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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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
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
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 is the time until Type I death (ie time on death certificate), and represents the duration of life. Therefore, lifespan is absolute and binary.
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.
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).
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.
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.
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.
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.
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.
Dr Attia discusses a nutrition framework that includes different dietary states.
SAD is the default, where most people start and remain. He works with patients to engage in different dietary patterns.
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.
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.
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).
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.
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.
Dr. Attia outlines how genetics do not play a large role in longevity until about the 8th 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.
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).
Listeners will learn a framework for thinking about longevity and practical tips for improving lifespan and healthspan.
After listening to this episode listeners will…
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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.
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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I love the Curbsiders for their practical, evidence-based information (all done in an entertaining format!) However, I was disappointed with this episode because it did not have any real practical information, nor did it provide substantial evidence for recommendations that primary care physicians can give their patients. More importantly, I thought some of the information and practices mentioned in the podcast came perilously close to "functional medicine" and "anti-aging medicine." The use of continuous glucose monitoring in non-diabetics, the need for blood tests (all of which presumably would be out of pocket costs), and several days of fasting did not reduce my concerns; neither did the link on his website to a company selling "gravity blankets", nor his relationship with "Salutoceuticals" (mentioned in his disclosure). Dr. Attia is brilliant and the information was interesting, but I think the Curbsiders should have at least provided an editorial (or disclaimer) either at the beginning or the end of the podcast.
I felt the exact opposite of Johnnie, the first person who left a comment. I loved this podcast. I am a long-time listener an rarely feel the urge to write a comment. Johnnie must be in his early 30s. I have never thought that much age until last year when I turned 55. Now I study my patients and wonder how I will age. So many of them make poor choices and we all know what future is inevitable for them. Modern medicine keeps them alive but with very poor quality of life. I wish I could come up with the words that would help them change their paths. This podcast was a nice break from the typical hard-core internal medicine podcasts. I am a long-time listener of the Curbsiders. It was the first podcast that I discovered and still in my top three (along with Core IM and Clinical Problem Solvers). I want to thank you guys for keeping me current while I trained for the New York marathon. I am proud to say that I finished 13th in my age group of 1311 runners (Stuart my best 5K time is 16:28 when I was half my age). You will be with me during my Boston Marathon training also. I have nurse practitioner students and for medical students with me every day and I feel confident that I am up-to-date on the latest in medicine and I will admit I rarely read anything. Thanks so much for everything you do. I especially want to thank Matthew who is funny and bright and absolutely knows how to break down the facts to what the listener needs to know.