Review: Outlive

Outlive Book Cover

What is the common wish that most of us heard in our birthday? Among them, perhaps is the wish for a long and prosperous life. Yet, it is not as prevalent as the wish for us to live our lives to the fullest. After all, how can we truly cherish a lengthy existence without experiencing a life brimming with fulfillment?

In the book “Outlive,” Peter Attia MD, a renowned expert in the field of longevity, presents an extensive and robust roadmap to enhance our healthspan. Healthspan refers to the duration of our lives when we are free from disabilities and diseases. He goes beyond offering practical guidance; he fortifies his assertions with the latest scientific discoveries, empowering us to optimize both our physical and mental capabilities.


Attia’s foremost concern revolves around the prevailing era of Medicine 2.0, wherein actions are predominantly taken only when we are already afflicted with illness or injury. Consequently, he advocates for a departure from this mindset, urging us to shift our focus towards prevention and the preservation of healthspan.

His primary objective is to delve into the scientific understanding behind the four horsemen of chronic diseases, namely heart disease, cancer, neurodegenerative diseases, and type 2 diabetes. By comprehending the science behind these ailments, Attia aims to formulate a comprehensive strategy that enables us to surpass life expectancy and optimize our physical, cognitive, and mental well-being.

Attia skillfully delves into the intricacies of longevity, even at the molecular level, which may present a challenge for readers without a medical background. The practical actions are not explicitly laid out in a direct manner; instead, the reader must approach the book gradually, absorbing the knowledge one page at a time.

Important Action


  • Avoid: smoking, having insulin resistance, and being obese.
  • Have a good nutrition, do regular physical activity, and some cognitive training → to maintain cognitive function and prevent cognitive decline
  • Have enough sleep.
  • Manage emotional health.


Grip strength

  • Male: can carry half body weight in each hand (full body weight in total) for at least a minute.
  • Female: can carry 75% of her body weight.
  • Dead-hanging from pull up bar for as long as you can → critical for scapular (shoulder) stabilizer muscle.
    • Men: at least two minutes; women at least 90 seconds at the age of 40.

Concentric (shortening) and eccentric (lengthening) loading for all movements.

Be able to lift the weight up and put it down, slowly and under control.

  • Eccentric loading: bicep curl.
  • Concentric phase: curling the dumbbell with biceps.
  • To test: stepping onto and off an 18-inch block and taking 3 full seconds to reach the ground

Pulling motions

Example: rowing machines

Hip-hinging movements

Example: deadlift and squat, step-ups, hips thrusthers, and countless single-leg variants.


  • breathing practice
  • toe yoga
  • spine practice
  • shoulders practice
  • hands: basic bicep curl with a (light) dumbbell
  • grip exercise


Protein Intake

  • Daily suggestion: 0.8 g/kg of body weight
  • For lean mass maintenance:
    • daily leucine and lycine: 3-4 g
    • daily methionine: 1 g
  • To increase lean mass:
    • daily leucine: 8-12 g


  • Eat monounsaturated fatty acids, such as extra virgin olive oil.
  • Saturated and polyunsaturated fatty acids depend in individual factors, such as lipid response and measured inflammation.


The most potent “drug” for longevity

  • Exercise
  • Nutrition
  • Sleep

The longevity genes

  • CETP
  • APOC3
  • APOE
    • known for its impact on Alzheimer’s diseases
    • involved in cholesterol transport and processing
    • important in shuttling cholesterol around the body, specifically in the brain
    • has 3 variants:
      • e2
        • highly associated with longevity
        • protect its carriers against dementia
        • people who carried at least one copy of e2 without e4 → 30% more likely to span old age
      • e3
      • e4
        • having one or two copies of the e4 → multiply one’s risk of developing Alzheimer’s disease
        • people with two copies of e$, one from each parent → 80% less likely to live long


  • can be influenced by our own behaviors
  • activated → activates genes that maintain our cells to be healthier

In addition to the aforementioned genes, scientists hypothesize that numerous other genes are associated with longevity. However, it is important to note that genetics alone do not solely determine lifespan. The environment also plays a crucial role, with certain individuals experiencing favorable conditions that rival the genetic luck of centenarians.

How does calorie deficit increase longevity?

  • less eat → decreasing the nutrients provided for a cell →
    • provoke the production of newer and more efficient mitochondria → replacing the old and damaged ones → new mitochondria help the cell to produce more energy
    • produce glucose in the liver and release stored energy in fat cells → triggers the body to provide more fuel for the new mitochondria
    • hinder the activity of mTOR → the cells become more energy-efficient and stress-resistant → activate autophagy, a recycling mechanism.

What is the downside of calorie deficit?

  • doubtful outside the lab; some experiments in animals exhibit that some of them may be more vulnerable to death from infection or cold temperature
  • long-term calorie deficit → challenging to sustain in human
  • no evidence shows that calorie deficit would actually lengthen the longevity in a complex organism, such as humans, who live in a complicated environment.

Cardiovascular diseases

What we eat doesn’t affect our cholesterol level and its risk to heart disease

According to the insights shared by nutrition scientist Ancel Keys, the long-held belief regarding the relationship between cholesterol, atherosclerosis, and rabbits is misguided. The research that led to our understanding of this connection was primarily conducted on rabbits, which have unique mechanisms that readily absorb cholesterol from their diet into their bloodstream. It is important to recognize that humans metabolize cholesterol differently.

While the consumption of saturated fat can indeed elevate the levels of atherosclerosis-lipoproteins in our blood, it is worth noting that a significant portion of the cholesterol we consume is ultimately eliminated from our bodies through waste. The majority of the cholesterol circulating in our system is actually synthesized by our own cells.

The mechanism of smoking and high blood pressure to cardiovascular disease

Smoking and high blood pressure → damaging endothelium → greater retention of LDL.

  • Smoking → damages it chemically.
  • Blood pressure → damages it mechanically.

How to reduce cardiovascular risk?

  • decreasing apoB and LDL-C as low as possible
  • reducing the burden of apoB particles, specifically LDLs buat also VLDLs, which can be harmful
  • no smoking
  • managing blood pressure level
    • change diet to lower triglycerides
    • manage insulin levels
    • some people need nutritional managements together with drugs interventions


Strategies for dealing with cancer

Avoid getting cancer at all

It is a perplexing challenge because there is still a lack of comprehensive understanding regarding the precise factors that govern the onset and progression of the disease.

The use of better cancer treatments

Currently, there is a wide range of innovative treatments that have emerged, offering more effective approaches to combat the multifaceted nature of cancer. These include strategies that exploit the insatiable metabolic demands of rapidly dividing cancer cells, as well as therapies that capitalize on their vulnerability to immune-based interventions.

Detect cancer as early as possible

Cancer in early-stage means they have fewer cancerous cells, fewer mutations → more vulnerable to treatments.


  • Do some early diagnosis: colonoscopy by age 40, visual examination of skin cancer and melanoma, pap smear for cervical cancer, imaging for lung cancer detection, and liquid biopsies to detect the presence of cancers via a blood test.

How does dietary intervention decrease the growth of cancer risk?

Lower insulin levels

  • insulin is a cancer enabler. More insulin in blood → accelerate cancer’s growth
  • PI3K play a major role by opening a gate in the cell wall → allowing glucose to flood in to fuel its growth
    • cancer cells rule specific mutations → turn up PI3K acitivity while shutting down tumor-suppressing protein, PTEN.
    • When insulin and IGF-1 activate PI3K → the cell is able to engu;f glucose at a fast rate to fuel its growth

Calorie deficit

Calorie deficit → turn down PI3K-associated pathway.

Fasting or fasting-like diet

  • in cancer’s patients, it improved the patients’ quality of life without significant adverse events. Morever, it could increase the ability of normal cells to resist chemotherapy, while extending cancer cells more sensitive to the treatment.

Neurodegenerative diseases

Insulin is critical in memory function

  • Insulin receptors are densed in the hippocampus as the memory center of the brain
  • A study: insulin resistance → glucose cannot get into neurons → blocks brain volume preservation in alzheimer’s disease patients
  • brain glucose metabolism, decades before the onset of other symptoms of vascular dementia
  • reduced glucose metabolism essentially starves the neurons of energy → triggering a cascade of responses:
    • inflammation
    • increased oxidative stress
    • disfunction of mitochondrial function
    • and neurodegeneration itself

Alzheimer’s disease is almost twice as common in women than in men

  • Menopause
    • A rapid drop in estradiol in women with a e4 allele is a driver of risk suggests a → possible role for perimenopausal hormone replacement therapy in these women.
  • Other reproductive history factors: number of children the woman has had, age of first menstruation, exposure to oral contraceptives → have a significant impact on Alzheimer’s risk and later life cognition.

Alzheimer’s disease prevention

nutrition, physical activity, and cognitive training → maintain cognitive function and prevent cognitive decline

How to hold back or delay the symptoms of Alzheimer’s disease?

By doing a set of activity called cognitive reserve, which means:

  • Expanding our knowledge by acquiring intricate skills like mastering foreign languages or musical instruments helps construct neural networks throughout our lifetime, rendering us more resilient against cognitive decline.
  • Engaging in tasks or activities that offer diverse challenges and demand agile thinking and processing, such as solving crossword puzzles on a daily basis.

How to resist or delay the symptoms of Parkinson’s disease?

  • Movement reserve
    • Individuals who exhibit superior movement patterns and have a prolonged history of physical activity, such as trained athletes or frequent exercisers, often display resilience against or experience a deceleration in the advancement of the disease. Movement and exercise, encompassing not only aerobic activities but also more intricate endeavors like boxing workouts, serve as a fundamental strategy for the treatment and prevention of Parkinson’s disease. Exercise stands as the sole intervention that has demonstrated the ability to delay the progression of this condition.
    • Example: dancing appears to be more effective than walking at delaying symptoms of Parkinson’s disease

The controversy of brain training

Distinguishing cognitive reserve from other elements, such as socioeconomic status and education, is a complex task, as these factors are interconnected with improved metabolic health and other variables. This connection is often referred to as “healthy user bias.” Consequently, the evidence regarding whether cognitive reserve can be “trained” or utilized as a preventive measure, such as through learning to play a musical instrument or engaging in brain training exercises, remains highly contradictory and inconclusive. However, it is worth noting that these activities are generally considered beneficial and unlikely to have any negative effects.

Author: Peter Attia, MD

Genre: non-fiction

Publication date: 28 March 2023

Publisher: Harmony

Number of pages: 496 pages


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