Discover more from Dr. Christin Glorioso, MD PhD
I have been asked a lot recently about what I think of Peter Attia’s new NY Times bestselling book on longevity medicine, Outlive. So I decided to take a read to be able to answer this question, inform myself about what is in the popular press, and make a reasonable recommendation to read this book (or not).
On a high level, I think this book is important conceptually and represents a profound shift in medicine that is much needed. I am eager for the public to embrace “Medicine 3.0” and start seeing disease as a continuum that starts with aging in your twenties- and is something that can be abrogated to a large degree by lifestyle interventions. I agree with about 95% of the content. I think it leaves out a few things (including most of the scientific advancements in the field around reprogramming and regeneration) and there are some parts that I disagree with from a medical and scientific perspective- mostly surrounding supplements and drugs (which he claims not to go into but then does go into to some extent).
From a reader perspective, all but the last two chapters were a slog. This maybe gets explained in the epilogue when he says that the book’s first draft was super technical and then he enlisted a co-author to make it into more of a personal story. I think I would have preferred a condensed technical manual that was about 1/3 of the length or better yet, an outline with bullet points (which I created for you to some extent below). I found myself skimming through the “too general” to be interesting patient and scientist anecdotes to get to the actual medical recommendations. This is with the exception of the last two chapters- those were actually compelling to read. Those chapters were a personal story about Attia’s own trauma and struggles with mental health. I think the points made in those chapters were not only compelling to read but also highlighted a missing fundamental piece about the longevity conversation. They could have been the start of a different book.
One device that stuck in my craw was Attia repeatedly referring to himself as “not thin Peter”. This was a reference to an unkind comment his wife made to him about needing to lose some weight. This comment was never explained as her concern for his health and left me thinking that she was complaining about his physical appearance from an attractiveness perspective. And if you google pics of Attia, which I did, you’d be hard pressed to find one where he looks to be overweight. So every time he would shame himself by calling himself “not thin Peter” (possibly in an attempt to be self-deprecating and therefore relatable to the reader or just because it is a negative narrative that genuinely drives him), I felt vicariously body shamed, a feeling that wasn’t pleasant to have to continually endure.
In general, this also speaks to the current incarnation of longevity medicine that has a large superficial streak and one that also seems very privileged. Another piece of the conversation that was missing was one about access and disparities in medicine. The mental health chapters in particular were glaringly obtuse to this. Attia’s journey towards better mental health involved unfettered access to out of pocket sessions with five of the most famous therapists in the world, including Esther Perel (I’m a big fan of her) and stays at expensive private pay clinics. If this is what the journey to mental longevity requires, then almost no one has access. This is a point that at least should have a few sentences to acknowledge. Attia’s story was vulnerable and brave, but also so so privileged.
And now for those bullet points…
THE AGREE COLUMN:
“I believe that our goal should be to act early as possible, to try to prevent people from developing type 2 diabetes and all the other horsemen [diseases of aging]”… Medicine 3.0 places a far greater emphasis on prevention than treatment. When did Noah create the ark? Long before it began to rain. Medicine 2.0 tries to figure out how to get dry before it starts raining. Medicine 3.0 studies meteorology and tries to determine whether we need to build a better roof, or a boat”
“Exercise is by far the most potent longevity “drug”” 1000%
“striving for physical health is meaningless if we ignore our mental health”
“There are many examples of how Medicine 2.0 gets risk wrong, but one of the most egregious has to do with hormone replacement therapy (HRT) for postmenopausal women” [interpretations of the WHI wrongly discouraged use of HRT]- Yes!!!
We need tools with a much longer reach than relatively brief clinical trials.
“Mendelian randomization helps tease out causal relationships between modifiable risk factors” 1000%- AI is the answer to much of this.
The older you get, the more genetics matters for longevity.
Pro preventative cancer screening using liquid biopsy.
Pro preventative screening using whole body MRI.
All of the Alzheimer’s chapter is spot on except that we have no approved amyloid drugs (we have two) and he misses the “Alzheimer’s is an aging program” theory of what causes it- which is the theory that I firmly believe in.
I’m glad he realizes that he contributed to the keto diet craze and that was potentially harmful to many people.
Loved the discussion of CR and the two conflicting primate studies.
“the best nutrition plan is the one that we can sustain”- basically we need to eat a normal amount of calories- the particulars of how we do that doesn’t matter that much.
Sleep deprivation is a huge problem for health, and dangerous for patients of sleep deprived clinicians. It’s not a badge of honor. Yes!!!!
THE DISAGREE COLUMN:
On longevity science: “On the other end of the spectrum are those convinced that science will soon figure out how to unplug the aging process itself, by tweaking some obscure cellular pathway, or lengthening our telomeres, or “reprogramming” our cells so that we no longer need to age at all. This seems highly unlikely in our lifetime, although it is certainly true that science is making huge leaps in our understanding of aging and of the Horsemen of disease”
These pathways may seem obscure to Attia because he is not a scientist. To those in the biotech and scientific fields, these are not obscure at all but actionable pathways where in some case drugs are currently in phase 2 clinical trials. Or they are currently approved drugs- in the case of PI3K. I would put the timeline for the first longevity drugs to be in the next decade- definitely a longevity pathway, likely reprogramming. If you want to learn more about the exciting science and biotech in the longevity space, check out the videos on Longevity Global YouTube.Centenarians and smoking: this is not exactly a point of disagreement but there is a link between longevity and smoking in super centenarians and I don’t think this is an accident. People die increasingly from neurodegenerative diseases in the oldest ages and smoking is linked to less Parkinson’s disease. That’s not to say that we all should smoke- definitely not- smoking causes lung cancer and heart disease. But in people above a certain age- say 80 years old- we should consider creating nicotine pathway drugs or prescribing nicotine patches- my two cents. I think this has been wildly understudied.
Attia promotes a “mouse-centric” view of popular longevity drugs and supplements, rapamycin, resveratrol, and NR, and metformin. Attia notes that mice are not humans but then only seems to hang his hat on the mouse studies, largely ignoring invertebrates and human studies. 90% of drugs that pass mouse studies fail in human clinical trials. I would pay a lot more attention to human data than mouse data to understand what’s what with regard to these drugs.
Metformin: Attia himself has backpedalled on promoting Metformin for longevity in his blog but basically promotes it in this book. I am against people taking Metformin when they don’t have diabetes. The primary reason for this is multiple clinical trials pointing to a potential increase in risk of Parkinson’s disease in metformin users.
Measuring aging: “aging itself is difficult— if not impossible— to measure with any accuracy” I completely disagree with this statement. Aging clocks and other biomarkers are being developed to measure aging and are relatively easy good approximates of aging and disease risk. See also here for an NIH blog post on some recent research on this out of the Wyss-Coray lab at Stanford.
Statins are safe at high levels to lower cholesterol to levels that children have. I think this is overkill and not proven to be safe. Children fundamentally have different biology than adults because they are still developing. I think ideal cholesterol levels are those of a fit person in their twenties and we should not use drugs to go below that level.
Every single amyloid drug for Alzheimer’s has failed— not true we have had two approved drugs last year including Lilly’s Lecanemab.
He has a negative view of yoga- calling people “yoginis” disparagingly and failing to recognize the literature on its benefits for flexibility, stability, and mental health.