🌱 (seedling) | Literature note |

Notes from book Outlive - topic Longevity

Main insight are about fighting against the four horseman diseases:

  • heart disease
  • cancer
  • neurodegenerative disease (Alzheimer, Parkinson)
  • type 2 diabetes and related metabolic dysfunction

through improvements in/via:

  • Exercise
  • Nutrition
  • Sleep
  • Emotional health

with the goal to live a long AND healthy live.


  • [[MD-Outlive]]
  • Author: Peter Attia MD
  • Reference: https://www.amazon.com/dp/B0BLBYCBQ9


  • how long you live, your chronological lifespan
  • healthspan - how well you live—the quality of your years
  • three-part approach to longevity: objective → strategy → tactics

  • five stages of grief described by Elisabeth Kübler-Ross
    • 📖 [[On Death and Dying - Elisabeth Kübler-Ross]]
  • genes may be responsible for only about 20 to 30 percent of the overall variation in human lifespan
  • growing body of research linking oral health, particularly the state of one’s gum tissue, with overall health

Heart disease

  • two biggest risk factors for heart disease, smoking and high blood pressure, cause damage to the endothelium


  • catching cancer early is almost always net beneficial
  • obesity and metabolic dysfunction are both powerful risk factors for cancer
  • Metastatic cancers can be slowed by chemotherapy, but they virtually always come back
  • immunotherapy, in particular, has enormous promise
    • immunotherapy is any therapy that tries to boost or harness the patient’s immune system to fight an infection or other condition
    • a third of cancers can be treated with immunotherapy
  • cancer cells don’t grow faster than their noncancerous counterparts; they just don’t stop growing when they are supposed to
  • cancer cells that do manage to survive chemotherapy often end up acquiring mutations that make them stronger
  • Otto Warburg discovered that cancer cells had a strangely gluttonous appetite for glucose
    • locate potential tumors is by injecting the patient with radioactively labeled glucose and then doing a PET scan
    • glucose into a little bit of energy and a whole lot of chemical building blocks—which are then used to build new cells rapidly.
    • insulin acts as a kind of cancer enabler, accelerating its growth
  • fasting, or a fasting-like diet, increases the ability of normal cells to resist chemotherapy
  • risks that really stand out in the data are smoking, insulin resistance, and obesity (all to be avoided)—and maybe pollution (air, water, etc.)

Neurodegenerative disease (Alzheimer, Parkinson)

  • a case for constant learning 1 - The more of these 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
  • movement and exercise, more complex activities like boxing workouts, are a primary treatment/prevention strategy for Parkinson’s
  • robust blood flow seemed to be critical to maintaining brain health
  • central insulin resistance plays a causal role in the development and progression of Alzheimer’s disease
    • reduced glucose metabolism essentially starves these neurons of energy, provoking a cascade of responses that include inflammation, increased oxidative stress, mitochondrial dysfunction
  • most powerful item in our preventive tool kit is exercise
  • focusing on steady endurance exercise to improve her mitochondrial efficiency
  • dry sauna - at least four sessions per week, of at least twenty minutes per session, at 179 degrees Fahrenheit (82 degrees Celsius) or hotter seems to be the sweet spot to reduce the risk of Alzheimer’s by about 65 percent
  • As you grow older, the risk grows exponentially that one or more of these diseases has begun to take hold in your body.
  • interventions around nutrition, physical activity, and cognitive training helped maintain cognitive function and prevent cognitive decline

    metabolic syndrome

  • 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)


  • Exercise is by far the most potent longevity “drug.”
    • even a fairly minimal amount of exercise can lengthen your life by several years
  • most important components: strength, stability, aerobic efficiency, and peak aerobic capacity
    • steady endurance work, such as jogging or cycling or swimming, where we are training in what physiologists call zone 2 – leads to healthy mitochondria
      • lower relative intensity will be burning more fat
      • you should be able to talk but not particularly interested in holding a conversation
      • 70 and 85 percent of peak number
      • about three hours per week of zone 2, or four 45-minute sessions, is the minimum required for most people to derive a benefit and make improvements
      • helps with cognition, by increasing cerebral blood flow and by stimulating the production of BDNF, brain-derived neurotrophic factor 2
    • maximal aerobic efforts on VO2 max
      • measure with small handheld lactate monitor
      • VO2 max is a pretty good proxy measure of our physical capability
      • VO2 max is typically expressed in terms of the volume of oxygen a person can use, per kilogram of body weight, per minute. An average forty-five-year-old man will have a VO2 max around 40 ml/kg/min
      • supplementing our zone 2 work with one or two VO2 max workouts per week
      • VO2 max intervals are a bit longer, ranging from three to eight minutes
      • peak aerobic cardiorespiratory fitness, measured in terms of VO2 max
    • improve metabolic flexibility
    • keep lactate levels constant, ideally between 1.7 and 2.0 millimoles
    • wattage output for a zone 2 session and divide it by your weight to get your watts per kilogram - a bit more than 2 watts/kg, which is about what one would expect from a reasonably fit person
  • An adult male can store a total of about 1,600 calories worth of glycogen = energy for two hours of vigorous endurance exercise.
  • improves the health of the mitochondria - our ability to metabolize both glucose and fat
  • When we are exercising, our muscles generate molecules known as cytokines that send signals to other parts of our bodies, helping to strengthen our immune system and stimulate the growth of new muscle and stronger bones
  • brain-derived neurotrophic factor, or BDNF, that improves the health and function of the hippocampus - memory
  • exercise to prevent loss of muscle mass: By age eighty, the average person will have lost eight kilograms of muscle, or about eighteen pounds
    • we lose muscle strength about two to three times more quickly than we lose muscle mass
    • we lose power (strength × speed) two to three times faster than we lose strength
    • important measure of strength, I’ve concluded, is how much heavy stuff you can carry
    • Grip strength, how hard you can grip with your hands
    • Attention to both concentric and eccentric loading for all movements, meaning when our muscles are shortening (concentric) and when they are lengthening (eccentric)
      • If you can grip strongly, you can open a jar with ease.
      • If you can pull, you can carry groceries and lift heavy objects.
      • If you can do a hip-hinge correctly, you can get up out of a chair with no problem.
      • standards we ask of our male patients is that they can carry half their body weight in each hand (so full body weight in total) for at least one minute

Exercise goals for aging

  • Get up off the floor under your own power, using a maximum of one arm for support.
  • Pick up a young child from the floor.
  • Carry two five-pound bags of groceries for five blocks.
  • Lift a twenty-pound suitcase into the overhead compartment of a plane.
  • Balance on one leg for thirty seconds, eyes open. (Bonus points: eyes closed, fifteen seconds.)
  • Have sex.
  • Climb four flights of stairs in three minutes.
  • Open a jar.
  • Do thirty consecutive jump-rope skips.

Exercise videos

Importance of stability

  • stability is the subconscious ability to harness, decelerate, or stop force. A stable person can react to internal or external stimuli to adjust position and muscular tension appropriately without a tremendous amount of conscious thought.
  • !we cheat or work around our existing injuries
  • Twice a week, I spend an hour doing dedicated stability training, based on the principles of DNS, PRI, and other practices
    • DNS (https://www.rehabps.com) and the Postural Restoration Institute (PRI) (https://www.posturalrestoration.com)
  • too many of us have lost basic strength and awareness of our feet (this connects well to walking barefooted and with barefoot shoes)
    • toes are crucial to walking, running, lifting, and, most importantly, decelerating or lowering
  • regain mental control, conscious or not, over key muscles and body parts
  • Radiologists see so much degeneration in the cervical spine, brought on by years of hunching forward to look at phones, that they have a name for it: “tech neck.”

Importance of Breathing

  • Notes from Neuro Resilience
  • If our breathing is off, it can disrupt our mental equilibrium, creating anxiety and apprehension
  • deep, steady breathing activates the calming parasympathetic nervous system
  • pause after each exhale for at least two counts to hold the isometric contraction—this is key, in DNS


  • Nutrition 3.0: scientifically rigorous, highly personalized, and (as we’ll see) driven by feedback and data
  • food molecules—which are basically nothing more than different arrangements of carbon, nitrogen, oxygen, phosphorus, and hydrogen atoms—also interact with our genes, our metabolism, our microbiome, and our physiologic state
  • protein becomes critically important as we age
    • (or 2.2 g/kg/day) is a good place to start
    • spread out over the day to avoid losing amino acids to oxidation
    • plant protein has less of the essential amino acids methionine, lysine, and tryptophan (Note: gather a more detailed overview on amino acid distribution for my vegan diet)
    • be sure to get about three to four grams per day of leucine and lycine and at least one gram per day of methionine
    • protein also helps us feel satiated, inhibiting the release of the hunger-inducing hormone ghrelin, so we eat fewer calories overall
  • what you eat matters, but the first-order term is how much you eat
    • quality of your diet may matter as much as the quantity
  • When food is plentiful, mTOR is activated and the cell (or the organism) goes into growth mode, producing new proteins and undergoing cell division
    • Reducing the amount of nutrients available to a cell seems to trigger a group of innate pathways that enhance the cell’s stress resistance and metabolic efficiency
  • Restricting nutrients, via dietary restriction or exercise, triggers the production of newer, more efficient mitochondria
  • as we get older, autophagy declines
  • more calories flood into your subcutaneous fat tissue, it eventually reaches capacity and the surplus begins spilling over into other areas of your body: into your blood, as excess triglycerides; into your liver, contributing to NAFLD; into your muscle tissue, contributing directly to insulin resistance in the muscle (as we’ll see); and even around your heart and your pancreas
    • These fat cells secrete inflammatory cytokines
  • fructose, also turns out to be a very powerful driver of metabolic dysfunction
    • Important: it is about fructose from juices, smoothies and mixed in nutrition like yogurt
    • It is very difficult to get fat from eating too many apples, for example, because the fructose in the apple enters our system relatively slowly, mixed with fiber and water, and our gut and our metabolism can handle it normally.
    • energy (ATP) levels inside the cell drop rapidly and dramatically. This rapid drop in energy levels makes the cell think that we are still hungry
  • food research is difficult - epidemiology is incapable of distinguishing between correlation and causation and can mainly not be used well for nutrition research
    • human - unruly, disobedient, messy, forgetful, confounding, hungry, and complicated creatures
    • food is so complex, made up of thousands of chemical compounds in millions of possible combinations that interact with human physiology in so many ways—in other words, nutritional biochemistry—that epidemiology is simply not up to the task of disentangling the effect of any individual nutrient or food
  • Avoiding diabetes and related metabolic dysfunction—especially by eliminating or reducing junk food—is very important to longevity
  • strong link between calories and cancer
  • goal: finding the best mix of macronutrients for our patient—coming up with an eating pattern that helps them achieve their goals, in a way that they can sustain.
  • measure glucose levels via CGM gives continuous, real-time information on blood glucose levels
    • healthy patients need to use CGM only for a month or two before they begin to understand what foods are spiking their glucose (and insulin) and how to adjust their eating pattern to obtain a more stable glucose curve
    • lower average blood glucose and reduce the amount of variability from day to day and hour to hour.
    • CGM powerfully activates the Hawthorne effect, the long-observed phenomenon whereby people modify their behavior when they are being watched
    • keep average glucose at or below 100 mg/dL, with a standard deviation of less than 15 mg/dL
    • tends to be more insulin sensitive in the morning than in the evening, so it makes sense to front-load our carb consumption earlier in the day
    • !Fructose does not get measured by CGM
    • Timing, duration, and intensity of exercise matter a lot:
      • aerobic exercise seems most efficacious at removing glucose from circulation
      • high-intensity exercise and strength training tend to increase glucose transiently
    • sleeping just five to six hours (versus eight hours) accounts for about a 10 to 20 mg/dL
  • another rule of nutrition, which is that timing is important
  • eat more than fifty grams of fiber per day (note: need to learn more about fiber distribution in nutrition)
  • Nonstarchy veggies such as spinach or broccoli have virtually no impact on blood sugar
  • we must obtain nine of the twenty amino acids
  • eating more olive oil and avocados and nuts, cutting back on (but not necessarily eliminating) things like butter and lard
  • extra virgin olive oil and high-MUFA? vegetable oils

Diets rely on three strategies

CALORIC RESTRICTION, or CR: eating less in total

DIETARY RESTRICTION, or DR: eating less of some particular element(s) within the diet (e.g., meat, sugar, fats)

TIME RESTRICTION, or TR: restricting eating to certain times

  • Usually a narrower window, such as 18/6 or 20/4, is needed to eke out enough of a caloric deficit.
  • sixteen hours without food simply isn’t long enough to activate autophagy
  • Time-restricted feeding is a way of putting the brakes on snacking and late-night meals

On Alcohol

  • “empty” calorie source that offers zero nutrition value
  • drinking alcohol very often leads to mindless eating


  • giving ourselves permission to sleep
  • sleep is critical to our innate physiological repair processes, especially in the brain
  • poor sleep triggers insulin resistance, cognitive decline, mental health issues
    • Stress prompts an elevation in cortisol,
  • sleep disruption or reduction dramatically impairs glucose homeostasis
    • severely restricted sleep, just 4.5 hours a night, and found that after four days they had the elevated insulin levels of obese middle-aged diabetics
  • one sleepless night can create a state that is the functional equivalent of being legally drunk.
  • powerful associations between insufficient sleep (less than seven hours a night, on average) and adverse health outcomes ranging from increased susceptibility to the common cold to dying of a heart attack.
  • need to sleep about seven and a half to eight and a half hours a night
  • Higher stress levels can make us sleep poorly
  • short sleep (defined as less than six hours a night) is associated with about a 6 to 26 percent increase in cardiovascular disease
  • REM and deep NREM sleep (which we’ll call “deep sleep” for convenience) are crucial to learning and memory
    • By generating seemingly random associations between facts and memories, and by sorting out the promising connections from the meaningless ones, the brain can often come up with solutions to problems 2
    • REM sleep helps us maintain our emotional awareness
  • deep sleep, the brain activates a kind of internal waste disposal system that allows cerebrospinal fluid to flood in between the neurons and sweep away intercellular junk
  • Epworth Sleepiness Scale and Insomnia Severity Index

Set up your environment for good sleep

  • darkness. Light is the enemy of sleep
    • more interactive devices subjects used during the hour before bedtime, the more difficulties they had falling asleep and staying asleep—whereas passive devices such as TV, electronic music players, and, best of all, books were less likely to be associated with poor sleep
  • keep your bedroom cool—around sixty-five degrees Fahrenheit seems to be optimal
  • alcohol turns from friend of sleep to foe, as it is metabolized into chemicals that impair our ability to sleep
  • half-life of caffeine in the body is up to six hours
  • Taking a nap during the day, while sometimes tempting, can also relieve too much of that sleep pressure, making it harder to fall back asleep at night.
  • cultivate sleep pressure is via exercise, particularly sustained endurance exercise (e.g., zone 2), ideally not within two or three hours of bedtime
  • avoid anything that might create stress or anxiety, such as reading work emails or especially checking the news
    • burning issue that I can’t get off my mind, I’ll write a few lines about it
  • turn down the sympathetic nervous system and prepare the brain for sleep is through meditation
  • Don’t eat anything less than three hours before bedtime—and ideally longer
  • spend time in a sauna or hot tub prior to bed
  • going to bed at least eight hours before you need to wake up, preferably nine

Emotional Health

  • Emotional suffering can decimate our health on all fronts, and it must be addressed
  • Emotional health and physical health are closely intertwined
  • addiction can take many forms, not merely to drugs or alcohol. Often it is an outgrowth of some trauma that has happened in a person’s past
    • undesirable behaviors that we manifest as adults, such as addiction and uncontrolled anger, are actually adaptations to the various types of trauma we suffered in childhood.
    • addiction, not only to vices such as drugs, alcohol, and gambling, but also to socially acceptable things such as work, exercise, and perfectionism
    • codependency, or excessive psychological reliance on another person
    • habituated survival strategies, such as a propensity to anger and rage
    • attachment disorders, difficulty forming and maintaining connections or meaningful relationships with others
  • most important component of healthspan
  • happiness, fulfillment, and connection to others
  • Trauma generally falls into five categories: (1) abuse (physical or sexual, but also emotional or spiritual); (2) neglect; (3) abandonment; (4) enmeshment (the blurring of boundaries between adults and children); and (5) witnessing tragic events
  • Children are remarkably resilient, and wounded children become adaptive children.
  • Emotional health has more to do with the way we regulate our emotions and manage our interpersonal relationships
  • 90% of male rage is helplessness masquerading as frustration
  • Family pathology rolls from generation to generation like a fire in the woods taking down everything in its path until one person, in one generation, has the courage to turn and face the flames.
  • reframing entails taking a step back from a situation and then asking yourself:
    • **What does this situation look like through the other person’s eyes?
    • How do they see it?
    • Why is your time, your convenience, or your agenda any more important than theirs?**
  • write out a list of forty-seven affirmations, representing one positive statement about myself for each year of my life.
  • True recovery requires probing the depths of what shaped you, how you adapted to it, and how those adaptations are now serving you
  • DBT is predicated on learning to execute concrete skills, repetitively, under stress, that aim to break the chain reaction of negative stimulus → negative emotion → negative thought → negative action.
  • because we are thinking about some painful event that occurred in the past or worrying about something bad that may occur in the future
  • powerful exercise - listen to my self-talk (record voice memos to myself on my phone)
  • deep breathing: four seconds to inhale, six seconds to exhale. Repeat. As the breath goes, the nervous system follows
  • changing the behavior can change the mood
  • strong link to Notes from Neuro Resilience and [[Working With Emotional Intelligence - Daniel Goleman]]


mindfulness, which gives you the ability to work through the other four:

  • emotional regulation (getting control over our emotions),
  • distress tolerance (our ability to handle emotional stressors),
  • interpersonal effectiveness (how well we make our needs and feelings known to others), and
  • self-management (taking care of ourselves, beginning with basic tasks like getting up in time to go to work or school)

Notes on biomarkers

  • biomarkers related to metabolism
    • canary in the coal mine of metabolic disorder, is elevated insulin
    • uric acid, elevated homocysteine, chronic inflammation, and even mildly elevated ALT liver enzymes
    • ratio of triglycerides to HDL cholesterol (it should be less than 2:1 or better yet, less than 1:1), as well as levels of VLDL, a lipoprotein that carries triglycerides
  • lowering apoB, the particle that causes all this trouble. (In short: get it as low as possible, as early as possible.) - knock someone’s apoB concentration down to 20 or 30 mg/dL
  • “premature” heart disease, elevated Lp(a) is the first thing I look for


  1. MOC Building a 2nd brain 

  2. Connect well with diffused more of learning MOC - Learning How to Learn  2

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