Table of Contents

The Book in Three Sentences

In this book summary of Outlive, you’ll learn to live longer and better. The author uses the latest advancements in the world of nutrition, exercise, sleep, and emotional and mental health to help us avoid the diseases of aging. With this in mind, Peter Attia created a framework to take action now, rather than when it’s too late.

Buy the Book

Outlive Summary

Chapter 1: The Long Game – From Fast Death to Slow Death

The author specializes in longevity, a problem that has puzzled mankind for thousands of years. Despite what people think, longevity isn’t the same as living forever. Unless there’s a medical breakthrough that changes things, everything alive will eventually die. Longevity isn’t about celebrating more birthdays while our health slowly declines. Longevity is about living longer and better.

Death comes at two speeds: fast and slow. Fast death is the result of automobile accidents or street violence. Slow death, on the other hand, is the result of diseases that go undetected for too long until it’s too late to stop them. At the beginning of the 20th century, most people died fast, but that’s changed recently and now people die of slow causes. The most common causes of death are what the author calls the Four Horsemen: heart disease, cancer, neurodegenerative disease, and type 2 diabetes. There are two parts to longevity: how long you live (lifespan) and how well you live (healthspan). This book encourages us to think about longevity so that we can do something about it now.

Most doctors have skills that are effective against fast death, but not so effective against slow death. To mitigate the issue of slow death, we must prevent people from developing certain diseases in the first place. The four diseases the author calls The Four Horsemen are part of a process. In other words, they are the result of numerous risk factors compounding over time.

Chapter 2: Medicine 3.0 – Rethinking Medicine for the Age of Chronic Disease

Modern medicine refuses to change even if that means saving lives. To change this, modern medicine could benefit from understanding risk. Some medical procedures are risky, but if they save someone’s life, the rewards are worth it. Risk shouldn’t be avoided at all costs. Risk is something to understand, analyze, and embrace. Every decision we make is based on a relationship between risk and reward. We also tend to forget that doing nothing is also a choice.

We can recognize three eras in medical history. The first era is what the author calls Medicine 1.0 and it was based on direct observation, as well as guesswork. This era lasted around two thousand years. Medicine 2.0 took place in the mid-nineteenth century and started with the germ theory of disease. As a result, we improved our sanitary practices and we discovered antibiotics. Next comes the current era or what Attia calls Medicine 3.0. This era is about preventing diseases from appearing rather than treating them when they do.

Chapter 3: Objective, Strategy, Tactics – A Road Map for Reading This Book

As we age, we all expect our health to decline to the point that we can barely take care of ourselves. This is avoidable by thinking about the last decades of our lives (our seventies and beyond). Suffering one of the Horsemen diseases and being unable to do activities you once loved is what the author calls the Marginal Decade.

When it comes to planning for the future, most people choose immediate gratification instead of potential gains. In economy, this tendency is known as hyperbolic discounting. To enjoy a healthy life in your later years, you must maintain and improve your physical and mental functions consistently. Medicine 2.0 delays your death without improving your quality of life, but that’s not the ideal trajectory. What you want is to maintain or improve your healthspan into your fifties and beyond. This helps you turn a Marginal Decade into a Bonus Decade. In other words, we want to delay death and take advantage of those extra years.

There are no shortcuts to get there. It’s not about following a strict diet, implementing a specific workout, or taking supplements. Instead, we need tactics (what you do) and a strategy (recognizing the strengths and weaknesses of the most common chronic diseases). Our tactics fall into different domains: exercise, nutrition, sleep, emotional health, and drugs and supplements. Our strategy, on the other hand, involves delaying death from chronic diseases using Medicine 3.0.

Chapter 4: Centenarians – The Older You Get, the Healthier You Have Been

A lot of centenarians attribute their longevity to unhealthy rituals like drinking alcohol, smoking cigarettes, or eating bacon. In reality, there’s no one secret to living a long, healthy, happy life. So studying the habits and routines of the people who have lived the longest isn’t useful.

Some people live a long time for genetic reasons. This is similar to inheriting luck. Centenarians live longer, but more importantly, they live better. The closest thing to a secret we can steal from centenarians is resilience. This refers to their ability to resist certain diseases, even when they have unhealthy habits.

Chapter 5: Eat Less, Live Longer? The Science of Hunger and Health

A molecule known as rapamycin has transformed the study of longevity. It’s said that rapamycin can extend the maximum lifespan of mammals. The molecule was discovered in the late sixties on Easter Island. Rapamycin seems to be a “wonder drug” that has several applications, but it’ll be a long time before it can be used on humans since there are some undesirable effects. People think eating less lengthens our lives. Similarly, some studies suggest that caloric restriction or CR lengthens your lifespan, but this is difficult to sustain, so the author doesn’t recommend it unless you’re overnourished.

Chapter 6: The Crisis of Abundance – Can Our Ancient Genes Cope with Our Modern Diet?

Consuming an abundance of extra calories every day damages the liver similar to the damage seen in alcoholics. The Mayo Clinic called this nonalcoholic steatohepatitis or NASH and its precursor is known as nonalcoholic fatty liver disease or NAFLD. Luckily, these conditions are reversible by losing weight.

Excess weight leads to many problems. These problems are often referred to as metabolic syndrome and it has the following criteria:

High blood pressure
High triglycerides
Low HDL cholesterol
Central adiposity
Elevated fasting glucose

If you meet three or more of these items, you have metabolic syndrome. This isn’t the same as obesity though and you can still have metabolic syndrome if you’re thin.

Metabolism is a process where we break down nutrients so that our body can use them. When our metabolism works well, those nutrients are processed and sent to the right destinations. When our metabolism doesn’t work well, they end up in places where they’re not needed or when they can cause harm. The safest place where our body stores calories is in the form of fat. If you consume too much energy, your body won’t know what to do with it and it’ll go to other areas of your body: your blood, your liver, your muscle tissue, around your heart, and your pancreas. This is when you start having problems. To mitigate said problems, you can do physical activity often.

Our environment has changed faster than our genome. We’ve evolved to get fat to live long enough to survive and reproduce. Fat allowed our ancestors to survive famines, cold climates, illnesses, and pregnancy. In the modern world, where calories are limitless, this represents a problem.

It’s worth pointing out that not all kinds of calories are created equal. Fructose (which we can find in soft drinks) is particularly harmful to our health. That said, fructose doesn’t pose a problem when we consume it in the form of fruit. It’s hard to get fat from eating apples, but easy to get fat from apple juice, for instance. To prevent this from happening, we must change how we exercise, what we eat, and how we sleep.

Chapter 7: The Ticker – Confronting – and Preventing – Heart Disease, the Deadliest Killer on the Planet

Heart disease kills more people in the world than any other cause. Luckily, heart disease is more easily prevented than Alzheimer’s disease or cancer. To be clear, you can’t cure or reverse heart disease, but you can delay it if you discover it early.

One of the terms most people associate with it is cholesterol. Contrary to what most believe, cholesterol is essential to life. We need it to produce important structures, such as hormones and bile acids. Similarly, heart disease isn’t caused by the cholesterol we eat. Most of our cholesterol comes from our cells. Finally, another common myth is that cardiovascular disease affects old people only.

To solve this problem, people should avoid saturated fats and replace them with monosaturated fats. The latter can be found in extra virgin olive oil, macadamia nuts, and avocados. There are also many “cholesterol-lowering” medications known as statins, though some patients can experience undesirable side effects.

Chapter 8: The Runaway Cell – New Ways to Address the Killer That Is Cancer

After heart disease, cancer is the most common cause of death in the US. The tricky part about the disease is that by the time it’s detected, it has been progressing for years. Modern medicine has limited tools to deal with cancer. It can be treated with surgery and chemotherapy, but the solution is limited. Another problem is that our ability to detect cancer at early stages is weak. Preventing the disease is difficult because we don’t fully understand why it starts in the first place.

Cancer cells don’t stop when they’re supposed to and, on top of that, these cells can travel to sites where they shouldn’t be (this is known as metastasis). This, combined, is what makes cancer such a fatal disease. Even when cancer is treated, it can come back. One way to treat it is with chemotherapy. The problem with this treatment is that it doesn’t just kill cancer cells, but the patient as well. On top of that, the side effects are incredibly painful.

Diets that lower insulin levels indicate that you can reduce cancer risk. Eating less offers some protection from the disease. Another obvious strategy is to not smoke. A healthy dietary regimen includes leafy vegetables, olive oil, avocados, nuts, and protein in the form of fish, eggs, and poultry. Also, avoid sugar and refined carbohydrates.

Immunotherapy is a therapy whose purpose is to fight an infection or condition. An example of immunotherapy is vaccines. The immune system could fight cancer, but a vaccine doesn’t exist yet. A small number of patients can benefit from immunotherapy though. That said, the most important tool we have to defend against cancer involves detecting it early. Identifying it too late makes most treatments ineffective, but unfortunately, medicine isn’t good at detecting the disease in the early stages.

Chapter 9: Chasing Memory – Understanding Alzheimer’s Disease and Other Neurodegenerative Diseases

Alzheimer’s disease is difficult to deal with because we don’t fully understand how and why it starts, and how we can prevent it. Once the symptoms begin, doctors don’t have a way to treat them. Neurodegenerative diseases (Alzheimer’s, Lewy body dementia, and Parkinson’s disease) result in cognitive decline and there’s no cure for them.

Alzheimer’s disease is often associated with mood changes, depression, memory loss, irritability, and irrationality and often starts manifesting itself in patients in their mid-sixties or later. Also, Alzheimer’s disease is more common in women than in men, but it’s not clear why that happens. According to experts, developing complex skills (such as learning languages or playing musical instruments) is a way to protect against cognitive decline. Athletes also tend to slow the progression of the disease when compared to sedentary people. The only intervention that delays Parkinson’s is exercise.

Even when there’s a high genetic risk of suffering from neurodegenerative diseases, there’s still the possibility of prevention. A recommendation includes switching to a Mediterranean-style diet. This involves consuming more monosaturated fats and fatty fish, and fewer refined carbohydrates (breads, pasta, cakes, fruit juices, cereals, ice cream, pizza, white rice, and refined grains). Also, exercise is the best preventative tool we have. Sleep is also extremely important because when we sleep, our brain heals itself and protects us from dementia.

Chapter 10: Thinking Tactically – Building a Framework of Principles that Work for You

As humanity progressed more and more, certain diseases spread: cancer, heart disease, type 2 diabetes, and dementia. Although modern life brought comfort and safety, it also limited our longevity. Our environment changed drastically. We have unlimited access to food and we don’t exercise as much as we should. Our environment has evolved, but our genes haven’t.

Medicine 3.0 has five domains that we should consider to extend our lifespan and healthspan: exercise, nutrition, sleep, emotional health, and exogenous molecules (these come in the form of drugs, supplements, and hormones).

Chapter 11: Exercise – The Most Powerful Longevity Drug

For most people, determining the optimal way of exercising is difficult because there’s a lot of contradictory advice. A lot of experts like to think in binary terms, so they compare two types of exercise and they like to tell which one’s superior. The author sees this discussion as pointless.

Without a doubt, the healthiest habit one can start is exercise. No drug comes close to the benefits of exercising regularly. People who exercise live as much as ten years longer than those who don’t. Any exercise is better than nothing, so start by walking. The two realms you should consider moving to are aerobic exercise and strength training. While aerobic exercise gives you more energy, strength training improves your mobility.

When it comes to exercise, we should become generalists. The author calls this framework, the Centenarian Decathlon and it’s about organizing a person’s physical aspirations for the last years of their lives. Thinking about one’s physical decline sounds unpleasant, but it’s an inevitable part of our lives, and thinking about it gives us an advantage.

To start the Centenarian Decathlon think about the activities you’d like to continue doing the rest of your life. Examples include hiking, picking up children, carrying groceries for a couple of blocks, lifting a backpack into an overhead compartment of a plane, having sex, climbing stairs, opening a jar, and so on. Once you have a list of activities, you can come up with a workout that’s tailored to your interests.

Chapter 12: Training 101 – How to Prepare for the Centenarian Decathlon

The problem with most exercise regimens is that they’re either too specific or too vague. Optimizing one’s fitness to delay chronic disease or death and maintaining your healthspan is complicated because numerous variables come into play. To maintain your health and strength, you should focus on aerobic fitness, strength, and stability.

For aerobic fitness, we aim at zone 2 which is doing an activity at a pace between easy and moderate. Zone 2 training gives you endurance and prevents chronic disease. Examples include biking, walking, swimming, or jogging.

The next step should be to add some weight training to your exercise regimen. Our muscle mass starts declining as early as our thirties, but that’s not an important metric to consider. Muscle mass is the variable that matters the most. To slow down this decline, we need resistance and power and the worst thing we can do is to be sedentary. Also, long periods of inactivity (ten days or more) are particularly dangerous. Strength training benefits from compounding, so the best thing to do is to start as early as possible so that we can reap its rewards from now until the day you die.

The best kind of workouts are those that involve lifting heavy things like dumbbells, kettlebells, or sandbags. Hiking with a heavy backpack (this is known as rucking) and someone who wants to join you is a great activity too. Carrying heavy things for long distances defines our species for millions of years and trading that for a life of comfort is unhealthy.

To build strength, consider the following examples:

Grip strength: how hard you can grip using your hands
Concentric and eccentric loading: this refers to our muscles shortening (concentric loading) or lengthening (eccentric loading)
Pulling motions: pulling from all possible angles
Hip-hinging movements: exercises that strengthen the legs, glutes, and lower back

Chapter 13: The Gospel of Stability – Relearning How to Move to Prevent Injury

Most people in their seventies or eighties stop moving because of some form of injury. Due to this, older people stop exercising regularly and as a consequence their health declines. The key is to avoid injury at all costs. Even if you experience injury when you’re young, this can lower the quality of your life in middle and older ages. To prevent injury, we need to focus on stability. Never push yourself without stability. Stability refers to the ability to adjust position without thought. This is why training for stability and strength is so important.

Stability training starts with the breath. How we inhale or exhale influences how we move our body, as well as our mental state. The next area we should focus on is our feet. Our feet are the foundation of all movement. Most movements should start with stable feet. Our feet should be flat, grounded, and stable. Next comes the spine. Most people spend a long time sitting down and this affects our stability. Yoga can help a lot in this department, but the idea should be to start slow and to be as deliberate as possible. Other important areas when it comes to stability are the shoulders, arms, and hands because this is how we transmit force. Our ancestors needed strong fingers to survive, but that’s something we lost in the world of comfort we live in.

Those are the basics of stability. The idea is to focus on a workout without a trainer at first so that we can master the different movement patterns. When it comes to exercise, there’s such a thing as trying too hard and making mistakes as a result. Unfortunately, those mistakes compound and can lead to several problems. Instead of going fast right from the start, focus on your form, and eventually, you’ll be able to go faster.

Chapter 14: Nutrition 3.0 – You Say Potato, I Say “Nutritional Biochemistry”

Like politics and religion, diet and nutrition are contentious topics because emotions get in the way. People in general are attracted to bullet points and a superficial analysis. It also doesn’t help that science doesn’t know that much about the topic. This is why we see so many “experts” who claim to have the perfect diet. The author doesn’t want to refer to it as a diet but as nutritional biochemistry. After all, when we eat, we’re ingesting chemical compounds and everyone reacts to them differently. Also, nutritional biochemistry places this discussion in the realm of science rather than in the realm of ideology, religion, and emotion. The idea is to determine what works for your body, what your goals are, and what you can sustain.

The goal is to reduce energy intake and add lean mass. In other words, we want to consume fewer calories, increase protein intake, and exercise. According to the author, these the the basics of nutrition:

Don’t eat too many calories and don’t eat often
Consume enough protein and essential fats
Obtain the necessary vitamins and minerals
Avoid pathogens and toxins

Chapter 15: Putting Nutritional Biochemistry into Practice – How to Find the Right Eating Pattern for You

Most people have their own “diet”, but they’re happy with the results. The Standard American Diet or SAD is one of the worst diets. In a way, this diet is brilliant because it solved four of humanity’s most serious problems. How to prepare enough food, how to do it inexpensively, how to preserve that food safely, and how to make it palatable. The problem is that something is missing in that equation: how to make it harmless. Originally, the type of food in this diet wasn’t supposed to cause harm, but since people started eating it in excess, it became an unfortunate side effect of this new business model.

Everything in the SAD has devastating consequences when eaten in large quantities. Added sugar, refined carbohydrates, low fiber, and processed oils are terrible for our health. When you think of SAD, think of junk food. The problem is that evolution hasn’t prepared us for the amount of calories we can consume as part of this diet. The primary goal we should have is to eat less. For overnourished people, the author suggests three strategies:

Caloric restriction or CR: eat fewer calories than you normally do
Dietary restriction or DR: eat less of certain elements
Time restriction or TR: restrict eating to specific times

The idea is to get rid of the three variables that define the SAD: eating whatever we want, whenever we want, and as much as we want.

Consuming calories in excess gives us more energy than we need and the surplus ends up in our body which leads to all kinds of problems. Excess calories also lead to chronic diseases. Limiting calories extends your lifespan and makes you healthier both physically and mentally. It’s worth pointing out that limiting calories is only helpful for unhealthy or overnourished people.

Dietary restriction is simpler than it seems. It’s identifying an unhealthy item from your diet and excluding it. The difficult part is figuring out what to exclude. A good way to start is to get rid of sugar-sweetened drinks, fruit juices, all foods with added sugar, and carbohydrates. The idea is also to manipulate our four macronutrients in such a way that you can achieve your goals. The four macronutrients are alcohol, carbohydrates, protein, and fat.

Alcohol has no nutritional purpose, but it’s widely consumed. It offers zero nutritional value, but it has some negative side effects. Alcohol is bad for our longevity. That said, a lot of people like to drink, so if you do it, make sure you drink mindfully.

Carbohydrates aren’t good or bad, but some types are better than others. Carbs give us energy, but too many of them can lead to problems. For this purpose, a lot of people measure their blood glucose levels and see how their body reacts to what they eat. This is helpful because not everyone should restrict carbohydrates. Some people can handle more carbs while others can handle less. It’s worth noting that measuring your blood glucose levels only measures one variable. So you could have an unhealthy diet and get positive measurements nonetheless.

There are some conclusions you can draw from using a continuous glucose monitor or CGM:

Refined carbs (such as potato chips) are worse than less refined ones.
Rice and oatmeal cause a rise in glucose levels.
CGM doesn’t measure fructose.
Exercise matters. The best type of exercise to reduce glucose is aerobic exercise. High-intensity exercise and strength training increase glucose.
Sleep influences glucose.
Stress also impacts glucose.
Nonstarchy vegetables (such as spinach or broccoli) don’t affect blood sugar, so they are safe to eat whenever you want.
Foods high in protein and fat (such as eggs or beef ribs) don’t affect blood sugar. Protein shakes do.
Naturally, avoiding stress, sleeping well, and making time for exercise matters.
Using a CGM can help you change your behavior.

Protein is important because, along with amino acids, it’s the building block of life. Without protein, we wouldn’t be able to build or maintain muscle mass. Protein isn’t a source of energy like carbs or fat, so the body gets rid of the excess. The average person needs a lot of protein (around 1.6 g/kg/day) in four servings per day. As a general rule, the more protein we consume, the better.

Fat is essential but somewhat problematic. For the longest time, people have been confused about fat. Fat works as a source of fuel, as well as building blocks. There are three types of fat: saturated fatty acids (SFA), monosaturated fatty acids (MUFA), and polyunsaturated fatty acids (PUFA). The difference between them is related to organic chemistry. Most foods that have fat in them contain all three types. Some good sources of fat include olive oil, salmon, anchovies, and avocados. Some foods to cut back on include butter, lard, soybean, and sunflower oil.

Fasting (or time-restricted eating) means to regulate when we eat. This is a way to accomplish our goals, but it isn’t without its downsides. Fasting for long periods has some desirable results, but the knowledge we have is new and weak.

To conclude, nutritional biochemistry is important, but it isn’t the only way to increase longevity. That said, a lot of people are metabolically unhealthy which means that they must focus on their nutrition. To address the problem, cut calories, eliminate foods that raise blood glucose, do aerobic exercise, have saturated fats, and avoid sodas and fruit juices. In the end, there’s no unique diet that applies to everyone, so come up with a plan that makes sense for you. One last piece of advice the author offers is that if you find yourself overthinking nutrition, go outside and exercise.

Chapter 16: The Awakening – How to Learn to Love Sleep, the Best Medicine for Your Brain

The importance of sleep can’t be overstated. Sleep-deprived people make mistakes and cause deaths. Poor sleep can lead to metabolic dysfunction, and it can destroy your body’s hormonal balance. We need good quality sleep because it’s important to our cognitive health, as well as our short-term health.

Sleep is extremely important. If it wasn’t important, evolution would have gotten rid of it a long time ago. After all, when we sleep, we’re not reproducing, hunting, or protecting our tribe. On top of that, sleeping puts us in a vulnerable spot, since predators can just attack us. All animals sleep, so this isn’t just reserved for humans.

For the longest time, Western society ignored sleep. In a world where working at factories was essential to the economy, sleeping felt like a waste of time. That’s changed over time, but everyone should make sleep a priority. Sleep is as important as nutrition and physical fitness and ignoring it can have disastrous consequences on your health.

On average, most people need eight hours of sleep every night. Getting less or more sleep leads to problems. Poor sleep can negatively impact our physical and mental performance. On top of that, the quality of your sleep is related to the risk of long-term diseases. Research shows that poor sleep destroys our metabolism. Unfortunately, the consequences of poor sleep go on and on.

Sleep is important because it keeps our brain healthy. Deep sleep helps us learn and retain certain memories. Sleep is important, but the problem is that it declines as we get older. Since sleep is such an essential part of our health, there’s a big demand for sleep drugs. Unfortunately, most of them don’t work well or have undesirable side effects. Using sleep drugs regularly is alarming, especially when the people who take them don’t have sleep disorders.

This is how we can improve our sleep habits. First, recognize you could do better and allow yourself to sleep. Next, use a sleep tracker to assess your sleep habits. You should also determine if you’re a morning person or a night owl which is entirely genetic. Finally, rule out serious sleep problems like sleep apnea.

Here are some tips to improve your sleep:

Make your bedroom as dark as possible.
Avoid using devices before bed. This includes your phone, laptop, and game console.
Avoid social media because this affects both our sleep and mental health.
Keep your bedroom cool (around 65° Fahrenheit or 18° Celsius) or take a bath before bed.
Avoid drinking alcohol.
Don’t drink coffee after noon.
Exercise often. Avoid exercising within two hours or three hours of bedtime though.
Get a half-hour dose of daylight.
Avoid stressful situations such as working too late, checking email, or watching the news.
Don’t eat too late.
Give yourself plenty of time to sleep.

Chapter 17: Work in Progress – The High Price of Ignoring Emotional Health

This chapter is about the emotional and mental aspects of healthspan and longevity. Emotional health is a process that demands as much time and effort as exercise. It’s also important because without happiness, fulfillment, and connection to others, longevity doesn’t mean that much. Misery and unhappiness destroy your physical health as much as some of the diseases and injuries discussed in the book.

One way in which people deal with emotional issues is by talking about their traumas. Trauma has five categories: abuse, neglect, abandonment, enmeshment, and witnessing tragic events. The author makes a distinction between big traumas (such as rape) and little traumas (such as having an alcoholic parent). Both types of trauma can do a lot of damage, but little trauma is harder to work on because the people who suffer it are more likely to ignore it. Trauma can lead to addiction, codependency, habituated survival strategies, and attachment disorders. Identifying these “barriers” is easy, the difficult part is working on them.

All of the aforementioned issues fall under emotional health. The idea is to recognize problems as early as possible so that you can start addressing them. To recover, you don’t need medication, drugs, or mindfulness (though they might help). True recovery requires self-exploration and this takes time and effort. Change is possible as long as you think is possible.

Book Summary: Outlive by Peter Attia