you understand how aggressive you might need to be in prevention. So those are a handful of the things that, you know, we just think are very important for everybody to know.

SREENIVASAN: You write in the book about emotional health and why it’s so important. And there’s a line from your therapist that kind of sums up the whole book: “I mean, why do you wanna live longer if you’re so unhappy?” I mean, it’s just a pretty simple question, but pretty profound.

ATTIA: Yeah. This is another one of those things that doesn’t show up anywhere in the standard diagnostic list of criteria. And it’s one of those things that probably matters more than anything else, because if you don’t have it, nothing else matters, right? So if, if your life sucks, living longer is actually a curse, not a blessing, regardless of the state of your physical health. So I do think that even though it’s probably not something as a profession, we spend enough time talking about, we do really want to understand what a person’s sense of purpose is, how strong their relationships are. I do think that generally people understand that there’s a reasonable correlation between the strength of your relationships and your happiness. Yeah. And there’s a reasonable correlation between happiness and length of life. And I, and I think that there’s some causality there too. And I, and I think the real question becomes, what can you do about it? Right? At, at the individual level, if you’re sitting where I was sitting six years ago, which was to say, you know, physically healthy but not emotionally healthy, can, can you bend the arc of that curve in the same way that you can bend the arc of the curve of your fitness, your muscle mass, your strength, your lipid numbers, your insulin resistance numbers? And the answer unequivocally is yes.

SREENIVASAN: Dr. Peter Attia, author of “Outlive: the Science and Art of Longevity.” Thanks so much for joining us.

ATTIA: Yeah, thank you so much for having me.