This is yet another summary of Outlive, the health book by Peter Attia. I enjoyed the book and found many specific takeaways, but reading was the easy part! Now, I have to implement the recommendations, and implementation is easier after extracting actionable advice. Thus this post is essentially a collection of quotes and insights for my own use.

(Work in progress)

Part I

The first part of the book exposes Peter Attia’s general approach to longevity and what he calls “Medicine 3.0”. The goal is to maximize healthspan instead of lifespan. To achieve that, the idea is to shift your focus from solely treating existing health issues to actively preventing chronic diseases through lifestyle modifications and early detection strategies.

This part of the book makes a lot of sense and gives some context for the rest of the book, but it does not contain very specific and actionable advice. Here are some high-level recommended actions:

  • Educate yourself about the Four Horsemen, i.e. the main causes of slow death: heart disease, cancer, neurodegenerative diseases, and diabetes.
  • Seek guidance from doctors, nutritionists, and other healthcare professionals to assess your individual risk profile and develop personalized strategies for preventing chronic diseases. Schedule regular screening tests and checkups.
  • Prioritize regular exercise, balanced nutrition, adequate sleep, and stress management practices to promote overall well-being and reduce the risk of chronic diseases.
  • Gradually incorporate healthy habits into your daily routine. Consistency is key, so focus on making small, sustainable changes over time.

I like the introductory quote a lot:

There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in. — Bishop Desmond Tutu.

Part II

The second part of the book is a sort of Biology 101 recap, explaining at a high level how aging, metabolic syndrom, diabetes, heart disease, cancer and neurodegenerative disease work. It’s really engaging and still remarkably detailed.

I might come back to this section later to add more notes. The other day I was talking to a friend and realized I wasn’t able to explain coherently on the spot how insuline response, glucose and diabetes were linked, which was embarassing.

Part III

Chapter 13: Stability

Peter Attia gives a series of small exercises he learnt from his coach Beth. He also provides videos for some exercises at https://peterattiamd.com/outlive/videos/.

Breath training.

The idea behind breath training is that proper breathing affects so many other physical parameters: rib position, neck extension, the shape of the spine, even the position of our feet on the ground. The way in which we breathe reflects how we interact with the world. “Making sure that your breath can be wide and three- dimensional and easy is vital for creating good, efficient, coordinated movement,” Beth says. Beth likes to start with an exercise that builds awareness of the breath and strengthens the diaphragm, which not only is important to breathing but is an important stabilizer in the body. She has the patient lie on their back with legs up on a bench or chair, and asks them to inhale as quietly as possible, with the least amount of movement possible. An ideal inhalation expands the entire rib cage— front, sides, and back— while the belly expands at the same time, allowing the respiratory and pelvic diaphragm to descend. The telltale is that it is quiet. A noisy inhale looks and feels more dramatic, as the neck, chest, or belly will move first, and the diaphragm cannot descend freely, making it more difficult to get air in. Now, exhale fully through pursed lips for maximum compression and air resistance, to strengthen the diaphragm. Blow all that air out, fully emptying yourself before your shoulders round or your face or jaw gets tense. Very soon, you will see how a full exhale prepares you for a good inhale, and vice versa. Repeat the process for five breaths and do two to three sets. Be sure to pause after each exhale for at least two counts to hold the isometric contraction— this is key, in DNS.

360 Abdominal Breathing.

In DNS, you learn to think of the abdomen as a cylinder, surrounded by a wall of muscle, with the diaphragm on top and the pelvic floor below. When the cylinder is inflated, what you’re feeling is called intra- abdominal pressure, or IAP. It’s critical to true core activation and foundational to DNS training. Learning to fully pressurize the cylinder, by creating IAP, is important to safe movement because the cylinder effectively stabilizes the spine. Here’s another quick exercise to help you understand how to create IAP: breathe all the way in, so you feel as if you are inflating the cylinder on all sides and pulling air all the way down into your pelvic floor, the bottom of the cylinder. You’re not actually “breathing” there, in the sense that air is actually entering your pelvis; you’re seeking maximal lung expansion, which in turn sort of pushes your diaphragm down. With every inhale, focus on expanding the cylinder around its whole diameter and not merely raising the belly. If you do this correctly, you will feel the entire circumference of your shorts expand evenly around your waist, even in the back, not just in the front. When you exhale, the diaphragm comes back up, and the ribs should rotate inward again as your waistband contracts. This inhale develops tension, and as you exhale, pushing out air, you keep that muscular tension all around your cylinder wall. This intra- abdominal pressure is the basic foundation for everything that we do in stability training— a deadlift, squats, anything. It’s as if you have a plastic bottle: with the cap off, you can crush the bottle in one hand; with the cap on, there is too much pressure (i.e., stability) and the bottle can’t be crushed. I practice this 360- degree abdominal breathing every day, not only in the gym but also while I am at my desk.

Toe Yoga.

First, Beth 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 toe, the inside and outside of your heel. This is easy, and revelatory; when was the last time you felt that grounded? Try to lift all ten toes off the ground and spread them as wide as you can. Now try to put just your big toe back on the floor, while keeping your other toes lifted. Trickier than you’d think, right? Now do the opposite: keep four toes on the floor and lift only your big toe. Then lift all five toes, and try to drop them one by one, starting with your big toe. (You get the idea.)

Cat-Cow.

The difference is that you have to really, really slow down, moving so slowly and deliberately from one end of your spine to the other that you can feel each individual vertebra changing position, all the way from your tailbone up to your neck, until your spine is bent like a sway- backed cow. Then reverse the movement, tilting your pelvis forward and bending your spine one vertebra at a time until your back is arched again, like a really scared cat. (Note: Inhale on Cow, exhale on Cat.)

Scapular Controlled Articular Rotations (CARs).

Stand with your feet shoulder- width apart and place a medium to light resistance band under your feet, one handle in each hand (a very light dumbbell also works). Keeping your arms at your sides, raise your shoulder blades, and then squeeze them back and together; this is retraction, which is where we want them to be when under load. Then drop them down your back. Finally, bring them forward to the starting point. We start out moving in squares like this, but the goal is to learn enough control that we can move our scapulae in smooth circles.

Tennis Balls in a Sock for Long Flights or Drives.

Back when I used to fly every week, I tried a clever trick that Michael Rintala showed me: put two tennis balls in an athletic sock about four to six inches apart, and position them just about at the level of my kidneys, or where my thoracic spine meets my lumbar spine. Then, with every breath I try to make sure I expand fully enough to feel the tennis balls on both sides. The idea is that it cues your breathing. When I did this, I could get off a five- hour flight and feel as if I had not been sitting for longer than about five minutes. (It also kept my seatmates from talking to me when I was trying to work.) It’s worth trying on a long flight or drive. *3 If you really want to go all in on toe yoga, get a set of “toe spacers,” which help restore the toes to a more natural, spread position, particularly in people with bunions or other shoe- related issues. I wear these things around the house a lot. I’m typing right now while wearing them. My kids mock me relentlessly.

Importance of grip and feet.

One way that Beth likes to illustrate the importance of this is via a basic bicep curl with a (light) dumbbell. First, try the curl with your wrist bent slightly backward, just a bit out of line with your forearm. Now try the same bicep curl with your wrist straight. Which one felt stronger and more powerful? Which one felt like the fingers were more involved? It’s about building awareness of the importance of your fingers, as the last link in the chain. One last way in which grip is important is in situations requiring reactivity— being able to grab (or let go of) a dog’s leash when needed, or gripping a railing to prevent a fall. Our grip and our feet are what connect us to the world, so that our muscles can do what they need to do. Even in a deadlift: one of the key things Beth taught me is that a deadlift is as much about feet and hands as hamstrings and glutes. We’re pushing the floor away as we lift with our fingers. These moves and drills that I’ve described thus far represent only the very basic elements of stability work. They may seem simple, but they require a great deal of focus; in my practice, we don’t even allow our patients to work out with heavy loads until they work on these basic principles for at least six months.

Film yourself.

Everything that we’ve covered in this last section serves two purposes: as a drill, and as an assessment. I would urge you to film yourself working out from time to time, to compare what you think you are doing to what you are actually doing with your body. I do this daily— my phone on the tripod is one of my most valuable pieces of equipment in the gym. I film my ten most important sets each day and watch the video between sets, to compare what I see to what I think I was doing. Over time, that gap has been narrowing.

The “Barry Get-Up”. Movement of standing up from a seated position on the ground, with only one arm or no arms. The name comes from a 81-year-old patient named Barry, who managed to re-learn this movement. It’s a typical Centenarian Decathlon exercise, which could be useful to stand up after a fall or to play with grandchildren.