Book review: Outlive by Peter Attia and Bill Gifford

Exercise daily, sleep well, get more protein, and prioritize your mental health

Here are my key takeaways of what you should do to live a long & healthy life according to the book:

1. Prioritize your emotional/mental health. This is probably more important than all the other factors.

   • Why would you want to live a long & healthy life if you aren't happy?

2. Exercise ~every day for the rest of your life. Peter Attia recommends an (ambitious) weekly regimen of:

   • 4 hours of zone 2 cardiovascular training

   • 1-2 hours of VO2 max (peak aerobic output) training

   • 4 hours of strength workouts (resistance training)

   • 1-2 hours of stability training (similar to what others would call flexibility/mobility/Pilates)

   • Generally, the book is super bullish on exercise as the most potent mediator of longevity.

3. Make sure you sleep well (sufficient quantity and high quality).

4. Make sure to cover your daily protein intake needs to achieve muscle growth. At least 1.6 g and up to 2.2 g per kg body weight if you are very active.

   • Nutritional biochemistry is important, but Attia urges readers to stop with all the quasi-religious fights about diet (vegan vs. keto vs. low-fat etc.), which doesn't matter so much.

     • What matters is distancing yourself from the horrible standard American diet (SAD).

   • Ask yourself:

     • Are you undernourished, or overnourished?

       • Calories in, calories out are the most important factor here.

     • Are you undermuscled, or adequately muscled?

       • Make sure to cover your protein needs, as stated above, if you need to build muscle.

     • Are you metabolically healthy or not?

       • Fasting can be useful to help fight insulin resistance in the most metabolically unhealthy people but isn't helpful for most people, as it conflicts with meeting your protein target.

   • Exercising is much more important than nutrition as long as you aren't eating absolute garbage (SAD).

5. Consider starting to take a statin or other apoB-lowering medication even if you are only in your twenties or thirties. Of course, consult with a physician and pay close attention to side effects. Peter Attia advocates for aggressively low LDL-C levels and takes an „as low as possible“ stance on apoB. This is quite extreme compared to regular medical practice, so I advise researching this yourself to see whether you buy it or not.

The book is characterized by the typical productivity-ish writing formula (think: Atomic Habits). Every chapter starts with an anecdote about one specific person, often Peter Attia himself or one of his friends. This makes it more engaging by leveraging our scope-insensitive stone-age biases, as we care much more about the stories of individuals than statistics.

In general, I was already familiar with most of the book's contents from Peter Attia's podcast and other sources. Still, I found it useful to have everything condensed together and laid out quite well. I thought that especially the case for focusing on preventing metabolic dysfunction is quite strong, as it is a risk factor for so many other diseases.

A few things surprised me. 

I have a lot of respect for people publicly changing their minds in a large way: Peter Attia used to be super bullish on fasting; IIRC, he did a 10-day water fast every 3 months for years himself. He even owns (?) an app dedicated to fasting (Zero). Yet in the book, he more or less dismisses fasting for longevity purposes for all but the most metabolically unhealthy people. The main reasoning behind this seems to be that fasting makes it much harder to meet your protein consumption and muscle-growth targets and therefore conflicts with building strength, which is hugely important for longevity. In fact, many people appear to lose lean mass (muscle) when they go on fasts.

He addresses not only prolonged fasts but also intermittent fasting (time-restricted eating), which has become very popular. I have been doing a 16:8 h TRE regimen on and off myself for a few years. For most of that time, I was aware of the issues with the research behind TRE, and it drove me crazy when even scientifically literate people like Andrew Huberman cited research in mice on a 16:8 h schedule as evidence that humans would get the same metabolic benefits when following that schedule (fasting for 16 h is very very different for a mouse than for a human)¹. Nonetheless, I mostly stuck with it because I figured that it could maybe have a small longevity benefit (something something mTOR), and I found it very easy to stick with as skipping breakfast also allowed me to save time in the mornings and concentrate more on work.

Now, I am relatively convinced that it seems better to drink a big protein shake in the morning instead of skipping breakfast entirely. The book explains that protein intake should ideally happen in 4 separate servings throughout the day. If you want to cover your protein needs mostly from plant sources (like me), you also need to pay special attention to amino acid composition, as protein quality scores are generally somewhat lower compared to animal sources. IIRC, vegans tend to be especially bottlenecked by leucine, lysine, and methionine, as, apparently, those are especially crucial for muscle growth. Managing to get all this protein over 4 separate servings is very difficult on a TRE schedule.

Most of the book’s recommendations about how to stay healthy are common sense: Exercise a lot, sleep well, take care of your mental health, etc. Another type of advice that your grandma could have also told you was emphasized surprisingly little: Eat your veggies. In fact, doing cmd+f for “vegetable” only returns 6 hits. Maybe the fact that eating vegetables is good for you is too obvious to warrant discussion here.  

In the last chapter on emotional health, Attia serves as a powerful negative role model of what kind of person you don't want to become. It is courageous to write about yourself like this, and I found it quite moving:

I wasn’t just some garden-variety road-raging maniac either. It was much worse than that. A few months earlier—on Tuesday, July 11, 2017, at 5:45 p.m., to be exact—I had received a call from Jill, my wife. She was in an ambulance with our infant son, Ayrton, on the way to the hospital. For some reason, he had suddenly stopped breathing and fallen unconscious. His eyes were completely rolled back in their sockets and he was lifeless and blue, with no heartbeat. Only the quick reaction of our nanny had saved him. She rushed him to Jill, who is a nurse. Her instincts took over and she immediately put him on the floor and began performing CPR, rhythmically but carefully pressing her fingers on his tiny sternum as the nanny frantically dialed 911. He was barely a month old. By the time the firefighters stormed into the house, about five minutes later, Ayrton was breathing again, and his skin was turning from blue back to pink as oxygen returned to his body. The firemen were stunned. We never see these kids come back, they told Jill. To this day, we still don’t know how or why it happened, but this is likely what occurs when babies die suddenly in their sleep: they choke for a moment on their own saliva, or some other vasovagal insult occurs, and their very immature nervous system fails to restart their breathing. When Jill called me from the ambulance, I was in New York, in a taxi on Fifty-Fourth Street, on my way to dinner. After she finished telling me the story, I just said, without a shred of emotion, “Okay, call me when you get to the hospital, so I can talk to the doctors in the ICU.” She got off the phone pretty quickly, and, of course, it’s obvious why she was upset: our son had nearly died, and the right thing for me to say, the only thing to say, was that I was getting the next flight home. Jill stayed in the hospital with Ayrton, alone, for four days. She pleaded with me to come home. I called in daily to talk to the doctors and discuss each day’s test results, but I stayed in New York, busy with my “important” work. Ayrton’s cardiac arrest happened on a Tuesday, but I did not come home to San Diego until Friday of the following week. Ten days later. Even today, just thinking about what happened, I feel nauseous about my behavior. I can’t believe I did that to my family. I can’t believe what a blind, selfish, checked-out husband and father I was. And I know I may never fully forgive myself for it, for as long as I live. 

The whole chapter is basically a case study of how important it is to prioritize your emotional/mental health. Without good relationships with your family, friends, and, most crucially, yourself, there isn't much point in living a long and physically healthy life. 

1. I remember hearing an amusing anecdote that the researchers studying the 16:8 h schedule in mice chose that time window because it allowed the grad student in charge of taking care of the mice to go home to his girlfriend at a reasonable hour. This shows that there is nothing magical about fasting for 16 h; it is a completely arbitrary number. Unfortunately, I can't find a source for this, so take it with a grain of salt. Please point me to the source if you have a reference in mind.