Peter Attia



Having been a regular listener of the author’s podcast, I was really excited for this book. It took me a few attempts to get through. I’ve long believed the way we think about healthcare is a little upside down, and this book provides a clear articulation of why.

You can’t help but reclaim some control and responsibility over the future of your health. There are things we can do today to reduce the chance of heart disease, cancer or neurodegenerative disease taking us early. We now have a good reason to train and eat well. As for the best way to do that? Clearly there are no shortcuts. Time to step away form keyboard, and get to the gym!

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Key Takeaways

The 20% that gave me 80% of the value.

  • Life span is how long you live. Health span is how long you have a high quality of life
    • We should be optimising for health span = time + health
  • The 4 horseman account for 80% of deaths in people over 50 who do not smoke…
    1. Cardiovascular disease and cerebrovascular disease
    2. Cancer
    3. Neurodegenerative diseases (e.g. Alzheimer’s)
    4. Foundational disease (e.g. the continuum hyperinsulinemia → insulin resistance → fatty liver disease → type 2 diabetes)
  • You can change your trajectory if you take the right steps now:
    • you can increase your lifespan by 10 years
    • you can increase your health span by 20 years
  • Three Era’s of medicine:
    • 1.0 Hippocrates said disease came from the environment not the gods. But mechanisms weren’t understood. Medicine 1.0 was largely guesswork and observation.
    • 2.0 The scientific method. Germ theory, antibiotics and improved sanitation. Lifespan increased but little preventative treatment. Medicine is still a reaction to something going wrong.
    • 3.0 A focus on prevention. Patients are individuals. The risk of doing nothing is considered. The realisation that health span is more important than lifespan. Treatment is part of our daily life (nutrition, diet, exercise, sleep, emotional health)
  • What do you want your endgame to look like?
  • We should be proactive not reactive. Start treatment as early as possible. Extend our quality years. Medicine 2.0 delays death without improving quality of life.
  • Breaks exercise into:
    • Strength
    • Stability
    • Aerobic efficiency (endurance)
    • Peak aerobic capability (intensity)
  • Ultimately, to increase your health span, you should aim to be fitter and stronger that most people who are 10 years your junior. That’s going to take some work and requires getting into the top few % of your age group.
  • The Randomised Controlled Trial is he cornerstone of Medicine 2.0, but it’s really hard to do for exercise, sleep and nutrition over long enough time horizons. Medicine 3.0 therefore has to draw on other techniques like animal studies, studying human outliers and the 4 main causes of death.
    • Therefore medicine 3.0 is more about probability and risk
  • At any one point, there are only about 300 people alive over 110 years old
    • More people become a billionaire than live to 110
    • Only one person has been verified to have lived 120 years
  • The goal is to phase shift → to delay on the onset of disease by decades
  • Two key tactics:
    • Early disease specific prevention
    • Early general prevention (all the 4 horseman)
  • We have a nutrition problem. Our bodies haven’t evolved to cope with the standard modern diet (which is unhealthy).
  • 42% of Americans are obese, 11% have diabetes, 50% have Type 2 diabetes or are on the path to having it.
    • Diabetes increases the risk of cancer, Alzheimer's and heart disease
  • Insulin resistance is a big problem and brings cancer, diabetes and obesity.
  • Metabolic disorders are a continuum. Look for the warning signs in your bio markers.Elevated insulin (spikes) is a strong signal that you have insulin resistance
    • Don’t consume more calories that you need
    • Only when type 2 diabetes has been diagnosed do we do anything (really bad idea)
  • Metabolic dysfunction can be stopped by diet, exercise and sleep. They require effort to escape the modern environment
  • Heart disease kills more than anything else (inc. cancer).
  • If your overweight and a little insulin resistant your heart might be calcifying
  • Heart disease is more preventable than the others. It should be the 10th leading cause of death, not the first
  • Most of the cholesterol in our system is produced by our own cells, and doesn’t come from our food. YET we steer people away from foods that are high in cholesterol
    • There’s no correlation between cholesterol in food and cholesterol in blood (unless you’re a chicken or rabbit)
  • 50% of heart attacks occur in people under 65
  • Insulin resistance and inflammation are risk factors for heart disease
  • Fat → Heart attacks → Strokes → Dementia
  • Diet is the best way to lower triglycerides and stabilise insulin
  • Start early → in your 30s.
  • Cancer and heart disease together account for 1 in 2 deaths
  • Cancer still kills at about the same rate it did 50 years ago. Once cancer is established, we’re not great at treating it.
  • 3 part strategy: prevention, new smarter treatments, earlier detection (colonoscopy, blood tests)
  • Obesity and diabetes increase the chance that you’ll get cancer. Not being insulin resistant or type 2 diabetic → its almost as important as quitting smoking
  • A strict diet of no added sugar and no carbohydrates could slow / stop cancer
  • Early detection is our best chance
    • With diagnostic tests there’s a tradeoff between sensitivity (ability of the test to detect an existing condition) and specificity (the ability to determine that somebody doesn’t have the condition)
    • Sensitivity is the true positives
    • Specificity is the true negatives
  • The most common gene linked to late-onset Alzheimer's disease is a risk gene called (APOE).
    • APOE e2 is least common and reduces the risk of Alzheimer's.
    • APOE e4 is a little more common and increases the risk of Alzheimer's
      • If you have E/4 E/4 you’re 12x more likely to develop Alzheimer’s disease
      • 2% of the population have this gene
  • Parkinson’s is largely physical, dementia is largely mental… all though they both do the other in the later stages.
  • Prevention is our only hope with neurodegenerative diseases:
    • Mediterranean diet, cut out alcohol, exercise, sleep, social interaction, sauna, brushing and flossing teeth
  • Medicine 2.0 can’t help dementia → so embrace 3.0
    • Adopt a preventative approach
    • What’s good for the heart is good for the brain (vascular health)
    • Metabolic health is key
    • Start early, time is key
    • Exercise is the most important

The 5 Key Domains

Aerobic efficiency: 4 sessions a week, 45mins in Zone 2 V02 Max: 2 sessions a week, 4 min max intervals & 4min recoveries Strength: Heavy weight training, Rucking, rowing, eccentric, hip hinging, split stance Romanian deadlifts Stability: 2 sessions a week, 1 hour. Pushups, feet, spine, shoulders, hands, yoga
Calories matter, try calorie counting. Don’t eat too many or too few. Consume sufficient protein and fats Obtain the vitamins + minerals you need Mediterranean diet → nuts and olive oil Compliance is the key, so it has to work for you If you’re already metabolically healthy, you don’t need to restrict calories Alcohol serves no nutritional or health purpose Extra carbohydrates are the problem, elevated glucose increases risks of the horseman Try to lower average blood glucose, and reduce the variability from hour to hour Eat 1.6g per kg of bodyweight per day (160g of protein) If you didn’t sleep well, or are stressed, you must eat healthy, don’t spike your blood sugar Eat more olive oil, avocado and nuts Only use fasting if nothing else has worked Don’t overthink nutrition, go outside and exercise instead
Fix wake up time Don’t clock watch Blackout bedroom and keep it cool. Take a bath or sauna before bed. Meditate before bed. Avoid caffeine after lunch No active screen use within 60mins of bed (Kindle is OK) Cultivate sleep pressure (exercise, and spend less time in bed) Don’t eat 3 hours before bed. Get 7.5 to 8 hours per night.
Emotional Health
DBT techniques: Emotional Regulation Distress tolerance: expand your tolerance window (exercise, sleep, nutrition, time with family, medication, social time, recreational activities). Stop shrinking your window: saying no (don’t take on too much). Interpersonal effectiveness Self management Are you kind to yourself? Listen to your self talk.
Exogenous Molecules Drugs & Supplements
(Nothing of note here)

Deep Summary

Longer form notes, typically condensed, reworded and de-duplicated.

This of medicine as too reactive. Don’t wait until you have cancer, do something about it beforehand.

Slow death is likely to get you:

  • cancer
  • Heart disease
  • Neuro degenerative
  • Type 2 diabetes

Longevity(health span) = time + health

All about your trajectory.

Take action now.

Modern medicine is good for fast death not slow death,

Proactive not reactive. Fight against slow death.

We treat things at the wrong end of the timescale. At the end not at the beginning.

Exercise is the best longevity drug.

Manual for longevity

  • extend lifespan by decade
  • extend health span by two

Sometimes doing nothing is the riskiest choice of all

The three era of medicine:

  1. 1.0 - guess work, and pure observation. Hippocrates said disease came from the environment/ nature not the gods.
  2. 2.0 - Germ theory, anti biopics, scientific method experimentation and testing. penicillin. Bad for long term health. Antibiotics and improved sanitation is what’s increased lifespan.
  3. 3.0 - Adapting to king slow diseases. Prevention focus. Patients are individuals, how are they similar or different. Risk attitude, the risk of doing nothing. Health span > lifespan.
  • Sketch out what you want your end game (later years) to look like
  • Med 2.0 extends you when you don’t need it
  • Delaying death without improving quality of life
  • Tactics without strategy don’t work
  • Objective → strategy → tactics
  • As you grow older, 4 horseman are more likely to get you
  • Aging makes you vulnerable
  • Best bet is to delay and prevent the onset of those diseases
  • Avoid the period of decline, dying in slow motion
  • Cognitive decline → physical decline (chronic pain, loss of breath) … having an accident is super serious when you’re old
  • the activities of daily living (list of things for old people)
  • The 4 horseman are preventable, and largely optional
  • Lifespan and health span are intertwined
  • the big difference between medicine 2.0 and 3.0 is when we apply our tactics
  • 2.0 is in reaction to something going wrong
    • Procedures
    • Medications
  • 3.0 tactics are part of our daily lives
    • Diet /nutrition
    • Exercise
    • Sleep
    • Emotional health
    • Exogenous molecules (supplements / drugs)
  • Exercise:
    • Strength
    • Stability
    • Aerobic efficiency
    • Peak aerobic capacity
  • Exercise is the most potent. Better than nutrition, makes you feel good
  • Nutrition
    • Avoiding diet wars
    • How many calories (not too much, not too little)
  • Sleep
    • Insulin resistance can come from sleep
  • Emotional health
  • from evidence based to evidence informed
    • Medicine 2.0 insist on randomly controlled clinical trials
      • RCTs are good for short time horizon studies
      • Nobody is doing the multi-decade studies on how to defeat heart disease
      • Too challenging to studying exercise, sleep and nutrition over long time horizons.
    • Instead, we should look at the data we can get, and do have and make a strategy
  • Combine insight from 5 sources. Move from evidence based, to evidence informed risk adjusted medicine
  • Sources of data:
    1. Centenarian data (the extreme outliers that have lived beyond 100) delayed or evaded diseases.
    2. Lifespan data from animal models. If a given intervention can expand lifespan in multiple species, it’s worth looking at
    3. Human studies of the 4 horseman
    4. Molecular and mechanistic insights derived from the study of ageing and ideas
    5. MR → Mendelian randomisation. Bridging the gap with random controlled trials that can establish causality, and pure epidemiology which can’t.
  • The best we can do is reduce our uncertainty.
  • We need to think in probabilities and risks.
  • Finding Alpha.
  • Lifestyle changes → minimise the most serious threats to lifespan and health-span
  • Tools and personal tactics

Part 2

Chapter 4: Centenarians

  • The older you get, the healthier you’ve been
  • We always look for a secret - what do the healthy centenarians have in common?
  • Centenarians are no more health conscious than the rest of us, they might be worse than average
  • At any one point, there are only about 300 people alive over 110 years old (Super Centenarians).
    • There are 9x more billionaires that people over 110 years old
  • Only one person has been verified as living 120 years old
  • The older you get, the more important genes are. If you’re the sister of a centenarian you’re 8x more likely to reach that age yourself, brothers are 17x more likely
  • Long lived parents are a great predictor.
  • Not all centenarians are in bad health. They delay cancer by 3 decades.
  • Females outnumber males.
  • The older males are of better health, as the ‘weaker’ have been weeded out by disease already. Women live longer but in poorer health
  • The older you get, the healthier you have been
  • Healthier and biologically younger than their peers by more than a decade throughout their life
  • Compression of morbidity.
  • Centenarians get 1,2 or 3 bonus decades
  • Natural Selection → Evolution doesn’t care if we live beyond 100. It doesn’t care much about us once we’re beyond reproductive age. Or dementia disease.
  • Apo E → Moves cholesterol around the body and brain
    • E2, E3 and E4 (E4 more likely to get dementia by 2x-12x)
    • Cholesterol, glucose
    • E2 protects against dementia
  • APoE → focus on cholesterol
  • Good news that there’s no single centenarian gene
  • FoxO3 → cellular repair, delegates to others
    • Can be activated by our own behaviours
    • Hungry / deprived of nutrients
    • Exercising
  • Genome is immutable, but gene expression can be influenced by environment and behaviours (e.g. exercise)
  • Phase shift → delaying disease by decades
  • Delay the onset of disease.
  • We treat diabetes as if it’s unrelated to Alzheimer's and cancer → even though its a big risk for both
  • Don’t attack the 4 horseman as individual diseases. They’re all related to aging
  • Two tactics:
    • Early disease specific prevention
    • Early general prevention (all the 4 horseman)
  • Cultivate the resilience

Chapter 5: Eat less, live longer. Science of hunger and health

  • Went to Easter Island (Rapa Nui)→ Rapamycin came from Easter Island
  • When people were sick, they’d spend a night in the volcano crater swamp, thought to have healing powers
  • They took samples. Rapamycin has powerful affects on the immune system.
  • It slows down cellular growth and devision (acts on M-Tor the mechanism that exists everywhere in the animal kingdom, M-Tor balances growth or recycling modes of cells).
    • Mice lived longer (28%)
    • No molecule had ever increased lifespan like that
  • Caloric restriction can increase lifespan. 25% less calories, can increase by lifespan by 15% (and health span too).
  • Less of a tactic that you should adopt, and more something that’s helped increase our understanding
    • Restricting nutrients to a cell, triggers pathways that enhance the cells stress resistance and metabolic efficiency
  • Exercise and Restricting nutrients prompts the cell to conserve and seek alternative forms of energy
    • Cells produce newer and more efficient mitochondria
    • And produce more fuel from the liver
    • And release energy stored in fat cells
    • Drop in amino acids that does it
    • Cell goes into fuel efficient mode, self-eating mode. Breaks down old proteins.
    • Cleans out junk in the cell, recycles it and disposes of it
    • ‘Autophagy’ is essential to life -
      • Good to avoid Parkinson’s and Alzheimer’s
    • As we get older, Autophagy declines
  • Can be triggered by rapamycin, exercise and fasting
  • Rapamycin’s immune suppression effect is what scares doctors and why it hasn’t been widely adopted
    • But later studies showed it was an immune modulator not suppressor… depending on the dose it can enhance or hinder
    • Taking it cyclically unlocks long term health benefits, without the immune suppression
    • Also helps against cancer
  • If aging is killing 80% of us, then drugs with some risk should be allowed if they can increase health-span
  • Diabetes drug metformin might help protect against cancer
  • What we eat, and how we metabolise it play an outsized role in longevity

Chapter 6: The Crisis of Abundance.

  • Can our ancient genes cope with our modern diet?
  • Normal doesn’t mean healthy. As the population diverge from healthy, the normal range isn’t helpful.
    • Average isn’t optimal
  • If you consume too many calories, too much fat, you’ll damage your liver
  • Obesity is a symptom of other problems. 1/3 of people who are obese are metabolically healthy.
    • 20-40% who aren’t overweight are metabolically unhealthy
  • 42% of Americans are obese.
  • Liver has to keep 5g of glucose circulating in your blood, 7g means you have diabetes
  • Insulin decides in what form we store energy
  • Fat is the safest place to store energy. Fat can store energy, and release it later. If you consumer energy in excess of your needs, your fat cells will fill up, once you reach the limit, the calories have to go somewhere (blood, liver, muscle (increasing insulin resistance in muscle), around your heart, or pancreas, abdominal fat - dangerous)
  • Visceral fat (hidden inside the body) is more dangerous. Fat will get in between your muscle and start insulin resistance
    • Cells don’t respond to insulin
    • Inactivity is a problem! And makes insulin resistance worse
  • Insulin resistance. Your body starts producing more and more, until you reach a limit, your cells become full of glucose
    • Fat starts insulin resistance → results in accumulation of more fat → stops us storing calories as anything other than fat
  • Cortisol → makes visceral fat. Cortisol is affected by stress and lack of sleep
  • Insulin is all about fat storage. Insulin issues bring cancer, diabetes and obesity
  • 1 in 9 have diabetes. It used to be really rare. Half of the population has Type 2 diabetes or is on the path to having it
  • Diabetes increases the risk of cancer, Alzheimer's and heart disease
  • To survive in colder climates apes evolved to turn fructose into fat. Became humans.
  • We don’t need it anymore, it’s unhelpful.
  • Don’t drink lots of orange juice. Liquid smoothies, or liquid fruit are bad news. No liquid fructose.
  • Fructose tricks us into thinking we’re still hungry.
  • Don’t consume more calories that you need
  • Fatty liver can lead to cancer.
  • Metabolic disorders are a continuum. Look for the warning signs years earlier (Bio markers)
  • Elevated insulin is a really strong signal. insulin spikes really high if you have insulin resistance.
  • Fatty liver and insulin resistance.
  • Only when type 2 diabetes has been diagnosed do we do anything (really bad idea)
  • Metabolic dysfunction can be stopped by diet, exercise and sleep. They require effort to escape the modern environment

Chapter 7: The Ticker / Heart Disease

  • Heart disease is the deadliest killer on the planet
  • Heart attacks are fatal 33% of the time
  • Kills more than anything else, even cancer
  • Women are 10x more likely to die from heart disease or breast cancer. 1/3 vs 1/30.
  • If your overweight and a little insulin resistant your heart might be calcifying
  • Heart disease is more preventable than the others
    • You can delay it
    • We have tools to prevent it
    • We can image your heart and assess it
  • This should be the 10th leading cause of death, not the first
  • Most of the cholesterol in our system is produced by our own cells, and doesn’t come from our food. YET we steer people away from food that are high in cholesterol
    • There’s no correlation between cholesterol in food and cholesterol in blood (unless you’re a chicken or rabbit)
  • 50% of heart attacks occur in people under 65
  • Risk builds throughout our lives.
  • Exposure to Apo B particles over time is the key risk factor.
    • Starts in 16 year olds
    • Fatty streaks in arteries
    • Plaque becomes calcified
    • That can lead to a clot
      • Heart attack or stroke
  • Insulin resistance is risk factor for heart disease
  • Inflammation is also a problem
  • Apo B is a good predictor of Heart Disease (Costs $20-$30)
  • How to reduce risk?
    • Apo B, LPLA
    • You can’t lower these things enough?
    • Reduce LDLs
  • Fat → Heart attacks → Strokes → Dementia
  • Smoking is bad
  • Diet is the best way to lower triglycerides and stabilise insulin
    • ketogenic diet can work
  • Statins can also work (5% get muscle pain, or insulin issues)
  • This process happens through decades. Think about prevention in 30s or 40s.
  • Start early → in your 30s.
  • Risk is proportional to ApoB exposure over time

Chapter 8: Cancer Part 1/Part 2

  • Cancer is the second leading cause of death without heart disease
  • Cancer and heart disease together account for 1 in 2 deaths
  • We’ve spent a huge amount of time, energy and focus on treating cancer
  • Cancer still kills at about the same rate it did 50 years ago
  • Cancer is a disease of aging. But it can kill you in mid-life
  • Once cancer is established, we’re not great at treating it. Surgery, radiation therapy.
  • 3 part strategy:
    1. Prevention
    2. Newer smarter treatments
    3. Detect cancer as early as possible
      • Colonoscopy
      • Blood tests
  • Cancer cells don’t listen to bodies signals that say grow/don’t grow
  • Cancer cells can travel from one side of the body to somewhere else where they shouldn’t be (Metastasis). Turns it from local and managable, to systemic and fatal.
  • Cancer isn’t a single disease. Cancer genome atlas showed that random mutations combine to make cancer. No two breast cancer tumour genomes are similar.
  • We need to prevent, detect and treat metastatic cancers to move the needle.
    • We don’t know why cancer spreads. Metastasis attracts less than 10% of funding
  • ChemoTherapy isn’t specific enough to target just cancer cells. Therefore it’s horrible to go through
  • Genetics isn’t going to help us fight cancer.
  • Obesity and diabetes increase the chance that you’ll get cancer. Likely to be because of insulin and inflammation
    • Chronic inflammation
    • Insulin resistance (a kind of cancer enabler)
  • Caloric restriction could help reduce cancer
  • The low hanging fruit of cancer prediction is to not be insulin resistant or type 2 diabetic → its almost as important as quitting smoking
  • A strict diet of no added sugar and no carbohydrates could slow / stop cancer
  • The best way to tackle cancer is likely to be by stacking different things (one of which could be a keto diet
  • Cancer cells are ‘our cells’: our body needs to be able to differentiate them to fight them. You might be able to inject bacteria and cause a response from the immune system (spontaneous cancer remission is possible)
    • Failures outnumbered successes
  • Immunotherapy is helping more people survive cancer
  • Early aggressive screening
  • Catching cancer early is almost always beneficial
  • Too many cancers are detected too late
  • The 10 year survival for those with metastatic cancers is almost 0%. If you detect early, in stage 1, then survival rate sky rockets
  • Early detection is our best chance
  • The fewer cancerous cells you have, the greater the likelihood that treatment will be successful
  • We only have good screening for a few types. It would be costly and there would be a lot of false positives if we did more
  • With diagnostic tests there’s a tradeoff between sensitivity (ability of the test to detect an existing condition) and specificity (the ability to determine that somebody doesn’t have the condition)
    • Sensitivity is the true positives
    • Specificity is the true negatives
  • You have to consider the prevalence of the condition in the population. How likely is it that they have it?
    • Mammography has:
      • Sensitivity of 85%
      • Specificity of 90%
    • If 1% have breast cancer, even a test with good sensitivity is going to generate a large number of false positivities. In this low risk group, if you do test positive, there’s only a 10% chance you have breast cancer
  • BUT if you stack a test with Ultrasound and MRI then your resolution improves.
  • Be smart with it. PSA values for prostate cancer, not just a hurdle rate. What were they before, what’s the rate of change?
  • Think of some tests as screening tests for screening tests.
  • Have a colonoscopy screen early. Asymmetric risk.
  • Skin Cancer is easily observed
  • Liquid biopsies → blood tests. Multi-cancer early detection.
    • Is it present?
    • How dangerous is it likely to be?

Chapter 9 & 10 Alzheimer’s Disease and other Neurodegenerative diseases

  • EpoE E4E4 → you’re 12x more likely to develop Alzheimer’s disease.
  • 2% of the population have this gene
  • It’s a marker of risk, that can be mitigated
  • Unlike type 2 diabetes, it’s not reversible
  • Parkinson’s is largely physical, dementia is largely mental… all though they both do the other in the later stages.
  • Some prevention strategies could apply
  • Rarely sets in before age 65 → gives you until them to prevent and delay with actions
  • Some patients with Alzheimer’s don’t have amyloid plaque -> it’s not necessary or sufficient


  • Can Neurodegenerative diseases be prevented?
    • Published a pamphlet on prevention
    • Nutrition, exercise and cognitive training
  • Prevention is our only hope and move with them
  • Alzheimer's is more common in women than men
  • It has a long prolog (posture, gate, depression, anxiety)
  • Our brains are good at compensating for degeneration.
    • You’re not going to decline as quickly if you’re mentally active

Exercise is the only prevention method that has been shown to delay the onset of Parkinson’s disease

  • Tasks that require more varied thinking are good at building cognitive reserve (crosswords, only make you better at crosswords, they’re too narrow)


  • Could be due to reduced blood flow to the brain
  • Blood flow to the brain is important for brain health
  • Blood flow declines as we age, but is made worse by vascular disease
    • High blood pressure
    • Smoking
    • Head injuries
    • Depression
    • All reduce blood flow too
  • Metabolic dysfunction —> having type 2 diabetes doubles or triples the chance of getting Alzheimer's disease
  • Insulin resistance is a factor -> starving the brain of energy.
  • APOE E4 -> appears to make everything worse
    • Moving cholesterol into and out of the brain
  • E4 people are likely to develop metabolic disfunction.
  • The preventative plan:
    • We know more about preventing Alzheimer's than cancer
    • Spot cognitive decline early
    • Switch to Mediterranean diet + fatty fish
      • KeTo diet
    • Cut out alcohol
    • Exercise -> helps glucose homeostasis, improves vascular health
      • Lowers inflammation
      • Grip strength + strength training (lowers risk)
    • Sleep is powerful too, its how the brain repairs
    • Hearing loss is associated with Alzheimer's disease -> as people withdraw, get them a hearing aid
    • Brushing and flossing teeth (gum disease)
    • 4 sessions per week of sauna
  • Medicine 2.0 can’t help dementia -> so embrace 3.0
    • Adopt an early and preventative approach
    • Whats’ good for the heart is good for the brain (vascular health)
    • Metabolic health is key
    • Time is key, start early
    • Exercise is the most important way (foundation of the program)

Part 3

Chapter 10: Building a framework of principles that work for you

  • Our environment has changed - our genes haven’t
    • E.g. we can take in way more calories and sugar than we need
  • What actions can we take?
  • 5 Domains:
  1. Exercise: the most potent on lifespan and health span
    • Aerobic efficiency
    • VO2 max
    • Strength
    • Stability
  2. Nutrition and diet
  3. Sleep
  4. Manage and improve emotional health
  5. Drugs supplements and hormones
  • Need effective tactics for each of these
    • Looking for minor efforts that result in big risk reductions
  • Key questions for exercise and nutrition
    • Are you over or under nourished?
    • Under muscled or over muscled?
    • Metabolically healthy or not?

Chapter 11: Exercise: The most powerful longevity drug

  • Too much advice, a lot of it contradictory
  • Is cardio or strength better? This is a false dichotomy
  • Even a small amount of exercise -> can extend your life by years
  • Great at expanding health span
  • 77% of the US population don’t exercise
  • Going from 0 to 90 minutes of exercise per week reduces risk of dying from all causes by 14% (better than any drug)
  • More cardio, more weights
  • Regular exercisers live a decade longer than others
  • The more we do, the better we will be
  • VO2 max is the single most powerful marker for longevity
    • 300ml of oxygen per minute to watch a movie
    • 2500ml to running, 4000ml to run up hill
  • VO2 max is expressed as: volume of oxygen you can use, per KG, per minute
    • Athlete: 60ml
    • Average person: 40ml per minute
  • Higher VO2 max is the best predictor of longevity
  • Makes a massive difference to go from bottom 25% to top 25%. Also makes a big difference to reach elite (top 2%)
  • Extremely high aerobic fitness is great. No upper limit of effect.
  • VO2 max can be increased with training.
  • Muscle mass and muscle strength are important too
  • Might even be as important as cardio-respiratory fitness
  • Exercise is often better than most drugs.
  • Exercise is great at health span
  • Muscle helps us survive old age
  • Maintain your exoskeleton (helps with falls, protects your skeleton)
  • Maintain muscle mass at all costs
  • Don’t be a one-dimensional athlete
  • Train for the centenarian decathlon
  • 10 most important tasks
    1. Hike 5km on a hilly trail
    2. Get up off the floor using only one arm
    3. Pick up a young child from the floor
    4. Carry 2 grocery bags for 5 blocks
    5. Lift a 20 pound suitcase into overhead locker on plane
    6. Balance on one leg for 30 seconds
    7. Have sex
    8. Climb 4 flights of stairs in 3 minutes
    9. Open a new jar
    10. Do jump rope skips
  • People want to do all of them
  • Lose 10% of strength per decade, you’re going to need to cross more
  • VO2 max needs to be high now
  • You need to do much more now, to put off aging
  • This is not out of reach. Helps us redefine what’s possible in our later years
  • Join him in training to be kick ass 100 year olds
  • Make every decade between now and then better too

Chapter 12: Training 101:

  • Maximising for longevity
  • Aerobic / Cardio
    • Long endurance work Zone 2
    • VO2 max
  • Strength
  • Stability
    • Helps us reduce injury

Aerobic efficiency, Zone 2

  • Zone 2 strained conversation, but slow enough to speak
  • Low intensity burns fat
  • High intensity burns glucose
  • Ability to use both fuels is called metabolic flexibility, is what we want
  • Professional cyclers spends 30 hours a week in Zone 2
  • Efficiency work is a pillar of training
  • Zone 2 is the max effort we can do without creating lactate. Keep lactate levels constant.
  • Zone 2 workouts can feel easy on a good day
  • Professional cyclists can do 300w in zone 2, unhealthy people can only do 100w
  • People who most need to burn fat struggle to do it, but athletes can burn fat easily
  • Exercise in Zone 2 - draws down insulin levels. Great for diabetes prevention
    • Able to talk in full sentences but strained
    • 4x45minutes a week is required
    • Measure your output in watts per kg
    • Watts per kg
    • Can be boring, do other things

V02 Max

  • Need to train to do it
  • You can and should know your V02 max
  • Do it annually
  • A measure of your fitness
  • Target the elite range, top 2% for your age
    • Then go for top 2% for the decade before yours
  • You need to train it
  • Sustained training can pay off
  • Train by:
    • 1 or 2 times a week
    • Hard intervals
    • 3-8 minutes each
      • 4 minutes at max speed for that time period
    • then recover for 4 minutes
    • Make sure you recover fully between sets

We lose strength faster than mass, we lose power faster than strength

  • You need big weights to keep your fast twitch type 2 fibres
  • After just 10 days you can lose a lot of your muscle
  • It’s hard to put on muscle mass later in life

Bone Mineral Density is important. Check it every few years

  • Optimise nutrition, protein and energy need
  • Heavyweight strength training
  • Building a reserve of muscle and bone density
  • It’s cumulative and compounding
  • Carrying is our superpower - carry heavy things when you can
  • Rucking: 50-60 pound backpack (1 hour, in the hills, don’t take a phone)
  • Carrying stuff over long distances
  • Going up hill will push your VO2 max, gaol is to build up to 33% of body weight
  • Grip, pull, hip hinge. Important functions
  • Grip strength is key, our primary point of contact, our interface with the world
  • Walk with weights in the gym.
    • Benchmark: great if you can carry half your body weight in each hand for 1 minutes
    • Benchmark: hang for 2 minutes
  • Stepping down and eccentric strength is really important to keep us safe from falls, and helps your knees
  • Train eccentric strength
    • At some point in each workout - doesn’t have to be each
  • Rowing can help with pulling, as can rows
  • Hip hinging, spit stance Romanian deadlifts


Chapter 13: The gospel of stability

  • Injury is a big factor in why people stop exercising
  • Injury and chronic pain is widespread
  • Backpack is a leading cause of disability
  • First do no harm, stability is a key ingredient
  • Push yourself too hard all the time is going to result in injury
  • Stability is often conflated with ‘core’
  • Harness, decelerate or stop force
  • Stability allows you to transmit more force
  • In the exercise context,
  • Stability lets us create the most force in the safest manor possible
    • Strong, flexible and agile
    • Let’s you keep doing what you want to do
  • Make sure you’re squatting well, don’t load one side more than others
  • Baby’s can do a great hip hinge
  • Sitting in chairs - you forget how to squat
  • Lie on your back - you can get into the good position, its the load that makes it difficult (not range of motion)
  • Stability Training Principles:
    • Build a solid foundation first
    • Twice a week doing 1 hour of stability training
    • 10 -15 minutes on other days
  • Deep steady breathing
  • Sad guy pose
    • Proper breathing
    • IN through the nose
  • Get your breathing right (360 abdominal breathing)
  • Do push ups
  • Feet our our foundation for any movement we make
    • Shoes are making us lose our connection with feet
    • Don’t spend ages in mushy shoes
  • Toe yoga can help, the big toe is important, toe strength is important
  • Ground your feet when you deadlift, load them evenly
  • The spine is key to protect
  • Three parts
    • Lumbar: lower back
    • Thoracic: mid back
    • Cervical: neck
  • Get on your hands and knees, go through cat cow
    • Slow down - so you can feel each vertebra
  • Shoulders have 17 connection points, prone to injury,
    • Know your shoulders
    • Retraction (for load) Raise shoulders and put them back
    • Depression - drop them down your back
    • Protraction - forward and down
    • Elevation - forward and up
    • Do this until you can move in smooth circles
  • Hands and grip strength are how we distribute force
    • Finger strength is key too
    • Add carries to your training
  • Grip and feet are what connect you to the world
  • Don’t be reliant on trainers all the time. If you never learn to do exercise on your own, you’ll rob yourself
  • Film yourself, what do you see? Vs what you think?
  • Slow down to go fast
  • How to do a step up (hip hinge, single leg, eccentric and concentric)
    • Everything should arrive at once
    • Do it over 3 seconds on the way down
    • Do it with dumbbells

Chapter 14: Nutrition 3.0

  • We don’t know that much about how diets affect our health
  • Most people spend too little or too much time thinking about this
  • There’s not one perfect diet - call it nutritional biochemistry
  • What’s your goal?
    • Are you under or over nourished?
    • Are you under muscled or adequately muscled?
    • Are you metabolically healthy or not?
  • More protein, less calories (less sugar?)
  • Nutrition is simple:
    • Don’t eat too many or too few calories
    • Consume sufficient protein and fats
    • Obtain the vitamins and minerals you need
    • Avoid pathogens and E coli
  • Omnivore diet is probably OK at thats what we evolved with
  • Epidemiology and clinical trials:
    • Epidemiology. Lots of people, in their environment, not controlled, observed
    • Clinical trials. Fewer people, in a controlled environment
  • Epidemiology can’t say anything about causality often
  • 9 Bradford Hill Criteria
    • Strength of association (effect size)
    • Reproducibility / consistency
    • Specificity
    • Temporality (does the cause proceed the effect)
    • Dose response (does the effect get stronger with a bigger dose)
    • Plausibility (does it make sense)
    • Coherence (does it agree with data)
    • Experiment (is there experimental evidence to back up)
    • Analogy (affect of similar factors can be considered)
  • Epidemiology is a bit of a scandal
    • Healthy user bias is a big problem
    • There is no dose of alcohol that is healthy despite epidemiology studies showing a low amount of drinking is better
  • Efficacy -> how well it does under perfect conditions
  • Effectives -> how well it does under real world conditions
  • Mediterranean diet -> nuts and olive oil
    • Olive oil group were doing really well

Key factors:

  • Compliance is a key issue
  • Also is if it works for you

Chapter 15: Nutrition: How to find the right eating pattern

  • Modern food is amazing:
    • Produce enough food to feed everyone
    • Inexpensively
    • Preserve it so it can be transported and stored safely
    • How to make it palatable
  • BUT it harms us
    • Not all processed foods are bad
    • Junk food is the problem
  • We eat more than we need to -> become over nourished
  • Low quality nutrients displace protein
  • Disrupts metabolic equilibrium - can’t control our blood glucose levels, makes us store fat instead of utilising it
  • Break free of the standard American diet
  • Diets:
    • Caloric restriction (less volume)
    • Dietary restriction (less of certain foods)
    • Time restriction (only at certain times)
  • Each approach has pros and cons
  • Caloric restriction is the winner (but its hard to stick to)
  • Time restriction might be the easiest (e.g. one meal a day)
    • End up protein deficient


  • Calories matter - if you’re ingesting too much you’re going to have a problem
  • Calorie counting - those people lose weight, its still not easy to do
    • Agnostic to food choices
  • Dual monkey studies on caloric restriction teach us:
    • Avoiding diabetes by eliminating or removing junk food is very important
    • Strong link between calories and cancer, lower calories lower cancer
    • Quality of the food is just as important as the quantity. If you’re eating the standard American diet -> eat less of it
    • If your diet is already healthy, and your metabolically healthy -> you don’t need to do calorie reduction
      • Not worth the tradeoffs, just eat healthy food


  • Dietary restriction
    • Advantage, you can make it individualised
    • Eliminate all sugar
  • A major risk is you can still eat too much
  • Pick a strategy that meets your goals, but to which you can adhere
  • Getting off carbohydrates and cut out energy drinks
  • A keto diet can help
  • The patient hasn’t failed the treatment, the treatment has failed the patient


  • Alcohol → serves no nutritional or health purpose, empty calorie source, increases mindless eating
    • Alcohol → Sleep badly → Alzheimer’s
    • Alcohol → increases mindless eating
    • Be mindful about alcohol, less than 7 servings per week, no more than 2 on any given day
  • You need to find the right mix of Carbohydrates, Protein and Fat for you as an individual
  • Carbohydrates
    • Not good or bad, some are better than others
    • You need to match the dose to tolerance and demand
    • Primary source of energy
    • Extra carbohydrates is a problem, elevated glucose over time increases the risk of all the horseman
    • People respond differently to them (based on exercise and other things)
    • Continuous glucose monitoring - real-time glucose is a good proxy for the insulin response. More actionable
    • Do it for a few weeks.
    • Or you could take your glucose every hour, and plotting it
    • Only need to use CGM for a month or two
    • Higher blood glucose, higher chance of death
    • GOAL: lower average blood glucose, and reduce the variability from hour to hour
    • See the effect of what you’re doing —> then it’ll change
    • Just eat normally for the first month
    • Aim for below 100ml per decilitre
    • Depends when you eat them -> better to eat throughout the day, better to eat in the morning.
    • Your CGM will show that if you’re doing a lot more exercise you can eat a lot more carbs
    • One night of bad sleep, means you won’t be able to get rid of glucose the next day
    • Don’t eat before bed.
    • Lessons from CGM:
      • Carbs aren’t the same the more refined (dinner roll) the higher the spike
      • Fibre can blunt the impact
      • Rice is pretty bad.
      • Don’t be alarmed of glucose spikes when you’re exercising
      • If you didn’t sleep well, or are stressed, you must eat healthy, don’t spike your blood sugar
      • Spinach, broccoli, and high fat/high protein foods don’t spike blood sugar
      • Lean protein will elevate it slightly
  • Protein
    • Important for building muscle mass
    • Protein supplementation helps build muscle
    • Eat 1.6g per kg per day (160g of protein)
    • Should be spread out over the day
    • Consume 4 servings of protein per day
    • Don’t worry about consuming too much protein (it’s too hard)
      • You could eat 8 chicken breasts a day healthily
    • Consume enough to maintain and build muscle mass
    • 2 protein meals, high protein snack, high protein shake
    • Most plant protein in plants isn’t easily absorbed, it’s the wrong structure too
    • The more protein the better
    • Try and get 30% of calories through protein - helps us feel full
  • Fat
    • Fats are both fuel (like carbohydrate) and building blocks for things we need (like protein)
    • The right mix of fat is good for us and our brains
    • Helps us feel satiated
    • Eat more olive oil, avocado and nuts
    • Cut back on butter and lard
    • Reduce omega 6 rich soy bean and sunflower oils
    • Increase salmon and anchovies (omega 3)
    • Reducing saturated fat doesn’t help that much
    • Often need to take supplements for certain types of fats
  • Fasting
    • Hunger disappears over long periods
    • Fasting triggers many of the triggers and markers we want to see
    • Time Restricted:
      • Eat in only 6-8 hours. Can help you reduce calorie intake
        • A 16 hour fast for a mouse is equivalent to days in a human
        • An early day feeding window could help
        • Helps put the breaks on snack
      • Alternate day fasting
        • Results aren’t good
        • Downsides lose muscle (vs reducing calories by 25% each day)
        • Doesn’t feel good
      • Frequent prolonged fasting
    • Use fasting if nothing else has worked try fasting, when there are no other options. - one week per month, 700 calories a day (the other 25 days you eat normally)
    • After day three, the hunger disappears
  • Bad nutrition can hurt us more than good nutrition can help us. Nutritional interventions can only do so much
  • Most Americans aren’t metabolically healthy
  • Don’t compromise on protein
  • Don’t overthink nutrition, go outside and exercise instead


Chapter 16: Learn to love sleep

  • One sleepless night is worse than being drunk (in terms of brain function)
  • Chronic sleep debt is bad
  • Quantity and quality is important
  • Health issues can often be tracked back to sleep issues
  • Sleep is as fundamental to health as stability is fundamental to strength
  • Sleep can make you feel great
  • 7.5 to 8.5 hours per night
  • Bad sleep drops exercise measures
  • Poor sleep reeks havoc on our metabolism
    • Insulin resistance and elevation levels
    • Can’t dispose of glucose
  • Poor sleep and high stress is a reinforcing bad feedback loop
  • Late night eating and drinking is bad
  • Sleeping less than 6 hours increases chance of heart disease
  • Sleep is good for brain health when we’re older.
  • A good nights sleep is good for memory test performance the next day, and for problem solving
  • Sleep helps with emotional healing
  • REM helps with emotional awareness
  • Sleep issues bring on Alzheimer's
    • cognitive impairment
  • Treat and avoid sleep disturbance
  • Our ability to get good sleep gets worse as we get older
  • Good sleep in middle age is important
  • Sleep medicines don’t work well, they don’t promote healthy sleep
    • trading high quality sleep for low quality sleep
    • Don’t use them regularly
  • What to do:
    • Give yourself permission to sleep
    • Track your sleep (if it doesn’t make you anxious)
    • Take sleep questionnaires
    • Make sure you don’t have sleep apnea
  • Sleeping better - create a good environment
    • Blackout your bedroom
    • Don’t use blue LEDs
    • Switch off lights as you approach bed
      • Passive activities are OK active aren’t
        • Scrolling social
        • Playing video games
    • Don’t use screens within 60 minutes of bedtime
    • Keep bedroom cool
    • Take a hot bath
    • Don’t drink alcohol
    • Coffee is not the
    • No caffeine after lunch
    • Cultivate sleep pressure
      • sleep restriction can help
      • Napping in the day hurts
      • Exercise helps
    • Don’t read news or do work in the evening (anxiety inducing)
    • Meditation can help
    • Sauna
    • Don’t eat anything 3 hours before bed
    • Give yourself sleep opportunity
    • Fix wake up times
    • Don’t obsess over sleep (don’t clock watch)
  • A good nights sleep depends on a good day (healthy)
  • Think of sleep as performance enhancing behaviour, physically, cognitively —> helps with health span

Chapter 17: Emotional Health

  • Emotional health and physical health are intertwined
  • Might be the most important aspect
  • Living alone or feeling alone can shorten your life
  • Feel connected, have healthy relationships with others and yourself
  • Why would you want to live longer if you’re so unhappy?
  • Rehab -> sit in your misery, only allowed to workout, no devices or books
  • Trauma:
    • Abuse
    • Neglect
    • Abandonment
    • Enmeshment(blurring of boundaries between adults and children)
    • Witnessing tragic events
  • Trauma and adversity isn’t the same thing. Adversity can be OK
  • Trauma results in:
    • Addiction
    • Co-dependency
    • Habituated survival strategy (propensity for rage)
    • Detachment disorder: not being able to make meaningful connections with others
  • Address emotional health - exercise, sleep, etc
    • Less able to recognise the need to make changes
  • 90% of male rage is helplessness manifested
  • Children will internalise the rage that you demonstrate even if it’s not directed at them
  • Don’t work for one day a week
  • Reframing -> see it from somebody else’s point of view. You’re the centre of your world
    • Step back, view if from their lengths
  • Resume virtues or Eulogy Virtues
    • You want to accumulate eulogy virtues
  • Don’t punish yourself (rage and self doubt)
  • Who cares how well you perform if you’re miserable
    • Perfectionism
    • Work-a-holic
  • Don’t become your own worst enemy
  • You need to understand the warning signs, spot problems early and take action
  • Practice DBT:
    • Theme: rooted in mindfulness, a really effective tool to create distance between your thoughts and yourself. A space between stimulus and response
      • Detach from your emotions
    • Pillars
      • Emotional regulation (gain control of emotions)
      • Distress tolerance
        • Expand your window:
          • Exercise
          • Sound sleep
          • Nutrition
          • Time with family
          • Medication
          • Deep Social connections
          • Spending time in nature
          • Recreational activities that aren’t about self judgement
        • Less control over things that shrink your window:
          • Saying yes to too much (say no more)
      • Interpersonal effectiveness
      • Self management
    • When you’re suffering - its normally about thinking about something in the past or in the future that hasn’t happened
  • Are you kind to yourself? Listen to your self talk.
  • Anger and shame downward spiral
  • DBT techniques:
    • Endure an abrupt sensory change (cold shower)
    • Slow deep breathing
    • Do the opposite action (if you find yourself doing something you don’t like, showing a side you don’t like)
      • Changing behaviour can change the mood
  • Rucking -> good for stillness
  • You have to believe real change is possible


  • Longevity isn’t an engineering problem
  • No point prolonging your life if you’re miserable
  • Don’t avoid living