Anyone who has ever visited a nursing home will have seen them, trapped in their recliners, mouths open and eyes blank, being fed liquids from sippy cups: elderly people who are entirely dependent on their carers. Some look close to death; arguably, their quality of life is so diminished they may as well be. It can be difficult to see these people. None of us want to envisage ourselves spending our final years that way.
But we ought to be envisaging it, says Canadian-American doctor and longevity expert Peter Attia. He believes we should be spending more time with those who are in their final 10 years – what he terms “the marginal decade” – and thinking about what we want for that time in our own lives. We need to focus on our endgame, says Attia.
“I ask every single one of my patients what they want to be doing in their marginal decade,” he explains. “The answers are usually quite ambitious. They might say they still want to be able to ski, for example. And so, I make them reverse engineer, and examine what they need to be doing now so that they have the strength, the lateral stability, the cardiovascular fitness, to still be skiing then. I’m not going to tell them they can’t do it. But if they are 50 and still skiing with ease now then they need to build up their resources to cope with the next decade or two of decline. Because decline is coming and it’s actually quite nonlinear. It really starts to hit us when we’re 75.”
Attia is based in Austin, Texas. At his practice, Early Medical, the focus is on guiding patients towards transforming their marginal decade into bonus years by building up their health and fitness to put them at a higher starting point, ready for when that inevitable decline kicks in. Generally, he asks them to list 10 to 15 late-life goals – anything from being capable of going out for a decent walk to carrying a bag of groceries or having sex – before coming up with a personalised strategy to achieve them.
This is healthcare for a wealthy elite. Every one of his patients undergoes a thorough investigation to see what their risks may be, then a team of experts develops an individual plan to mitigate those risks as much as is possible.
“With all our patients, the first month is pretty similar. We figure out everything that is known about you up to this point in time. So, we do an elaborate family tree, to understand everything about your relatives – how they lived, how they died, what their state of health is. Obviously, we take a very thorough look at your own medical history. Then we begin forward-looking data analysis.”
A battery of blood tests, scans and fitness tests follows. The bodies and brains of Attia’s patients are thoroughly explored.
“There is a finite number of things that are going to be a threat to your lifespan and healthspan,” he explains. “Within less than a year we want to have a very clear sense of how to rank those things in you. You’ll never eliminate risk entirely. The goal is just to be constantly chipping away and reducing it.”
If you discover that unfortunately you carry two copies of the APOE4 gene, a strong risk factor for Alzheimer’s, at Attia’s clinic you will work with a preventive neurologist to fine-tune your lifestyle with evidence-based strategies. When it comes to any aspect of your health, the more the deck is stacked against you genetically, the more effort you will need to make and the sooner you need to start, he says.
Falling eggs
Attia, who studied at Stanford Medical School, had set out to become a cancer surgeon, but was plagued by a recurring dream. In it, he was trying to catch eggs that were being flung at him from above, and was unable to prevent many of them crashing to the ground and breaking. This seemed to him to be an analogy for the kind of work he was doing. Because no matter how clever the surgery, many of his cancer patients would still die within the next few years. Those eggs were going to hit the ground.
Disillusioned, he quit medicine and worked in management consulting for a while. When he returned, it was with a rigorously preventive and proactive approach that he terms Medicine 3.0. He became a longevity doctor.
As he explains it, Medicine 1.0 was the first primitive era of healthcare, when physicians believed most illness was spread by miasmas in the air. Medicine 2.0 is the form still practised today, made possible by the invention of the microscope, which led to germ theory and antibiotics. Medicine 3.0 is the future, and it is going to require a major mind shift before we all have access to it.
The problem with Medicine 2.0 is that it tends to intervene well after the disease has taken hold. Odds are that most of us will die of one of the chronic diseases of ageing: heart disease, cancer, neurodegenerative disease and metabolic dysfunction – Attia calls them the Four Horsemen. “We want to delay or prevent these conditions so we can live longer without disease rather than lingering with disease,” he says.
He maintains that Medicine 3.0 means longevity will become more malleable. And, although all the testing and tracking his patients undergo isn’t cheap, he argues that the current system – with the majority of an individual’s healthcare dollars spent in the final few years of their life – is even pricier.
“I believe Medicine 3.0 will produce longer and better life, and is less expensive.”
Communicating this philosophy has become a passion. Attia has developed a 12-module digital programme (available through his website earlymedical.com). He presents a health podcast, The Drive, and has appeared in a docuseries, Limitless, alongside actor Chris Hemsworth. And now, perhaps inevitably, there is a book, Outlive: The Science & Art of Longevity, which he describes as an actionable operating manual. In it, he takes readers through the science that has informed the way he practises medicine today and describes his own journey.
‘Dad bod’ moment
Attia turned his health around at 36, and his wife Jill was the prompt. One day when they were at a beach together, she suggested that he needed to work on being “a little less not-thin”. At first, he was shocked. He was into long-distance ocean swimming and physically very fit. Still, he had developed a “Dad bod”, his blood sugar was high, his coronary arteries were clogging up and he recognised the trajectory he was on. It wouldn’t end well.
Doing nothing is not his style. Driven and obsessive, he turned his laser focus on the science of longevity. Cardiovascular diseases run in his family, so he developed a strategy to try to avoid them. He lost weight, buffed up and got more sleep.
“My long, comprehensive programme of prevention seems to have paid off,’ he writes in Outlive. “I feel a lot better now at age 50 than I did at 36, and my risk [of cardiovascular disease] is a lot lower by any other metric than age. One major reason for this is that I started early, well before Medicine 2.0 would have suggested any intervention.”
Deterioration is preventable and largely optional, in Attia’s thinking. He believes we all need a strategy tailored to our individual goals – there is no blueprint of what to eat, how to exercise, etc, to stave off decline. In fact, he is constantly fine-tuning his own approach.
He no longer thinks the ketogenic diet and water-based fasting are key, for instance. Instead, it is physical activity that he considers the most potent tool, and, he says, if people adopt only one new set of habits after reading his book, then it should be in the realm of exercise.
All his patients have their VO2 Max measured, because Attia believes it is the single most powerful marker for longevity (it shows the maximum rate at which a person can use oxygen in full-on exercise and is an indicator of cardiovascular health).
Weights and measures
Although aerobic fitness is crucial, muscle strength shouldn’t be neglected. His own carefully structured regime involves lifting heavy weights four times a week no matter where he is or what else he is doing. And his idea of a pleasant walk around the neighbourhood involves wearing a heavily weighted backpack – this is known as “rucking”. Attia keeps a couple of spare backpacks for any house guests who may want to join him for a walk. He also tracks his heart rate and the levels of lactic acid in his muscles to make sure he is pacing his workouts optimally.
His brand of discipline sounds intimidating and unachievable for most. “I don’t know that I have incredible discipline,” he argues. “And actually, I don’t think discipline or willpower are great long-term strategies. You have to create systems and environments that nudge you in the right direction and make it easier.
“I’m fortunate that I enjoy exercise – not always when I’m doing it and it hurts, but I always feel better afterwards, and that’s a reward. Conversely, food will always be a challenge. I have to be careful to keep an environment that is less toxic around me, because if my favourite treats are in the cupboard, I’ll eat them. So, when people think I’m a beacon of willpower, that’s the furthest thing from the truth.”
Stability & breathing
With physical fitness, he considers stability to be just as important as aerobic fitness and strength, and all of his patients are put through a series of tests to assess their degree of stability and their breathing technique, which relates to it. In his view, this is essential to any kind of movement, particularly if the goal is to keep moving for many decades to come. Training for stability helps prevent the injuries that are usually what propel people into inactivity in their later years.
“The goal is to be strong, fluid, flexible and agile as you move through your world.”
Attia has retrained using “dynamic muscular stabilisation” techniques. The theory is that we all have the ability to move properly as young children, but that we lose this in adulthood thanks to years of folding our bodies into chairs and putting out feet into cushioned shoes. So both our brain and body need to relearn. Twice a week, he spends an hour doing dedicated stability training, and does 10-15 minutes of it on other days.
“It’s a difficult concept,” he concedes. “I struggled more from a technical standpoint writing the chapter on stability than any other chapter in the book.”
Toe yoga
One of his regular routines is what his trainer, Beth Lewis, likes to call toe yoga”. Our toes are crucial to walking, running, lifting, slowing and lowering, and yet we don’t tend to include our feet in a typical workout.
Attia’s patients work on this, along with things such as grip strength, breathing and the correct positioning of the shoulder blades, for at least six months before they’re unleashed on heavy loads.
His philosophy of stability and movement stretches to his three children.
“They have standing desks here at home. They’re wearing minimalist shoes or bare feet. I want to make sure they don’t make the mistakes the rest of us made. The goal is to preserve what we are innately wired to do.
“But for people like me who do have to go back and relearn, the good news is it can be done, and it doesn’t take as long as you might think to override the mistakes.”
Much about his approach covers territory familiar to anyone with an interest in wellness: sleeping well and for long enough, for example; finding the right eating pattern for you and making sure you are not “over-nourished”; consuming enough protein to maintain muscle mass. (For a person with healthy kidney function, Attia advocates 2.2 grams per kilo of body weight, spread through the day, which is higher than standard recommendations. He reaches his target with a daily protein shake, high-protein snack and two protein meals.)
Toe yoga is a lot harder than it sounds, says Peter Attia, who demonstrates this and other exercises online. His movement trainer, Beth Lewis, tells her students to think of their feet as having four corners, each of which needs to be rooted firmly on the ground at all times, like the legs of a chair. As you stand there, try to feel each “corner” of each foot pressing into the ground: the base of your big toe, the base of your pinky, the inside and outside of your heel.
Try to lift all 10 toes off the ground and spread them as wide as you can. Now, try to put just one big toe back on the floor while keeping your other toes lifted. Then do the opposite: keep four toes on the floor and lift only your big toe. Finally, lift all five toes and try to drop them one by one, starting with your big toe.
Attia also wears toe spacers, which help restore the toes to a more natural spread position, and distribute body weight more evenly over the surface of the foot. “I wear these things around the house a lot,” he says. “My kids mock me relentlessly.”
Epic meltdown
Perhaps less predictable is his focus on the importance of emotional health. “What good is a long life if you’re unhappy?”
Poor emotional health, along with the drug use, alcohol abuse, eating disorders, suicide and violence that may accompany it, affects longevity just as poor physical health does. Still, for many years, even while he was fanatical about eating well and exercising, Attia’s own emotional health was terrible.
In Outlive, he confides that as a child, he was sexually and physically abused, and although he doesn’t share the details of what happened, he is open about the consequences. To the outside world he appeared to be a successful man with a great life. In reality, he was rage-filled, detached and obsessive.
Three years ago, at his lowest point, there was an epic meltdown in which he screamed in rage and pain, tore his clothing and threw a table across the living room, while his wife begged him to leave the house for fear he was going to harm her and the children.
Fortunately, a close friend made sure he got the help he so badly needed. This has included two stays in residential facilities and ongoing therapy. He now accepts that his perfectionism and workaholism were built on shame, self-loathing and guilt, and keeping himself emotionally healthy remains something he works on every day.
“Of all the things that we talk about in the book, whether it be nutrition, sleep, exercise, this arena is the hardest one in which to make change, because it is generally the hardest one in which to acknowledge the problem.
“Some of the worst offenders are people like me, whose addictions are socially acceptable addictions to have. It might be different if my weakness was gambling or alcohol. But when you’re addicted to performance and perfection, at the surface that can look reasonable.”
Never say die
On all his platforms, Attia’s key message is that change is possible. Maybe not all the changes, all at once, but if we focus on our lifestyles and routines, then we’re in with a chance of rerouting the trajectory we’re on so that we get to that active, independent older age that everyone hopes for.
The earlier you start, the more you can mould that trajectory for the better, but it is almost never too late to make some degree of improvement.
“What’s the alternative? To accelerate the decline by doing nothing? That sounds awful. If you’re going to go down, then go down swinging, right? Do everything in your power.
“I think people don’t appreciate how much you can move the needle. Everybody knows exercise is good, but probably they aren’t aware just how good it is. I also don’t think most people are spending enough time considering what their marginal decade looks like.”
Outlive: The Science & Art of Longevity, by Dr Peter Attia (Penguin Random House, $40).