Derek Sivers
Outlive - by Peter Attia

Outlive - by Peter Attia

ISBN: 0593236599
Date read: 2023-05-10
How strongly I recommend it: 7/10
(See my list of 360+ books, for more.)

Go to the Amazon page for details and reviews.

Expert advice on how to stay healthy into middle and old age. First half of the book was fluff for context. Second half was great specific advice. In short: exercise as much as an athlete.

my notes

The odds are overwhelming that you will die as a result of heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction.

The time to repair the roof is when the sun is shining.

If you increase your muscle strength and improve your cardiorespiratory fitness, you have also reduced your risk of dying from all causes by a far greater magnitude than you could achieve by taking any cocktail of medications.

Exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention.

The older you get, the healthier you have been.

Older people who were put on a regular exercise program shifted to a more youthful pattern of gene expression after six months.

Hungry animals become more resilient and better able to survive.

“Metabolic syndrome” (or MetSyn) is defined in terms of the following five criteria:
* high blood pressure (>130/85)
* high triglycerides (>150 mg/dL)
* low HDL cholesterol (<40 mg/dL in men or <50 mg/dL in women)
* central adiposity (waist circumference >40 inches in men or >35 in women)
* elevated fasting glucose (>110 mg/dL)
If you meet three or more of these criteria, then you have the metabolic syndrome.

I insist my patients undergo a DEXA scan annually - and I am far more interested in their visceral fat than their total body fat.
I have all my patients tested for apoB regularly, and you should ask for the same test the next time you see your doctor.
If you have a history of premature heart attacks in your family, you should definitely ask for an Lp(a) test.

There’s no connection whatsoever between cholesterol in food and cholesterol in blood.

Lipid-Lowering Medications:
rosuvastatin (Crestor)
bempedoic acid (Nexletol)
ezetimibe (Zetia)
PCSK9 inhibitors
Ethyl eicosapentaenoic acid (Vascepa)

Excess weight is a leading risk factor for both cancer cases and deaths, second only to smoking.

Caloric restriction is the low-hanging fruit of cancer prevention, right up there with quitting smoking.

Fasting, or a fasting-like diet, increases the ability of normal cells to resist chemotherapy, while rendering cancer cells more vulnerable to the treatment.
Combining a PI3K inhibitor with a ketogenic diet

Lynch syndrome guarantees that its carriers develop early-onset colon cancer, but they are also at very high risk for other cancers.
Some patients with mismatch-repair deficiency (common in Lynch syndrome) had been successfully treated with Keytruda, the anti-PD-1 drug.

The most important tool in our anticancer arsenal is early, aggressive screening. Catching cancer early.
Earlier-stage cancers comprise fewer total cancerous cells, with fewer mutations, and thus are more vulnerable to treatment with the drugs that we do have, including some immunotherapies.
Early detection is our best hope for radically reducing cancer mortality.

Colon cancer has been documented to appear within the span of as little as six months to two years after a normal colonoscopy.
Colorectal cancer is one of the easiest to detect, with the greatest payoff in terms of risk reduction.

Other cancers that are relatively easy to spot on visual examination include skin cancer and melanomas.
Low-dose CT scans for lung cancer.
15 percent of lung cancers are diagnosed in people who have never smoked.

The more networks and subnetworks that we have built up over our lifetime, via education or experience, or by developing complex skills such as speaking a foreign language or playing a musical instrument, the more resistant to cognitive decline we will tend to be.
The brain can continue functioning normally, even as some of these networks begin to fail.
This is called “cognitive reserve,” shown to help resist the symptoms of Alzheimer’s disease.
Takes a longer time for the disease to affect their ability to function.
“Movement reserve” is relevant with Parkinson’s disease.
People with better movement patterns, and a longer history of moving their bodies tend to resist or slow the progression of Parkinson’s.
Exercise is the only intervention shown to delay the progression of Parkinson’s.

Robust blood flow is critical to maintaining brain health.

Improve glucose metabolism, inflammation, and oxidative stress.
Switch to a Mediterranean-style diet, relying on more monounsaturated fats and fewer refined carbohydrates, in addition to regular consumption of fatty fish.
Supplementation with the omega-3 fatty acid DHA, found in fish oil, may help maintain brain health.

Ketogenic diet: cut out not only added sugar and highly refined carbohydrates but also alcohol.

A regular exercise program, focusing on steady endurance exercise to improve her mitochondrial efficiency.
Endurance exercise produces factors that directly target regions of the brain responsible for cognition and memory.
It also helps lower inflammation and oxidative stress.

Grip strength, an excellent proxy for overall strength, was strongly and inversely associated with the incidence of dementia.
No upper limit or “plateau”: the greater the grip strength, the lower the risk of dementia.

Sleep is when our brain heals itself; while we are in deep sleep our brains are essentially “cleaning house,” sweeping away intracellular waste that can build up between our neurons.

Sauna use is linked to brain and heart health.
At least four sessions per week, of at least twenty minutes per session, at 82C or hotter seems to be the sweet spot to reduce the risk of Alzheimer’s by about 65 percent (and the risk of ASCVD by 50 percent).

What’s good for the heart is good for the brain.
Vascular health (meaning low apoB, low inflammation, and low oxidative stress) is crucial to brain health.
What’s good for the liver (and pancreas) is good for the brain.

Regular exercisers live as much as a decade longer than sedentary people.

Peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, is perhaps the single most powerful marker for longevity.
Even someone of moderate fitness (40th to 60th percentile) is still at more than double the risk of all-cause mortality than the fittest group.
Extremely high aerobic fitness was associated with the greatest survival.

Having more muscle mass and stronger muscles helps support and protect the body.
It also maintains metabolic health, because those muscles consume energy efficiently.
Your exoskeleton (muscle) is what keeps your actual skeleton (bones) upright and intact.
Having more muscle mass on your exoskeleton appears to protect you from all kinds of trouble.

A lower risk of falling, a leading but oft-ignored cause of death and disability in the elderly.
Falls are by far the leading cause of accidental deaths in those ages sixty-five and older.

Find a way to lift heavy weights four times per week, no matter what.

Adopt the philosophy of a decathlete: the ten most important physical tasks you will want to be able to do for the rest of your life.
Visualize, with great precision, exactly what kind of fitness you need to build and maintain as you get older.
(Hike with a twenty-pound backpack for an hour. Carry my own luggage. Walk up a steep hill.)

To be able to climb four flights of stairs in your 80s means you should be able to sprint up those same stairs today.
You need to be doing much more now to armor yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age.

Jack LaLanne kept doing his usual rigorous daily workout right up until his death at age 96.

Various levels of intensity all count as cardio but are fueled by multiple different energy systems.
Long steady endurance work, and maximal aerobic efforts where VO2 max comes into play.

Stability is just as important as aerobic.
Stability makes us bulletproof.
Place a great deal of emphasis on long, steady endurance training.

Healthy mitochondria are key to both athletic performance and metabolic health.

Remaining in zone 2: If we are “feeling the burn” in this type of workout, then we are likely going too hard, creating more lactate than we can eliminate.

Using a small handheld lactate monitor, to make sure my pacing is correct.
The goal is to keep lactate levels constant, ideally between 1.7 and 2.0 millimoles. This is the zone 2 threshold.

3 hours per week of zone 2, or 4 45-minute sessions, is the minimum required for most people to derive a benefit and make improvements.
Four times a week, I will spend about an hour riding my stationary bike at my zone 2 threshold.

Introduce VO2 max training after about five or six months of steady zone 2 work.
Your VO2 max is an important number that you can and should know.
The VO2 max test is an unpleasant affair that entails riding an exercise bike or running on a treadmill at ever greater intensity, while wearing a mask designed to measure oxygen consumption and CO2 production.
VO2 max declines steeply with age. This decline corresponds to diminished functional capacity.
Train for as high a VO2 max as possible. Reach for the elite level for your sex, but two decades younger.
Increasing your VO2 max makes you functionally younger.
VO2 max can always be improved by training, by supplementing our zone 2 work with one or two VO2 max workouts per week.
VO2 max intervals range from three to eight minutes.
Go four minutes at the maximum pace you can sustain for this amount of time - not an all-out sprint, but still a very hard effort. Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down to below about one hundred beats per minute. Repeat this four to six times and cool down.
Get as close to fully recovered as possible before beginning the next set. If you fail to recover sufficiently between sets, you will not be able to reach your peak effort. Give yourself enough time to warm up and then cool down from this intense effort.

Even if someone has been training diligently, a short period of inactivity can erase many of those gains.

Bone mineral density or BMD. Measure BMD every year, looking at both hips and lumbar spine using DEXA.
This also measures body fat and lean mass, so it’s a useful tool across all of the body-composition domains.
BMD is important, demanding at least as much attention as muscle mass.

Strength training, especially with heavy weights, stimulates the growth of bone.
Think of strength training as a form of retirement saving. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach older age with enough of a “reserve” of muscle (and bone density) to protect us.
Incorporate some kind of carrying, typically with dumbbells, kettlebells, or sandbags, into most workouts.

Hike or walk at a fast pace with a loaded pack on your back.
3-4 days a week, I’ll spend an hour rucking around my neighborhood, up and down hills, typically climbing and descending several hundred feet over the course of three or four miles.
The 20-25kg pack on my back makes it quite challenging. A good goal is to be able to carry one-quarter to one-third of your body weight.

Structure training around exercises that improve the following.
* Grip strength
* Concentric and eccentric loading for all movements: lift the weight up and put it back down, slowly and with control.
* Pulling motions, at all angles from overhead to in front of you,
* Hip-hinging movements, such as the deadlift and squat, but also step-ups, hip-thrusters, and countless single-leg variants of exercises that strengthen the legs, glutes, and lower back.
Focus on these four foundational elements of strength.

Carry half your body weight in each hand (so full body weight in total) for at least one minute.

Test your grip by dead-hanging from a pull-up bar for as long as you can.
Men should hang for at least two minutes.

Training eccentric strength = focusing on the “down” phase of lifts.

Twice a week, spend an hour doing dedicated stability training, based on the principles of DNS, PRI, and other practices, with ten to fifteen minutes per day on the other days.
Postural Restoration Institute (PRI) (

Toe yoga is a lot harder than it sounds, which is why I’ve posted a video demonstration of this and other exercises at
If you really want to go all in on toe yoga, get a set of “toe spacers,” which help restore the toes to a more natural, spread position.

Religion is a culture of faith; science is a culture of doubt.

Differentiate between behavior that maintains good health versus tactics that correct poor health and disease.
Wearing a cast on a broken bone will allow it to heal.
Wearing a cast on a perfectly normal arm will cause it to atrophy.

Don’t eat too many calories, or too few.
Consume sufficient protein and essential fats.
Obtain the vitamins and minerals you need.
Avoid pathogens like E. coli and toxins like mercury or lead.
Beyond that, we know relatively little with complete certainty.

There is no dose of alcohol that is healthy.

Nuts and olive oil are good.

Caloric restriction is the winner. The catch is that you have to do it perfectly.

Drinking alcohol is a net negative.

Continuous glucose monitoring, or CGM.
A microscopic filament sensor that is implanted in the upper arm, attached to a fingertip-sized transmitter that sends data to the patient’s phone in real time.
It’s extraordinary: the patient can see, moment by moment, how their blood sugar levels are responding to whatever they eat.
CGM is available only by prescription.
It’s currently fairly easy for a nondiabetic to obtain a CGM from one of several online metabolic health start-ups.
CGM costs about $120 a month.
Use CGM only for a month or two before you begin to understand what foods are spiking your glucose.

If you consume more protein than you can synthesize into lean mass, you will simply excrete the excess in your urine.
Proteins are the building blocks for our muscles, our enzymes, and many of the most important hormones in our body.
Proteins go into everything from growing and maintaining our hair, skin, and nails to helping form the antibodies in our immune system.

That the more protein we consume, in general, the better.
If someone weighs 180 pounds, they need to consume a minimum of 130 grams of protein per day, and ideally closer to 180 grams, especially if they are trying to add muscle mass.
It should not be taken in one sitting but rather spread out over the day to avoid losing amino acids to oxidation.
The ideal way to achieve this is by consuming four servings of protein per day, each at ~0.25 g/lb of body weight.
A six-ounce serving of chicken, fish, or meat will provide about 40 to 45 grams (at about 7 grams of actual protein per ounce of meat), so our hypothetical 180-pound person should eat four such servings a day.
It’s very difficult for me to consume four actual meals. Typically, I will consume a protein shake, a high-protein snack, and two protein meals.

Only about 60 to 70 percent of protein from plants.
The overall quality of protein derived from plants is significantly lower than that from animal products.

Older people in particular should try to keep track of their lean mass, such as via a body-composition-measuring scale (or better yet, DEXA scan).

Eat more olive oil and avocados and nuts.
High-omega-3 marine PUFAs from sources such as salmon and anchovies.

Some good things happen when we are not eating:
Insulin drops dramatically because there are no incoming calories to trigger an insulin response.
The liver is emptied of fat in fairly short order.
Within three days, the body enters a state called “starvation ketosis,” where fat stores are mobilized to fulfill the need for energy.
Fasting over long periods also turns down mTOR, the pro-growth and pro-aging pathway.
Lack of nutrients accelerates autophagy, the cellular “recycling” process that helps our cells become more resilient.
It activates FOXO, the cellular repair genes that may help centenarians live so long.
Fasting triggers many of the physiological and cellular mechanisms that we want to see.
It can be useful sometimes, in some patients - typically the ones with the most severe metabolic dysfunction.

Rule of thumb for any eating pattern: eat enough to maintain lean mass (muscle) and long-term activity patterns.

New class of sleep drugs: orexin antagonist inhibitors such as Dayvigo (lemborexant) and Quviviq (daridorexant), appear to be promising.
One drug that we do find helpful for assisting with sleep is trazodone.
At the doses used to treat depression, 200-300mg per day, it had the unwanted side effect of causing users to fall asleep.
We typically use it at much lower doses, from 50-100mg.
Find the amount that improves sleep quality without next-day grogginess.
We have also had good results with the supplement ashwagandha.

Assess your own sleep habits. Sleep trackers work by measuring variables such as heart rate, heart rate variability (HRV), movement, breathing rate, and more.

Morning person and a night owl: this has a possible basis in evolution. If all members of a clan or a tribe adhered to the exact same sleep schedule, the entire group would be vulnerable to predators and enemies for several hours every night. But if their sleep schedules were staggered, with some individuals going to bed early while others were more inclined to stay up late and tend the fire, the group as a whole would be much less vulnerable.

Sleep apnea is surprisingly prevalent yet underdiagnosed. It is possible to get a formal test for this, in a sleep lab or at home, but there is yet another questionnaire, called STOP-BANG, that correlates pretty strongly with the formal apnea test.

Keep your bedroom cool - around 65F / 18C.

Most people think of caffeine as a stimulant that somehow gives us energy, but actually it functions more as a sleep blocker. It works by inhibiting the receptor for a chemical called adenosine, which normally helps us go to sleep every night. Over the course of the day, adenosine builds up in our brain, creating “sleep pressure,” or the drive to sleep. We may be tired and needing sleep, but if we ingest caffeine it effectively takes the phone off the hook, so our brain never gets the message.

The half-life of caffeine in the body is up to six hours.

A half-hour dose of strong daylight during the day, helps keep our circadian cycle on track, setting us up for a good night of sleep.

People get old when they stop thinking about the future.
If you want to find someone’s true age, listen to them. If they talk about the past and they talk about all the things that happened that they did, they’ve gotten old. If they think about their dreams, their aspirations, what they’re still looking forward to - they’re young.