#183 Longevity, Healthspan and Lifespan with Peter Attia MD

November 18, 2019 | By Elena Gibson

How to become the fittest 100 year old in history

Summary

We want to live longer… and healthier too! Dr Peter Attia, a physician focusing on the applied science of longevity, walks us through lifespan and healthspan, exploring tactics aimed at extending both. Listeners will challenge the conventional approach to primary care and explore tactics to optimize exercise, nutrition, and health, including counseling on different dietary patterns, fasting, exercise, emotional well-being and how to prepare for the Centenarian Olympics!

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Credits

Written and Produced by: Matthew Watto MD, FACP and Elena Gibson MD 

Cover Art and Infographic: Elena Gibson MD

Hosts: Elena Gibson MD, Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editor: Emi Okamoto MD

Audio Editor: Clair Morgan of Nodderly

Guest: Peter Attia MD 

Check out Peter’s podcast, The Drive!

Time Stamps

• 00:00 Intro, disclaimer, guest bio
• 04:22 Guest one-liner, Career Advice, Picks of the Week*
• 14:30 Case: A couple seeking maximize longevity; Defining longevity, healthspan, lifespan and the 4 types of death
• 19:30 Lifespan, the longevity curve and the long tail
• 23:50 Peter’s approach to shepherding patients toward longevity; Exploring motivations
• 32:06 Back to our couple: What exercises should they perform
• 42:09 Peter’s advice on nutrition; the standard American diet; Intermittent fasting; Dietary Restriction
• 51:20 Periodic fasting and water only fasting
• 54:33 Genetics and longevity
• 56:40 Metformin; SGLT2 inhibitors; Allopurinol and uric acid lowering
• 61:47 Peter’s take home points and a plug for David Foster Wallace’s commencement speech from Kenyon College
• 66:40 Outro

Longevity Pearls

Longevity is a product of lifespan (how long you live) and healthspan (how well you live)

Mortality defines lifespan while cognitive, physical and emotional health contribute to healthspan. 

Improving longevity revolves around increasing lifespan duration while another aspect focuses on slowing down the decline in healthspan.

The perfect longevity curve would be a square with a sudden event simultaneously ending lifespan and healthspan. The aim is to “square the longevity curve”

Providers should aim to establish goals and motivation to improve longevity with patients 

Sleep, exercise and nutrition are the pillars to improved longevity 

Refined carbohydrates, added sugars such as sucrose or high fructose corn syrup, and alcohol should be avoided completely 

Time restricted feeding and elimination diets are often stepping stones to improved nutrition

The similarities between and outcomes among various dietary trends are what matters

Longevity Show Notes 

Lifespan and Healthspan

Dr. Attia describes longevity as a product of lifespan (how long you live) and healthspan (how well you live). As such, longevity is the practice of improving lifespan and healthspan by optimizing four interdependent declines in health. He outlines declines in health as four types of death: 1) Type I death: mortality 2) Type II: cognitive death 3) Type III: physical death 4) Type IV: emotional death. 

Lifespan

Lifespan is the time until Type I death (ie time on death certificate), and represents the duration of life. Therefore, lifespan is absolute and binary. 

Healthspan

The duration of healthspan is defined by types II, III,  and IV death. It is relative, and a spectrum.

Type II cognitive death is an erosion of cognition and the decline in mental capacity. 

Type III physical death marks decline in the exoskeleton function including loss of muscle mass or bone density, chronic pain, and an overall inability to physically accomplish activities that matter to the individual. Markers of cognitive and physical decline vary based on an individual’s baseline and values. 

Type IV emotional death probably gets the least attention in modern medicine, but it is the most valuable aspect of healthspan as the other declines don’t matter if an individual is unhappy. Emotional death does not include mental illnesses but rather the ability to practice mindfulness, be present, minimize suffering, and participate in relational living. In summary, emotional healthspan is the ability to minimize one’s own suffering. He encourages people to listen to “This is Water” commencement speech by David Foster Wallace. 

Longevity Curve 

Dr. Attia describes a longevity curve (see figure below) that has lifespan on the x axis and healthspan on the y axis. Lifespan starts at 0 on the x axis and healthspan starts at its peak on the y axis. Lifespan ends (Type I death) when the line crosses the x axis, and healthspan (Types II-IV death) starts to decline as the line slopes downward. 

The perfect longevity curve would be a square with peak healthspan maintained until a sudden event simultaneously ended lifespan and healthspan (ie, living very healthy and active until an old age, then suddenly dying in your sleep). Therefore, improved longevity aims to pull the curve up and to the right,  to “square the longevity curve”. One aspect of improving longevity revolves around increasing the length of one’s lifespan (prolonging Type I death) while another aspect focuses on slowing down the decline in healthspan (Types II, III and IV deaths). 

Increasing longevity

Most adults die from one of the following four etiologies: cardiovascular/cerebrovascular disease, neurodegenerative disease, cancer, and accidents (CDC 2017). Therefore, Dr. Attia discusses how goals to increase longevity require investing heavily in the mitigation and prevention of chronic disease.

Improving healthspan

Per Dr. Attia,  improving healthspan requires aiming  to reduce the inevitable age-induced decline in cognitive, physical and emotional health. Thus, the goal of improved healthspan is diminished morbidity associated with loss of function.  In general, an individual’s cognitive and physical peaks occur around ages 20-30 years old. Longevity curves usually remain relatively flat until a slow decline starts in the 5th decade of life and becomes precipitous during the 7th decade of life. By the 8th decade, most people have reached the “halfway point” of their existence, meaning they are functioning at about 50% of their cognitive and physical peak. Unfortunately, reaching the 50% mark with a decade of life expectancy left leads to prolonged morbidity. 

Patient Care 

Establish Goals

Dr. Attia explains the importance of establishing internal motivation for wanting to live longer (increased lifespan) and better (improved healthspan) because the lifestyle changes required to improve longevity are challenging. He recommends asking patients to write down their motivation to live longer on a piece of paper to carry around as a constant reminder. Another exercise Dr. Attia uses to develop motivation is drawing a visual example of a patient’s lineage to reveal  how living an extra decade could be the difference between knowing or not knowing an entire generation of one’s lineage. 

Pillars of longevity

Dr. Attia discusses how the benefits of increased longevity require attention to sleep, exercise, nutrition, and stress management. These are the pillars to improving longevity, and no drug can replace them. Results necessitate a willingness to change these aspects of life. Longevity is a perfect linear optimization problem as the earlier you start the more benefit expected, but the later you start motivation the motivation is higher.

Exercise 

The exercise framework Dr. Attia uses in practice revolves around the “Centenarian Olympics”. Described as a sport we often neglect to train for,  the Centenarian Olympics include eighteen physical activities or movements successfully completed at 100 years old. These include activities such as picking up a grandchild or lifting luggage in an airplane, and training is based around maintaining the ability to accomplish these tasks. Our guest defines two important benefits of exercise: 1) metabolic 2) structural. The metabolic benefits include production of brain-derived neurotrophic factor (BDNF), an important protector from dementia, and muscular insulin sensitivity (Laske, 2006). As we age, we build unhealthy habits of movement that lead to repetitive injury and chronic instability. The structural benefits improve movement by focusing on the four components of exercise which include a foundation of stability, strength, aerobic efficiency and anaerobic performance. 

Nutrition 

Dr Attia discusses a nutrition framework that includes different dietary states. 

1. Standard american diet (SAD) 

SAD is the default, where most people start and remain. He works with patients to engage in different dietary patterns.

2. Time restricted feeding 

Time restricted feeding is limiting the time of eating, even without limiting the quality or quantity of nutrition. Time restricted feeding has been proven to increase metabolic health in animal models, but not in humans. If a mouse is restricted to eating for 8 hours per day is more protected from weight gain and the risk of metabolic illness decreases (Chaix, 2019). However, 16 hours of fasting for a mouse is probably analogous to a week or more of fasting for a human. In Dr. Attia’s experience, time-restricted feeding has led to weight loss, improved energy and even statin tolerance among patients. Many people start with this option.

3. Dietary restriction 

Dietary restriction involves eliminating or limiting specific types of food. Vegan and paleo diets are two restriction diets that look very different on the surface. BUT, both diets usually lead to increased intake of healthy foods such as vegetables and monounsaturated fats. Overall, the similarities in elimination diets may be more important than the differences, and what matters is the outcome. 

4. Reduced calorie fasting 

Reduced calorie fasting is restricting calories (eg 50-70% of baseline diet) periodically, for example 5 days a month. The Fast Mimicking Diet is a popular option of 5 days consuming 750 calories per day quarterly (The Longevity Diet by Valter Longo). 

5. Water only fasting 

Water only fasting involves fasting with only water. Dr Attia describes his regimen of 7 days every 3 months. It is an extreme, far from the SAD, and he typically does not recommend this to patients.

General Nutrition Principles 

For most people, there is no benefit in refined carbohydrates and added sugars such as sucrose or high fructose corn syrup, and these should be avoided completely. Furthermore, alcohol is a toxin and should also be avoided. Regarding fatty acids, patients should aim to increase intake of EPA and DHA. Compared to our ancestors who lived near water, Dr. Attia believes we are very deficient in EPA and DHA probably by a factor of 5 to 10. These are great general principles. 

Genes and Longevity

Dr. Attia outlines how genetics do not play a large role in longevity until about  the 8^th decade of life, and rare centenarian genes (Motta, 2005) only become predictive of longevity during the 9th and 10th decades of life. Therefore, the majority of longevity is influenced by health patterns created and maintained prior to the 8th decade of life. Modifications to sleep, nutrition and exercise can improve lifespan and often more importantly, healthspan. 

 Supplements and Medications 

Dr. Attia discusses how although metformin is still useful in insulin resistant individuals, it is possibly harmful in insulin sensitive individuals due to negative effects on the benefits of exercise. For example, a recent study of hypertrophic training among older adults found metformin use was associated with a reduction in muscle mass and muscle density (Walton, 2019). SGLT2 inhibitors represent another promising medication to optimize metabolic health in patients with reduced insulin sensitivity. Dr. Attia emphasizes the supporting evidence for both metformin and SGLT2 inhibitors is derived from data in metabolically unhealthy individuals. He also discusses the potential for allopurinol based on the negative effects of increased uric acid levels on metabolic health and describes aiming for a uric acid level below 5 mg/dL in his patients. Supporting this, one study by Johnson et al. found an association between allopurinol and improved metabolism metabolic function, including blood pressure (Johnson, 2004). 

Goal

Listeners will learn a framework for thinking about longevity and practical tips for improving lifespan and healthspan.

Learning objectives

After listening to this episode listeners will…  

1. Define longevity, healthspan,and lifespan 
2. Recall the four types of death.
3. Explain the objectives of improved aging (longer lifespan, delayed rate of decline, and compressed period of morbidity).
4. Learn basic dietary principles to improve lifespan/healthspan and compare various dietary patterns
5. Describe some tactics to promote lifespan/healthspan (in nutrition, exercise physiology, sleep, distress management, medications and supplements, etc.)
6. Explore the possible longevity benefits of fasting

Links*

1. The Straight Dope on Cholesterol Part V- Peter Attia MD
2. Peter Attia, “How you Move Defines how you Live” 
3. Surely You’re Joking, Mr. Feynman!, book by Richard Feynman
4. The Transformed Cell, book by Steven Rosenberg
5. Mistakes Were Made (But Not By Me), book by Carl Tavris and Elliot Aronson
6. The Longevity Diet- Fasting Mimicking Diet by Valter Longo
7. “This is Water” David Wallace Foster Commencement Speech
8. The Drive Podcast and ShowNotes
9. Peter Attia Provider Directory

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Laske C et al. Stage-dependent BDNF serum concentrations in Alzheimer’s disease. J Neural Transm. 2006. [https://www.ncbi.nlm.nih.gov/pubmed/?term=16362629]
2. Center for Disease Control and Prevention (CDC). “Leading Causes of Death”. 2017. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
3. Chaix A, et al. Time-Restricted Feeding Prevents Obesity and Metabolic Syndrome in Mice Lacking a Circadian Clock. Cell Metab. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/30174302]
4. Motta M,et al. . Successful aging in centenarians: myths and reality. Arch Gerontol Geriatr, 40 2005. [https://www.ncbi.nlm.nih.gov/pubmed/?term=15814158]
5. Walton RG et al. Metformin blunts muscle hypertrophy in response to progressive resistance exercise training in older adults: A randomized, double-blind, placebo-controlled, multicenter trial: The MASTERS trial. Aging Cell.2019. [https://www.ncbi.nlm.nih.gov/pubmed/31557380]
6. Johnson RJ & Rideout BA. Uric acid and diet–insights into the epidemic of cardiovascular disease. N Engl J Med. 2004. [https://www.ncbi.nlm.nih.gov/pubmed/15014177].

Disclosures

Dr Peter Attia reports the following relevant financial disclosures: Peter receives speaking honorariums from organizations including hospitals and health-related businesses when he is asked to speak on longevity, metabolic-related topics, athletic performance, and his personal experience. Peter is the co-founder and Chief Medical Officer of the fasting app Zero. Peter is an advisor to, and/or investor in, the companies Virta Health, Hu Kitchen, Oura Health Oy, Magic Spoon Cereal, Inevitable Ventures, Salutoceuticals, and Supercast. Further information can be found at his website https://peterattiamd.com/about/. 

The Curbsiders report no relevant financial disclosures. 

Citation

Attia P, Gibson E, Williams PN, Brigham SK, Watto MF. “#183 Longevity, Healthspan and Lifespan with Peter Attia MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 18, 2019.

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