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How to Die in Good Health

Some of my earliest memories are of summers with my grandparents, in New Delhi. I spent long, scorching months drinking lassi, playing cricket, and helping my grandparents find ripe mangoes at roadside markets. Then I’d return to the U.S., my English rusty from disuse, and go months or years without seeing them. At some point, my India trips started to feel like snapshots of loss. My grandfathers died suddenly, probably of heart attacks. My Biji, my father’s mother, fell and broke her hip in her seventies, and she spent her last years moving back and forth between her bed and her couch. My Nani, my mother’s mother, developed excruciating arthritis in both knees; in order for her to leave her fifth-floor walkup, my uncle practically had to carry her down the stairs. I have always wondered whether their fading vitality—the way their worlds contracted and their possibilities vanished—was an inevitability of aging or something that could have been averted.

Many of us have come to expect that our bodies and minds will deteriorate in our final years—that we may die feeble, either dependent or alone. Paradoxically, this outcome is a kind of success. For most of history, humans didn’t live long enough to confront the ailments of old age. In 1900, a baby born in the U.S. could expect to live just forty-seven years, and one in five died before the age of ten. But twentieth-century victories against infectious diseases—in the form of sanitation, antibiotics, and vaccines—dramatically extended life spans, and today the average newborn lives to around seventy-seven. Lately, though, progress has slowed. In the past six decades, medicine has added about seven years to the average life span—less by saving young lives than by extending old ones, and often in states of ill health. In many cases, we’re prolonging the time it takes to die.

A growing number of celebrity doctors, futurists, and so-called biohackers now argue that it doesn’t have to be this way. There are, by some estimates, hundreds of specialized “longevity clinics”—including some that charge six-figure annual fees—which claim to offer more of the world’s most valuable commodity: years of healthy life. Perhaps the most prominent longevity evangelist is Peter Attia, the author, with Bill Gifford, of the best-selling book “Outlive: The Science and Art of Longevity.” Through his telemedicine practice in Austin, Texas, for an undisclosed price, Attia offers health advice, diagnostic tests, exercise protocols, and supplements to a wealthy and exclusive clientele. He also interviews an eclectic mix of scientists, doctors, and entrepreneurs for a popular podcast, “The Drive.” Oprah has interviewed him; Hugh Jackman and Gwyneth Paltrow follow his regimens.

Attia graduated from medical school and trained to be a surgeon, but grew disillusioned during residency and dropped out. He became a consultant for McKinsey instead, and then worked for an energy company. Finally, in his mid-thirties, a fixation with his own health brought him back to medicine. As a new father, he learned that he was prediabetic, and he reflected on men in his family who’d died early, of heart disease. In his book, he describes his former physique as “sausage-like”; on a beach one day, his wife told him, “Peter, I think you should work on being a little less not thin.” Soon, he was “down the rabbit hole of complete physical optimization.”

Attia, now fifty-one, has become convinced that science, technology, and targeted work can solve a uniquely modern problem: the “marginal decade” at the end of our lives, when medicine keeps us alive but our independence and capacities bleed away. It’s a scandal, in his view, that our life span has grown so much more than our health span. Many of Attia’s prescriptions are obvious: work out, eat healthily, sleep well, nurture relationships. (The Harvard Study of Adult Development has found, in eight decades, that human connections may be the single most critical determinant of long-term happiness and health.) But Attia often extrapolates from scientific data to offer jarringly intense and specific advice. Want to be able to lift a grandchild when you’re eighty? Goblet squat fifty-five pounds when you’re forty. Hope to lift yourself off the floor unassisted in old age? Try “toe yoga.” Attia notes that each decade after thirty we lose a meaningful amount of muscle mass and cardiovascular fitness. If we wish to slow that decline, and to complete a “Centenarian Decathlon” of important late-in-life activities—carry groceries, climb stairs, have sex—we need to become “athletes of life.”

The increasing obsession with longevity has inspired a backlash. Many in the life-extension movement are quacks or hacks who peddle pills, potions, and false promises; longevity skeptics tend to see the loss of our capacities as something to accept, not avoid. Ezekiel Emanuel, an oncologist and a health-policy professor at the University of Pennsylvania, derides Attia as an “American immortal” who overcomplicates straightforward advice. “The idea that you’re going to get another healthy decade of life just by doing the things he says is hocus-pocus,” Emanuel, who served as a special adviser to the Obama Administration, told me. “No one’s got that evidence.” Half an hour of daily exercise clearly improves and extends lives, but it’s hard to prove that Attia’s intensive regimens are much more beneficial. By incessantly preparing for the future, the skeptics say, we mistake a long life for a worthwhile one.

On a recent afternoon, I chased my three-year-old daughter around the playground for an hour. When we returned home, she spread a jigsaw puzzle out on the floor and looked up expectantly. I liked the idea of sitting still, but my knees hurt and my back was tense. I had to transfer the puzzle to a grownup table and sit my daughter in a booster seat. She didn’t seem to mind, but I remember that day as the first time that my physical limits noticeably constrained what we could do together. Longevity has become a concrete problem, just as it was for my grandparents: I wake up with aches in long-ignored joints and tendons; I calculate, with dismay, the age I’ll be when my children graduate from college or start their own families. One day, we’re going to die. What should that mean for how we live today?

In 1980, James Fries, a Stanford rheumatologist, predicted in The New England Journal of Medicine that better medicines and behaviors would soon enable a “compression of morbidity,” which would delay disease and debility until the very end of our lives. In the late nineties, Fries supported his hypothesis by publishing a decades-long study. University of Pennsylvania graduates who, in their forties, exercised more, weighed less, and didn’t smoke much were half as likely as others to suffer a significant disability in their seventies; they seemed to postpone the onset of disability by more than five years. But the alumni of an élite college may not have been representative. Fries died of end-stage dementia in 2021, at the age of eighty-three, and his broader prediction never seemed to come true. If anything, longer lives now appear to include more difficult years. The “compression of morbidity may be as illusory as immortality,” two demographers, Eileen Crimmins and Hiram Beltrán-Sánchez, wrote in 2010. According to the World Health Organization, the average American can expect just one healthy birthday after the age of sixty-five. (Health spans are greater in countries such as Switzerland, Japan, Panama, Turkey, and Sri Lanka.)

Earlier this year, I flew to Austin to hear Attia’s thoughts about how to change that. When my Uber pulled into his driveway, he was finishing his morning workout, so an assistant led me inside, where I spent a few moments looking at Formula 1 paraphernalia. Floor-to-ceiling windows overlooked lush hills, and a herd of life-size elk and deer models stood in the sun. I would soon learn that they served as targets for archery practice.

Attia has a shaved head, a sharp nose, and a stubbled chin, which make him look like a mix of Stanley Tucci and Jeff Bezos. When he appeared, he was wearing a fitted T-shirt that emphasized his biceps. He led me to his kitchen, where he offered me coffee and mixed a brightly colored concoction for himself. “I always try to get some protein in the morning,” he said. He eats as many as six sticks of venison jerky a day.

When I asked Attia about the longevity movement, he bristled. The term “just smells of snake oil,” he said. “Most of what I see out there is what I think of as sci-fi longevity. We’re going to live to be two hundred, and death is going to become irrelevant .” He handed me my coffee. “The way I talk about it is in a very low-tech way.” Attia has said that he wouldn’t want to live forever, even if he could, and he seems wary of a stereotype of longevity doctors. At parties, he sometimes pretends he’s a race-car driver or a shepherd. “I thought I was going to get skewered for writing ‘Outlive,’ ” he told me. “I thought doctors were going to say, ‘This guy is a grifter. He doesn’t know what he’s talking about.’ ” Some do say that—but others have become his followers.

Like a consultant, Attia often explains himself using frameworks. In the time of Hippocrates, he said, there was Medicine 1.0, a pre-modern system of diagnosis and treatment based on observation, anecdote, and guesswork. In the twentieth century, Medicine 2.0 deployed the randomized controlled trial to produce scientific marvels such as dialysis, organ transplants, and antiviral drugs. But Attia also sees Medicine 2.0, arguably the type of medicine that I practice, as passive. It often acts after the onset of damage—debilitating arthritis, a broken hip—instead of aggressively and proactively warding off illness and injury. Attia preaches Medicine 3.0.

We sat down at a sort of command center in his home office. On a large monitor, Attia pulled up a patient’s “longevity risk assessment”—his team’s calculation of threats to life and limb, ranked by relative importance both now and in the future. Although Attia describes his approach as low-tech, his patients receive dozens of tests, some of them outside the medical mainstream: full-body MRIs, body-fat-composition scans, DNA analyses. He often screens for Alzheimer’s risk, something that many doctors advise against, in part because patients can’t do much about a distressing result. (While filming an episode of the longevity docuseries “Limitless,” Chris Hemsworth, the host, learned from Attia that he has a gene associated with a roughly eight-hundred-per-cent increase in Alzheimer’s risk; afterward, Hemsworth took time off from acting.)

The assessment on Attia’s monitor was for a middle-aged patient who had been given a diagnosis of attention-deficit disorder, and had also undergone several surgeries. Running down the left side of a chart was a list of conditions, starting with the ones that posed the greatest risk: emotional-health problems and physical injury. The right side showed percentages—the guesstimated chance that each condition would become an issue in the future. Cancer and neurodegenerative disease were small risks now, but they ballooned into dominant hazards later in life. “It’s more art than science,” Attia told me. “There’s no A.I. that’s ever going to be able to spit out these numbers. It requires clinical judgment.”

The patient’s results seemed to trouble Attia. “They’re on a path to have a very physically debilitated last decade of life,” he said. (His practice omitted the names of patients and asked me to change their pronouns, to protect their privacy.) Attia’s staff focussed on three near-term suggestions: see a recommended therapist, work with a recommended exercise team, get a colonoscopy. They may have been powerful in their simplicity, but they were standard enough that I wondered whether all that testing was really necessary.

Many more patients will soon receive a version of Attia’s advice. Not long ago, he débuted a program called Early, a kind of MasterClass on longevity which costs twenty-five hundred dollars to access online. In a series of slick videos, Attia—in the hybrid persona of doctor, teacher, and coach—sits in a leather chair and talks about anticipating and averting diseases. Soft music plays; one video cuts to Attia’s muscles tensing as he aims a manual crossbow and strikes a faraway target. “Hope is not a strategy,” he says later, looking into the camera. “The marginal decade is the most important decade.”

When I asked Attia what he sees as a threat to his own longevity, he spoke of a lifelong battle to keep his emotions in check. He previously described himself as a workaholic with anger-management issues. During a business trip in 2017, he received a call from his wife, who was in a state of terror: their month-old son had stopped breathing and turned blue, and didn’t have a pulse. She’d started CPR on his tiny body. By the time first responders arrived, he’d regained a heartbeat and his skin was transitioning to pink.

“Okay, call me when you get to the hospital, so I can talk to the doctors in the ICU,” Attia remembers telling her, in his book. Then he went to dinner. Ten days passed before he flew home.

“I don’t try to forgive myself for it,” Attia told me recently. “There was a really, really broken person who did those things.” He paused, as though replaying the episode in his mind. “Don’t ever forget that that bastard is out there. . . . And make sure you work really hard to keep him at bay.”

The quest for physical optimization can easily become a substitute for deeper fulfillment. A decade ago, Attia exercised twenty-eight hours a week and observed a strict ketogenic diet. His “biomarkers were out of this world,” he has said, but he refused cookies that his children baked for him and pasta during trips to Italy. “I was doing everything to live longer, despite being completely miserable emotionally,” he writes in “Outlive.” In a recent interview with the Times , Attia said that, before attending an event at his son’s kindergarten, he thought for a moment of the downsides: it would eat into his time for squats and deadlifts. “That’s costing me a little in terms of fitness,” he said. “But that’s the trade-off I wanted to make.”

Attia wouldn’t tell me how many patients he sees, or how much they pay; there has been speculation that his services cost around a hundred and fifty thousand dollars a year. One of his clients, Carl Barney, is the eighty-two-year-old founder of a nonprofit inspired by Ayn Rand. He told me that, during the past three years, Attia has encouraged him to diversify his exercise routines and sleep more. At Attia’s urging, he now scoops collagen protein powder into his morning tea, drinks bone broth before dinner, and tries to consume another hundred-plus grams of protein during the day. I asked him whether Attia’s advice was worth the high price. “I have wealth, so, for me, it’s a bargain,” he said.

Attia let me join a video call in which five telegenic members of his team discussed new patients. A primary-care doctor told the group about a patient who managed career stress by engaging in extreme sports. “If they can’t do those things, a lot of their coping mechanisms will crumble,” she said. But it is difficult to quantify the risk that an injury might incapacitate someone. “We have questions like ‘Do you wear a seat belt?’ ” the doctor said. “We don’t have questions like ‘Do you cliff-jump into the ocean?’ ”

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The patient’s tests had identified hearing and vision issues; a full-body MRI showed ambiguous cysts in an internal organ. Genetic screenings suggested early-dementia risks, and the patient had recently asked the team, “Should I just quit my job right now and focus on living my life?” But a neurologist observed that the patient’s relatives had developed dementia only later in life. “This is probably going to be the most hopeful piece of news we give them,” Attia said. “We can say, clearly, no. . . . We have a lot of runway.”

I was envious that the doctors could pay so much attention to one patient. Attia had time to ask how well this person flossed—something I don’t ask my wife, let alone the patients I see in fifteen-minute increments. But the primary-care doctor made me ponder whether there was such a thing as too much attention. The patient struggled with anxiety, she said, and seemed to be looking for validation of their fitness routine. “Instead, we show them all these medical problems,” she joked. “And then we’re, like, ‘Why are they so anxious?’ ”

A few years ago, Attia started an intense fasting regimen. Some lab studies have suggested that fasting may reduce inflammation and clear the body of precancerous cells, but there is no agreed-upon “dose” for healthy fasting; Attia decided that for about two weeks each quarter he would drink only water. After losing fifteen pounds of muscle, however, he abandoned the practice. “He has always been extreme,” Steven Levitt, the University of Chicago economist and co-author of “Freakonomics,” who is a patient and a friend of Attia’s, told me. “Peter has been wrong a lot, but he changes his view when he runs into evidence that contradicts his theory.” Levitt trusts and admires Attia, but acknowledged that Attia’s fans in the longevity movement could go too far. “Followers often become more extreme than the leaders,” he told me.

Attia takes rapamycin, a drug that affects the immune system and is normally used by organ-transplant patients; the drug, which occasionally gives him mouth sores, has seemed to lengthen the lives of laboratory animals. Animal experiments are unreliable indicators of how drugs work in humans, and rapamycin is not endorsed by the Food and Drug Administration or medical societies for prolonging life. “This isn’t like a vitamin,” Eric Topol, a cardiologist and the director of the Scripps Research Translational Institute, told me. “It’s a serious drug that can potentially lower your body’s ability to fight off infections.” When I asked Attia why he has promoted the drug in his book and on his podcast, he said, “There’s a big difference between saying everyone should take rapamycin and saying, ‘I take rapamycin.’ ” He also cited a study suggesting that rapamycin bolstered immunity in elderly people.

It’s clear that Attia has prompted people to take the drug. Topol said that some of his patients had read “Outlive” and then asked him for prescriptions. “People see him as the expert, so they are going to try something if he says he’s doing it,” he told me. “His followers aren’t going to be able to detect which recommendations are firmly grounded in evidence.” Meanwhile, training dozens of hours a week might take more time than it will ever tack on; good health could even drag out some terminal illnesses. “Peter’s theory of Medicine 3.0 is that you get this long life where you’re healthy, and then you fall off a cliff,” Topol said. “It would be great if it were true. There isn’t any evidence for it.”

Emanuel, the University of Pennsylvania professor, has said that he wants to live to seventy-five. (He is sixty-six.) “Living a long time is not an end in itself,” he told me over Zoom. “If it becomes the focus of your life . . . that is one of the worst mistakes you can make.” It’s not that we shouldn’t exercise or eat well—but “everyone goes through a decline,” Emanuel said. “Spending your life worried about all these tiny things is a waste of time.”

During our video call, Emanuel walked to his bookshelf, pulled out a copy of “Outlive,” and read a line from the epilogue: “It was only after much reflection on this whole experience that I really began to understand how emotional health relates to longevity.” He slapped his palm against his forehead in a mock epiphany. “Oh, really? Longevity doesn’t matter if your life sucks? . . . I mean, come on. It’s ridiculous.”

Leon Kass, who served as the chair of the President’s Council on Bioethics under George W. Bush, has written that losing our capacities might be a kind of prerequisite to accepting our mortality: maybe the slowing of body and mind is what makes death tolerable. He quotes Michel de Montaigne, the sixteenth-century essayist. “Inasmuch as I no longer cling so hard to the good things of life when I begin to lose the use and pleasure of them, I come to view death with much less frightened eyes,” Montaigne wrote. “When we are led by Nature’s hand down a gentle and virtually imperceptible slope, bit by bit, one step at a time, she rolls us into this wretched state and makes us familiar with it.”

Nir Barzilai, the director of the Institute for Aging Research at the Albert Einstein College of Medicine, is sometimes credited with discovering the first “longevity gene,” an unusual variation in DNA that is linked to exceptionally long life. When people ask him to define aging, however, he doesn’t talk about that, and instead tells a two-sentence story. An elderly woman turns to her husband and says, “Honey, why don’t we go upstairs and make love?” Her husband responds, “Sweetie, I cannot do both.”

For decades, Barzilai has followed hundreds of Ashkenazi Jews and examined genetic, behavioral, and environmental factors that have helped them age past ninety-five in exceptional health. Centenarians die of the same things as the rest of us, but later, he told me. You might live to a hundred if you could pick your genes—picking the healthy lunch option isn’t likely to be enough. Strikingly, around half the centenarians in Barzilai’s study have been overweight; thirty per cent of the women and sixty per cent of the men have been heavy smokers. When he asked a hundred-year-old whether anyone had warned her about the harms of tobacco, she responded, “Yes, all four of the doctors who told me to stop smoking—they died.”

Attia tends to argue that individual choices matter not because they are all-powerful but because they are the power that we have. He compares healthy aging to investing in retirement: contribute what you can, whether it’s a daily walk or an extra half hour of sleep, and the benefits may compound over time. “If I’m being brutally honest, I think some people are looking for a reason not to do it because it’s hard,” he said.

He acknowledged that health, like wealth, is unequally distributed; indeed, one of the most powerful longevity “medicines” is money, which can buy people less stress, better education, safer neighborhoods, and higher-quality medical care. For this reason, Emanuel argues that doctors should focus less on “getting rich people from ninety to a hundred” than on improving health in communities where people die young. When I asked Attia whether his practice might perpetuate this divide, he told me, “I’ve never concerned myself with that. I don’t think it’s unimportant, but it’s absolutely not a problem I’m interested in addressing.” He pointed out that his podcast is free and his book costs less than twenty dollars.

Attia has a term for his unproven ideas: evidence-informed medicine, or interventions that rest more on theory than on randomized controlled trials in humans. In his view, medical recommendations are often too conservative; in some cases, rigorous studies would not only take too long but also be unethical or impractical. (Try randomly assigning babies to ketogenic diets at birth.) According to Attia, medicine’s admonition to do no harm is “sanctimonious bullshit” that steers doctors toward passivity and resignation. But this line of reasoning leaves enormous room for extrapolation, and could be used to justify almost any practice.

Talking to Attia, I frequently reminded myself that I can’t diet and exercise my way out of many diseases, and there’s no regimen to eradicate uncertainty. Still, I felt the pull of becoming an “athlete of life.” Too often, conversations about life extension devolve into unhelpful abstractions and untestable speculation; one appeal of Attia’s advice is that it’s so tangible. Critics can paint his counsel as blindingly obvious or needlessly complex—but he has, at least, inspired large audiences to imagine what a better approach to aging could look like. “There is actually no such thing as atheism,” David Foster Wallace once said. “The only choice we get is what to worship.” In a society that chases money, power, fame, and beauty, there are worse gods than longevity.

Attia is a history buff and an avid rucker, which means that he likes to lug a heavy rucksack on long walks. In June, to mark the eightieth anniversary of D Day, Attia plans to set out from Utah Beach, in Normandy, with four friends, carrying supplies plus a twenty-five-pound weight, just because. They hope to trek eighty kilometres through the night and arrive at Omaha Beach less than twenty hours later.

During my visit, Attia agreed to take me on a gentler ruck, in the hills around his neighborhood. We had lunch delivered beforehand; he had a salad with chicken, nuts, and balsamic vinegar, while I had a saucy pasta. I caught him glancing at my bowl and imagined him judging my macronutrients. Then I changed into my workout gear and met him in his garage, where he outfitted me with an Army-green rucksack. “I generally recommend that people new to rucking start light,” he said, and slipped a thirty-pound weight plate into my bag. He added a few to his own, and we set out into the afternoon sun.

After climbing a hill, we entered a clearing. Around us, a circle of oak trees stretched majestically into the air. A mild breeze cooled the sweat on my brow, and a flock of birds darted across the open sky. I considered stopping to look around, but I could hear the weights in Attia’s rucksack clanging like a metronome, so I sped up. I was feeling pretty good; I made a mental note to offer to take one of his plates. I changed my mind after the next hill, when my neck stiffened and my shoulders started to hurt.

“Why not just go for a hike?” I asked, panting.

“I wouldn’t find that as fun,” he said. “Plus, it’s not as good for your trunk.”

In the distance, a school bus drove by. I envisioned myself lifting my hypothetical granddaughter one day, then adjusted my rucksack and straightened my posture.

As we walked on, I thought about a curious body of psychological research, which suggests that as we age and lose our capacities we tend to grow more content, not less. This finding clashes with popular conceptions of getting older, but seems to hold across continents, cultures, and eras. “I can’t do everything I used to,” a family friend, who is in his eighties and has been married for sixty years, recently told me. “But I wouldn’t say I’m any less happy than I was before.” Lost pleasures, he said, could sometimes be replaced: rounds of golf gave way to brisk walks, and when walking became difficult he spent more time talking to his children and grandchildren. As we grasp that our days are limited, we seem to abdicate our need for control; we may try to close the gap between what we want and what we have. Healthy aging seems to require a shift in mind-set as much as a shift in muscle mass.

My calves started to burn. I felt a knot in my back. White clouds veiled the sun, and a few ethereal rays came through. It looked so much like the entrance to TV Heaven that I half expected a deep voice to boom from above.

“Sometimes I think about all the people who’ve ever lived, and how lucky I am to be alive right now,” Attia told me. “Like, if I died tomorrow, it would be O.K.” We started down a final hill. His house came into view. “But, while I’m here, I want to know that I gave it my all,” he went on. “We have this one shot. Wouldn’t it be a shame if we didn’t make the most of it?” ♦

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THE SCIENCE AND ART OF LONGEVITY

by Peter Attia with Bill Gifford ‧ RELEASE DATE: March 28, 2023

It may not produce a new Methuselah, but Attia’s welcome book deserves the attention of anyone seeking a healthier life.

A data- and anecdote-rich invitation to live better, and perhaps a little longer, by making scientifically smart choices.

Trained as an oncological surgeon, Attia became interested in longevity because he saw that the “Four Horsemen” worked against it: diabetes, heart disease, cancer, and Alzheimer’s disease. All play a role in an unhealthy system, and all interrelate. If you have Type 2 diabetes, then your chances of developing heart disease, cancer, and neurological disorders increases, and if your goal is to live well in old age, then it behooves you to change your ways in order to keep your insulin reception levels in the clear. How to do so? Attia avoids toss-off recommendations, instead examining categories of self-care. One powerful component of healthful living is the sort of exercise that burns body fats and sugar most efficiently. This, too, interrelates with diet. “The best science out there,” he writes, “says that what you eat matters, but the first-order term is how you eat: how many calories you take into your body.” Accordingly, caloric reduction strategies play a role, combating the effects of what he calls the Standard American Diet, “our default food environment.” Attia, a lucid and careful writer, eschews easy recipes for what to eat and how to exercise, for his conception of what he calls Medicine 3.0 tailors self-care to self, as in “know thyself.” Therein lies a key point: His book abounds in science and not pat prescriptions precisely because biology doesn’t have the same axiomatic certainties as mathematics and because, in order to participate in Medicine 3.0, readers must be truly active and not reactive. “You must be well informed, medically literate to a reasonable degree, clear-eyed about your goals, and cognizant of the true nature of risk,” he writes.

Pub Date: March 28, 2023

ISBN: 9780593236598

Page Count: 496

Publisher: Harmony

Review Posted Online: April 20, 2023

BODY, MIND & SPIRIT | HEALTH & FITNESS | SCIENCE & TECHNOLOGY | SELF-HELP

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GREENLIGHTS

by Matthew McConaughey ‧ RELEASE DATE: Oct. 20, 2020

A conversational, pleasurable look into McConaughey’s life and thought.

All right, all right, all right: The affable, laconic actor delivers a combination of memoir and self-help book.

“This is an approach book,” writes McConaughey, adding that it contains “philosophies that can be objectively understood, and if you choose, subjectively adopted, by either changing your reality, or changing how you see it. This is a playbook, based on adventures in my life.” Some of those philosophies come in the form of apothegms: “When you can design your own weather, blow in the breeze”; “Simplify, focus, conserve to liberate.” Others come in the form of sometimes rambling stories that never take the shortest route from point A to point B, as when he recounts a dream-spurred, challenging visit to the Malian musician Ali Farka Touré, who offered a significant lesson in how disagreement can be expressed politely and without rancor. Fans of McConaughey will enjoy his memories—which line up squarely with other accounts in Melissa Maerz’s recent oral history, Alright, Alright, Alright —of his debut in Richard Linklater’s Dazed and Confused , to which he contributed not just that signature phrase, but also a kind of too-cool-for-school hipness that dissolves a bit upon realizing that he’s an older guy on the prowl for teenage girls. McConaughey’s prep to settle into the role of Wooderson involved inhabiting the mind of a dude who digs cars, rock ’n’ roll, and “chicks,” and he ran with it, reminding readers that the film originally had only three scripted scenes for his character. The lesson: “Do one thing well, then another. Once, then once more.” It’s clear that the author is a thoughtful man, even an intellectual of sorts, though without the earnestness of Ethan Hawke or James Franco. Though some of the sentiments are greeting card–ish, this book is entertaining and full of good lessons.

Pub Date: Oct. 20, 2020

ISBN: 978-0-593-13913-4

Page Count: 304

Publisher: Crown

Review Posted Online: Oct. 27, 2020

Kirkus Reviews Issue: Dec. 1, 2020

BIOGRAPHY & MEMOIR | BODY, MIND & SPIRIT | ENTERTAINMENT, SPORTS & CELEBRITY | SELF-HELP | GENERAL BIOGRAPHY & MEMOIR

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F*CK IT, I'LL START TOMORROW

by Action Bronson ; photographed by Bonnie Stephens ‧ RELEASE DATE: April 20, 2021

The lessons to draw are obvious: Smoke more dope, eat less meat. Like-minded readers will dig it.

The chef, rapper, and TV host serves up a blustery memoir with lashings of self-help.

“I’ve always had a sick confidence,” writes Bronson, ne Ariyan Arslani. The confidence, he adds, comes from numerous sources: being a New Yorker, and more specifically a New Yorker from Queens; being “short and fucking husky” and still game for a standoff on the basketball court; having strength, stamina, and seemingly no fear. All these things serve him well in the rough-and-tumble youth he describes, all stickball and steroids. Yet another confidence-builder: In the big city, you’ve got to sink or swim. “No one is just accepted—you have to fucking show that you’re able to roll,” he writes. In a narrative steeped in language that would make Lenny Bruce blush, Bronson recounts his sentimental education, schooled by immigrant Italian and Albanian family members and the mean streets, building habits good and bad. The virtue of those habits will depend on your take on modern mores. Bronson writes, for example, of “getting my dick pierced” down in the West Village, then grabbing a pizza and smoking weed. “I always smoke weed freely, always have and always will,” he writes. “I’ll just light a blunt anywhere.” Though he’s gone through the classic experiences of the latter-day stoner, flunking out and getting arrested numerous times, Bronson is a hard charger who’s not afraid to face nearly any challenge—especially, given his physique and genes, the necessity of losing weight: “If you’re husky, you’re always dieting in your mind,” he writes. Though vulgar and boastful, Bronson serves up a model that has plenty of good points, including his growing interest in nature, creativity, and the desire to “leave a legacy for everybody.”

Pub Date: April 20, 2021

ISBN: 978-1-4197-4478-5

Page Count: 184

Publisher: Abrams

Review Posted Online: May 5, 2021

Kirkus Reviews Issue: June 1, 2021

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Ground Truths

A Review of OUTLIVE

Peter attia's #1 nyt bestseller book.

I met Peter Attia in early 2020 when we did a podcast ( The Drive episode #91, he’s now past #260). He’s an exceptionally bright physician with an outstanding medical training at Stanford, Johns Hopkins (surgery), and the National Cancer Institute (surgical oncology). His career path is atypical, since he left medicine for a stretch to work at McKinsey and Company in financial credit risk, a stint that he believes gave him a better understanding of risk in medicine.

Since Outlive was published at the end of March, I’ve had several patients come to clinic visits and ask me about various points in the book. So I knew it was time to give it a close read. In the introduction, he positions himself well: “This is how I see my role: I am not a laboratory scientist or a clinical researcher but more of a translator, helping you understand and apply these insights.” He provides extensive citations to support the vast majority of his assertions, with nearly 40 pages of single-spaced references. Overall, I think it’s quite worthwhile and well done, but I’ve got a few issues that I’ll discuss.

Major Themes and Strengths of the Book

Medicine 3.0.

Rather than emphasizing longevity (“staving off death”), Peter’s “Medicine 3.0” is focused on maintaining healthspan with the major emphasis on prevention, recognizing each person as a unique individual. Throughout the book, he systematically reviews the ways this shift to the right of the theoretical curve below can be achieved. This means addressing and countering what he calls the “Four Horsemen”—heart disease, cancer, Alzheimer’s (and related neurodegenerative diseases) and metabolic dysfunction (insulin resistance, Type 2 diabetes). He does an exceptional job of weaving all the common threads together for these 4 chronic conditions, such as how metabolic dysfunction is a key underpinning across the board. Through details of his tactics of better exercise, nutrition, sleep, and emotional health, the Four Horsemen and our burden of chronic disease can be prevented, or, at the very least, forestalled. The overarching hypothesis is that a “compression of morbidity” might be attainable by preventing these conditions, reducing the time in decline, as shown by the sudden drop of the Medicine 3.0 curve below. It’s quite alluring, since we’d rather not live in a prolonged debilitated state. It’s hopeful, even likely, but it’s not proven.

“I now consider exercise to be the most potent longevity “drug” of our arsenal.” Attia is really big on exercise, personally spending hours a day to be in top shape, and has dedicated several chapters and portions of the book to this and related matters of fitness, such as stability. One notable study he cites is from over 750,000 U.S. veterans ages 30 to 95. The least fit 20% group had 4-fold higher risk of dying than a person in the top 2% of their age and sex category (Figure below, JACC, 2022). He reiterates the paper’s conclusion: “Being unfit carried a greater risk than any of the cardiac risk factors examined.”

While most physicians do not emphasize (that’s putting it politely) its importance, Attia is deeply into this and conveys much useful information, especially in Chapters 14 and 15. He goes through his recommendation for protein intake per day—1 gm per pound—which is nearly 3-fold the minimal recommendation, no less obtaining 9 of the 20 amino acids from our diet since we can’t synthesize them. He gets into depth for each of the energy substrates (warning against alcohol, putting carbs in context, along with good and bad fats). There is no push for supplements, which is refreshing to see with little to no data to support their use. Whereas he used to advocate the keto diet as beneficial, he’s revised his perspective, and is much more balanced about the right, individualized nutrition plan, whether it is caloric restriction, dietary restriction, time-restricted eating, or whatever works to achieve the objective of being metabolically healthy.

Insulin and Metabolic Dysfunction

Attia really shines with his knowledge in this area, and it’s the best presentation of the data and explainers that I’ve seen. He makes a solid case for insulin resistance to be recognized as a critical condition, since it’s the precursor to not just diabetes, but also liver disease (NASH and NAFLD), and the other 3 Horsemen. We’ve placed too much emphasis on obesity per se, without zooming in on metabolic dysfunction which can occur in people who are lean (approximately 33 million of the 100 million Americans with metabolic dysfunction are non-obese). 90% of American adults have at least 1 of 5 factors of the metabolic syndrome (hypertension, high triglycerides, low HDL, high fasting glucose, and central adiposity).

Other Good Stuff

Some other things I particularly liked are his great use of metaphors for explainers of complex topics, for example: “atherosclerosis as kind of like the scene of a crime—breaking and entering, more or less. Let’s say we have a street, which represents the blood vessel, and the street is lined with houses, representing the arterial wall. The fence in front of each house is analogous to something called the endothelium, a delicate but critical layer of tissue that lines all our arteries and veins…”

That’s in the heart disease chapter, which he covers well, making the case for ApoB and Lp(a) measurements to supplement LDL and HDL cholesterol for risk assessment. To get a very good handle on a person’s genetic risk beyond blood tests, I use the heart disease polygenic risk score with my patients. Our team at Scripps developed a free app for this purpose. I agree with his perspective on the value of knowing one’s ApoE isoform. His summary statement about women and heart disease can’t be highlighted enough: “American women are up to 10 times more likely to die from atherosclerotic disease than from breast cancer (not a typo: one in 3 vs 1 in 30).”

I love the way he rips on Hippocrates “Do No Harm,” covers very difficult areas like Mendelian randomization, and reviews the Bradford Hill criteria for strength evidence of epidemiology. His personal and patient’s insights about using continuous glucose monitoring (CGM) are valuable (full disclosure: I am on the BoD of Dexcom, so I stay away from advocating CGM).

The last chapter (“Work in Progress”) is especially poignant, in which Peter reveals his abuse as a child, his personal mental health difficulties and how he’s dealing with it. When I met Peter to do the podcast his marriage was in rocky shape, so it is terrific to see how all is good now with his wife and family.

Some Concerns

There are a few points where it seems Peter gets off track of a supportive body of evidence, or gets ahead of his skis. For example, he takes rapamycin (page 88) and apparently advocates its use in his patients, because of the data of consistent benefit for improving longevity across animal species. But, as he also points out, it induces immune system suppression (it’s a drug to prevent organ transplant rejection) so it may not be safe. He apparently suggests his patients get total body MRI imaging (page 172) to spot cancer early. There aren’t any data that I know of, except anecdotal data from companies like Human Longevity Inc, which incorporates this in their expensive checkup package. The concern I have here is engendering “incidentalomas” (a word my friend Issac Kohane coined )—that is finding something that leads down a rabbit hole that has to be chased down, like a nodule in the lung or liver that requires a biopsy, which carries risks, no less considerable anxiety and expense. In short, total body MRI could do more harm than good and we need prospective studies to meaningfully assess this approach. Multi-cancer early detection blood tests may ultimately prove to be a better tool, spotting cancer well before it is large enough to be a mass on an MRI, but that’s also not adequately validated, as I’ve recently summarized .

The bigger picture issue is that the full package that Attia presents, what he and his colleagues provide in their clinic, is not affordable except for the most affluent individuals. But that doesn’t detract from his book that is highly informative, with many ways to take a more aggressive position to promote one’s health. It’s inspirational. We know as physicians how hard it is to get people to take charge of their health and develop comprehensive plans to focus on exercise, nutrition, sleep, and mental health—by reviewing the science behind, in depth, and in a way people can understand it, this book helps people do that.

I’ve invited Peter to turn the table and do a Ground Truths podcast to discuss the book further and address the points I’ve raised here—I’m hopeful he’ll find the time to do it in the weeks ahead.

Finally, let me say I’m very appreciative to Peter for the multiple years and arduous work he put into writing Outlive. It’s an important resource for people who want to take more initiative to stay healthy, and it is deserving of its major success.

Thanks for reading Ground Truths!

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My Reaction to Peter Attia MD’s New Book “Outlive”

Greg Damian shares his thoughts on Dr Peter Attia’s new book, including his approach to medicine and physical and mental health

I started listening to Peter Attia MD’s “The Drive” podcast in December of 2021. At first I was skeptical of some of Dr Attia’s thoughts and positions. I assumed he was a standard medicine 2.0 doctor. Medicine 2.0 is the term that Peter , himself, uses for the current state of healthcare, or more properly labeled “disease care.” I was quickly convinced that his approaches were much more holistic and thoughtful than typical Western medicine.

I started listening to the very first episodes and worked my way through many topics. Peter actually started his podcast as a way to engage experts in different fields to help him create content for his upcoming book. I listened to many of the podcasts several times to fully understand the ideas. Twenty years earlier, in my forties, I quit my job, studied and applied to medical school but did not go. The background in biology and organic chemistry was helpful because many of Peter’s guests are researchers and they tended to go deep into topics.

I adopted much of what I learned from the podcasts. I purchased a sleep tracker and improved my sleep considerably. I also purchased a continuous glucose monitor and wore it for 30 days and changed the way I looked at and consumed food. I started playing the long game as it applies to aging.

Writing the Book

Several times in the podcasts Peter mentioned that he was working on a book. When the book was released, Peter and his co-author Bill Gifford recorded a podcast where they discussed the back story of the book. Peter said that his initial manuscript was considered to be too long, too technical, and did not reflect his personal experiences. It was suggested that he work with a co-author and that is when he engaged Bill. Peter said that not much of his initial work survived to the published book. Peter also mentioned that his first publisher fired him. He did not say why he was fired, but it seems clear that the book was taking too long and was still reading like a medical school text. The manuscript lay dormant for almost a year until someone asked if they could read it. This person connected Peter with a new publisher and this time they were able to get the book completed.

Since I had listened to over 100 podcasts, I decided to listen to the audio book. The audio recording, read by Peter, is long; over 17 hours long. I finished listening to it last weekend as I was hiking in the Grand Canyon. The book is also expensive. Not many first time authors can command a premium price for their book. The audio book cost $25.

Peter starts the book with an overview of aging and how he got into medicine. He discusses the history of medicine. He labels medicine 1.0 as the initial understanding of “germs” and how the light microscope changed how doctors understood cellular function. He discusses the slow transition to medicine 2.0 driven by randomized control trials, where most medicine is practiced today. He describes medicine 2.0 as primarily reactionary and typically dealing with disease when or right before it occurs. Medicine 2.0 frustrated Peter and he quit his residency and became a McKinsey consultant for a few years. Medicine 3.0 he describes as predictive and preventative of disease providing a longer and higher quality of life. This is a reference to the book title Outlive .

“The Four Horsemen”

Peter provides considerable information related to the four main causes of death he calls “the four horsemen.” The horsemen are cardiovascular disease, cancer , cerebral vascular disease (such as Alzheimer’s) and metabolic disease. As the length of the recording implies, his coverage of these topics is very thorough and the content was fact checked by experts in each field. The book is not quite as technical as Peter’s podcasts but there is much information presented and I suspect the average consumer does not care to know this much about the nature of these diseases.

Including Bill Gifford as a co-author was a good idea. There are places in the book where Bill’s influence is clear. One type of influence is where a simple metaphor is used to explain a complex topic.

Diet, Exercise & Sleep

In the next sections, Peter focuses on what his experience and the scientific literature have to say about exercise, diet and sleep. He loves to exercise and talk about exercise but would rather discuss almost anything but diet. Peter’s approach to all three of these topics has changed over the years and I found that history interesting.

Peter was a boxer growing up and was a long distance swimmer and a competitive cyclist. His current approach to exercise focuses on long-term health rather than athletic performance. He has set goals for when he turns 100 and uses considerable amounts of both cardiovascular and resistance exercise to support his goals.

His approach to diet is quite simple. Peter suggests that managing glucose and protein intake are key. He avoids at all cost discussing particular diets and the dogmatic approaches that come with them, though he does discuss the challenges of plant-based protein. Peter used to fast regularly. In hindsight he does not feel that was the best approach. He laments how much muscle mass he lost due to chronic dieting by comparing his prior and current DEXA scans.

The very shortened version of Peter’s story related to sleep is that we should all be sleeping about seven to eight hours every night and the consequences of short sleep, as he puts it, are severe. For me, I have found I need to be in bed about seven hours and forty five minutes to get seven hours of actual sleep as measured on my tracking device.

Emotional Health

I found the most interesting chapter of the book to be Peter’s discussion of emotional health. Peter suggests that emotional health is the most important aspect of aging because, as one of his therapists said, if you are not happy, why would you want to live a long time?

Peter is quite candid and admits here he is the patient and not the physician. This is the one section of the book that I listened to twice. I wanted my girlfriend to hear this chapter with me. She has heard me talk on and on about Peter Attia and she has listened to parts of a couple of podcasts. Peter had challenges as a child and this translated into anger issues as an adult. He shares he very reluctantly went to counseling centers for multiple weeks on two separate occasions. Hearing Peter candidly share his story brought tears to both of our eyes and in my case I had already heard the story once before.

Anyone who is willing to take the time to read or listen to Outlive will benefit handsomely from their investment. Because of my prior podcast consumption, my exercise, diet and sleep already aligned with Peter’s strategies and tactics. I had also set goals for when I turn 80 including summiting Kilimanjaro . My personal takeaways from the book were setting higher metabolic goals. I aim to lower my blood glucose A1c from 5.4% to 5.1%. I want to lower my ApoB cholesterol carrying particles to below 50 mg/dl and I want a VO2 max of 50 mL/kg/min which would put me in the top 2% of men 10 years younger than me. 15 years ago I had a VO2 max of 56 mL/kg/min. I also acknowledge that my emotional health would benefit from counseling.

The other big takeaway for me was that I realized that what I really wanted to be when I applied to medical school twenty years ago was to become a medicine 3.0 doctor. I did not want to be a disease management specialist. I wanted to help people prevent disease through a combination of lifestyle and preventative measures such as colonoscopies.

Written by Greg Damian: I am a 60-year-old author, motivational speaker, health and fitness disruptor and a coach. My book, Abs at 60: The Four Steps to Look and Feel Younger at Any Age was recently released on Amazon. My mission is to assist men over 50 to overcome perceived limits of their age to look and feel younger. I do this by applying my four step DOLR(TM) system that is described in the book. Each chapter has a set of questions for you to answer. You can download a free workbook that includes all of these questions at www.absat60.com .

A thorough review, which helps me understand the work of Dr. Attia better. Thank you. Setting health and fitness goals for every stage of life is a refreshing approach. Americans have become an unhealthy society–many at age 60 can do little, we have a lot of work to do to help improve our health, as a nation, both physically and mentally.

I am glad you enjoyed my review.

I have just ordered Dr. Attia’s book, although he has little to tell me that I have not learned. At 96, still driving, managing my own affairs, writing opinion pieces for the news papers, enjoying friends, tennis on court reduced to WII tennis on the TV. Dealing with what every aging person does: every day I may lose something, forget something, not be able to open something, drop something. This I believe, getting to old age is dumb luck and inherited genes and not falling down. I have lived longest among my known relatives, but most made it past 80. What do you say?

Wow! Julia – you sound amazing and very inspiring – I hope I can be thriving like you in 35 years from now! Thank you for posting that! Here’s yo your continued great health and mental clarity more many more years to come! Bless you!

I have been diagnosed with idiopathic neuropathy. I have a neurologist that I think is excellent, work out regularly, and have read that although no cure, we “can” improve the symptoms, but I find nothing on line or anywhere else about exercises to improve the physicality or symptoms of my disease. Help anyone?

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The ideas expressed here are solely the opinions of the author and are not researched or verified by AGEIST LLC, or anyone associated with AGEIST LLC. This material should not be construed as medical advice or recommendation, it is for informational use only. We encourage all readers to discuss with your qualified practitioners the relevance of the application of any of these ideas to your life. The recommendations contained herein are not intended to diagnose, treat, cure or prevent any disease. You should always consult your physician or other qualified health provider before starting any new treatment or stopping any treatment that has been prescribed for you by your physician or other qualified health provider. Please call your doctor or 911 immediately if you think you may have a medical or psychiatric emergency.

Dr. Christin Glorioso, MD PhD

Outlive- a review of the book and its science

I have been asked a lot recently about what I think of Peter Attia’s new NY Times bestselling book on longevity medicine, Outlive. So I decided to take a read to be able to answer this question, inform myself about what is in the popular press, and make a reasonable recommendation to read this book (or not).

On a high level, I think this book is important conceptually and represents a profound shift in medicine that is much needed. I am eager for the public to embrace “Medicine 3.0” and start seeing disease as a continuum that starts with aging in your twenties- and is something that can be abrogated to a large degree by lifestyle interventions. I agree with about 95% of the content. I think it leaves out a few things (including most of the scientific advancements in the field around reprogramming and regeneration) and there are some parts that I disagree with from a medical and scientific perspective- mostly surrounding supplements and drugs (which he claims not to go into but then does go into to some extent). From a reader perspective, all but the last two chapters were a slog. This maybe gets explained in the epilogue when he says that the book’s first draft was super technical and then he enlisted a co-author to make it into more of a personal story. I think I would have preferred a condensed technical manual that was about 1/3 of the length or better yet, an outline with bullet points (which I created for you to some extent below). I found myself skimming through the “too general” to be interesting patient and scientist anecdotes to get to the actual medical recommendations. This is with the exception of the last two chapters- those were actually compelling to read. Those chapters were a personal story about Attia’s own trauma and struggles with mental health. I think the points made in those chapters were not only compelling to read but also highlighted a missing fundamental piece about the longevity conversation. They could have been the start of a different book. One device that stuck in my craw was Attia repeatedly referring to himself as “not thin Peter”. This was a reference to an unkind comment his wife made to him about needing to lose some weight. This comment was never explained as her concern for his health and left me thinking that she was complaining about his physical appearance from an attractiveness perspective. And if you google pics of Attia, which I did, you’d be hard pressed to find one where he looks to be overweight. So every time he would shame himself by calling himself “not thin Peter” (possibly in an attempt to be self-deprecating and therefore relatable to the reader or just because it is a negative narrative that genuinely drives him), I felt vicariously body shamed, a feeling that wasn’t pleasant to have to continually endure. In general, this also speaks to the current incarnation of longevity medicine that has a large superficial streak and one that also seems very privileged. Another piece of the conversation that was missing was one about access and disparities in medicine. The mental health chapters in particular were glaringly obtuse to this. Attia’s journey towards better mental health involved unfettered access to out of pocket sessions with five of the most famous therapists in the world, including Esther Perel (I’m a big fan of her) and stays at expensive private pay clinics. If this is what the journey to mental longevity requires, then almost no one has access. This is a point that at least should have a few sentences to acknowledge. Attia’s story was vulnerable and brave, but also so so privileged. And now for those bullet points… THE AGREE COLUMN:

“I believe that our goal should be to act early as possible, to try to prevent people from developing type 2 diabetes and all the other horsemen [diseases of aging]”… Medicine 3.0 places a far greater emphasis on prevention than treatment. When did Noah create the ark? Long before it began to rain. Medicine 2.0 tries to figure out how to get dry before it starts raining. Medicine 3.0 studies meteorology and tries to determine whether we need to build a better roof, or a boat”

“ Exercise is by far the most potent longevity “drug”” 1000%

“striving for physical health is meaningless if we ignore our mental health ”

“There are many examples of how Medicine 2.0 gets risk wrong, but one of the most egregious has to do with hormone replacement therapy ( HRT) for postmenopausal women” [interpretations of the WHI wrongly discouraged use of HRT]- Yes!!!

We need tools with a much longer reach than relatively brief clinical trials.

“ Mendelian randomization helps tease out causal relationships between modifiable risk factors” 1000%- AI is the answer to much of this.

The older you get, the more genetics matters for longevity.

Pro preventative cancer screening using liquid biopsy.

Pro preventative screening using whole body MRI.

All of the Alzheimer’s chapter is spot on except that we have no approved amyloid drugs (we have two) and he misses the “Alzheimer’s is an aging program” theory of what causes it- which is the theory that I firmly believe in.

I’m glad he realizes that he contributed to the keto diet craze and that was potentially harmful to many people.

Loved the discussion of CR and the two conflicting primate studies.

“the best nutrition plan is the one that we can sustain”- basically we need to eat a normal amount of calories- the particulars of how we do that doesn’t matter that much.

Sleep deprivation is a huge problem for health, and dangerous for patients of sleep deprived clinicians. It’s not a badge of honor. Yes!!!!

THE DISAGREE COLUMN:

On longevity science: “On the other end of the spectrum are those convinced that science will soon figure out how to unplug the aging process itself, by tweaking some obscure cellular pathway, or lengthening our telomeres, or “reprogramming” our cells so that we no longer need to age at all. This seems highly unlikely in our lifetime, although it is certainly true that science is making huge leaps in our understanding of aging and of the Horsemen of disease” These pathways may seem obscure to Attia because he is not a scientist. To those in the biotech and scientific fields, these are not obscure at all but actionable pathways where in some case drugs are currently in phase 2 clinical trials. Or they are currently approved drugs- in the case of PI3K. I would put the timeline for the first longevity drugs to be in the next decade- definitely a longevity pathway, likely reprogramming. If you want to learn more about the exciting science and biotech in the longevity space, check out the videos on Longevity Global YouTube .

Centenarians and smoking: this is not exactly a point of disagreement but there is a link between longevity and smoking in super centenarians and I don’t think this is an accident. People die increasingly from neurodegenerative diseases in the oldest ages and smoking is linked to less Parkinson’s disease . That’s not to say that we all should smoke- definitely not- smoking causes lung cancer and heart disease. But in people above a certain age- say 80 years old- we should consider creating nicotine pathway drugs or prescribing nicotine patches- my two cents. I think this has been wildly understudied.

Attia promotes a “mouse-centric” view of popular longevity drugs and supplements, rapamycin, resveratrol, and NR, and metformin. Attia notes that mice are not humans but then only seems to hang his hat on the mouse studies, largely ignoring invertebrates and human studies. 90% of drugs that pass mouse studies fail in human clinical trials. I would pay a lot more attention to human data than mouse data to understand what’s what with regard to these drugs.

Metformin : Attia himself has backpedalled on promoting Metformin for longevity in his blog but basically promotes it in this book. I am against people taking Metformin when they don’t have diabetes. The primary reason for this is multiple clinical trials pointing to a potential increase in risk of Parkinson’s disease in metformin users.

Measuring aging: “aging itself is difficult— if not impossible— to measure with any accuracy” I completely disagree with this statement. Aging clocks and other biomarkers are being developed to measure aging and are relatively easy good approximates of aging and disease risk. See also here for an NIH blog post on some recent research on this out of the Wyss-Coray lab at Stanford.

Statins are safe at high levels to lower cholesterol to levels that children have. I think this is overkill and not proven to be safe. Children fundamentally have different biology than adults because they are still developing. I think ideal cholesterol levels are those of a fit person in their twenties and we should not use drugs to go below that level.

Every single amyloid drug for Alzheimer’s has failed— not true we have had two approved drugs last year including Lilly’s Lecanemab .

He has a negative view of yoga - calling people “yoginis” disparagingly and failing to recognize the literature on its benefits for flexibility, stability, and mental health.

Dr. Christin Glorioso, MD PhD is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

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The Science and Art of Longevity

• 4.4 • 681 Ratings

Publisher Description

#1 NEW YORK TIMES BESTSELLER • OVER ONE MILLION COPIES SOLD • A groundbreaking manifesto on living better and longer that challenges the conventional medical thinking on aging and reveals a new approach to preventing chronic disease and extending long-term health, from a visionary physician and leading longevity expert   “One of the most important books you’ll ever read.”—Steven D. Levitt, New York Times bestselling author of Freakonomics AN ECONOMIST AND BLOOMBERG BEST BOOK OF THE YEAR Wouldn’t you like to live longer? And better? In this operating manual for longevity, Dr. Peter Attia draws on the latest science to deliver innovative nutritional interventions, techniques for optimizing exercise and sleep, and tools for addressing emotional and mental health.   For all its successes, mainstream medicine has failed to make much progress against the diseases of aging that kill most people: heart disease, cancer, Alzheimer’s disease, and type 2 diabetes. Too often, it intervenes with treatments too late to help, prolonging lifespan at the expense of healthspan, or quality of life. Dr. Attia believes we must replace this outdated framework with a personalized, proactive strategy for longevity, one where we take action now, rather than waiting.   This is not “biohacking,” it’s science: a well-founded strategic and tactical approach to extending lifespan while also improving our physical, cognitive, and emotional health. Dr. Attia’s aim is less to tell you what to do and more to help you learn how to think about long-term health, in order to create the best plan for you as an individual. In Outlive , readers will discover:   • Why the cholesterol test at your annual physical doesn’t tell you enough about your actual risk of dying from a heart attack. • That you may already suffer from an extremely common yet underdiagnosed liver condition that could be a precursor to the chronic diseases of aging. • Why exercise is the most potent pro-longevity “drug”—and how to begin training for the “Centenarian Decathlon.” • Why you should forget about diets, and focus instead on nutritional biochemistry, using technology and data to personalize your eating pattern. • Why striving for physical health and longevity, but ignoring emotional health, could be the ultimate curse of all.   Aging and longevity are far more malleable than we think; our fate is not set in stone. With the right roadmap, you can plot a different path for your life, one that lets you outlive your genes to make each decade better than the one before.

APPLE BOOKS REVIEW

Dr. Peter Attia doesn’t just want you to live longer, he wants you to live better. In this helpful guide, the former surgeon outlines his individual-centered approach (which he calls “Medicine 3.0”): promoting blood work and other lab tests to catch major issues like diabetes, heart disease, and cancer earlier. Attia also argues that developing peak muscle mass and strength while we’re in our forties and fifties is the best thing we can do to make sure we can withstand the inevitable loss of both muscle and bone density as we age, and we love his tip for customizing your workouts—creating a “Centenarian Decathlon,” which entails choosing 10 or more activities we’d still like to be doing as we get up in years (like golf or swimming) and targeting exercises to those specific desires. If you’re looking for long-term fitness inspiration, this is a great place to start.

PUBLISHERS WEEKLY FEB 20, 2023

This rigorous debut by physician Attia dispenses guidance on living longer while staying healthier. "The odds are overwhelming that you will die as a result of... heart disease, cancer, neurodegenerative disease, or type 2 diabetes," he writes, outlining strategies to stave off these four "chronic diseases of aging." The author's medical philosophy emphasizes prevention over treatment, recognizes that what works for one person might not work for the next, evaluates "risk versus reward versus cost" on a case-by-case basis, and prioritizes maintaining one's "healthspan." He strikes the delicate balance between providing scientific background and keeping his explanations accessible, as when he relates that long-distance running and biking help fend off neurodegenerative disease because they cause the body to generate a molecule that bolsters the health of brain structures implicated in storing memories. Attia's acknowledgement that diets aren't one-size-fits-all is a welcome departure from the overgeneralizations of similar volumes, and he provides recommendations on modulating protein, fat, and carbohydrate intake depending on one's age, sex, and activity levels. The familiar suggestions to reduce stress, eat healthier, and exercise are elevated by the depth of detail and lucid prose that Attia brings to the table. This stands a notch above other fare aimed at boosting health and longevity.

Customer Reviews

Worth reading again.

A very detailed book. Peter Attia was instrumental in my taking longevity seriously. Now, I exercise aerobically and anaerobically several hours a week. Take my bloodwork seriously as well. I feel that I’ve added some extra time to my life.

Loved this book! I have been reading, researching and listening to blogs about nutrition for six years. So much of this book has helped me understand and has made so much information I have accumulated now make sense to me! Thank you, Dr. Attia…loved your informative podcasts in the past, but this book hit a HOME RUN! Truly appreciate your great presentation of the science as I journey my own path in life!

Textbook for the next generation of physicians

In Outlive, Peter Attia presents, without hyperbole, an ambitious yet actionable and evidence-informed strategy to dramatically minimize the risk and burden of the chronic diseases that rob us of vitality as we age and ultimately end our lives. Amidst a vast wasteland of books on health, is this one any different? In a word, very. There are two reasons why. First, Attia’s knowledge base is unparalleled. He graciously attributes this to the all-star line-up of experts in cardiology, lipidology, oncology, neurology, psychiatry, endocrinology, biochemistry, nutrition, exercise physiology, etc. who’ve tutored him over the years, and whose expertise is shared generously on his podcast. The depth of his dives with them and his fluency in each specialty are extraordinary. But Peter’s superpower is not simply the intellect to master the nuances of each niche. It’s that, plus the broad perspective to integrate that knowledge into the grand landscape of human health—to see the forest and the trees. It’s a rare alchemy of assets: the breadth of a primary care physician, the depth of a specialist, the granularity of a laboratory scientist, and the heart of a teacher. That is Peter Attia. Second, Outlive stands uniquely poised to do what others have not: transform healthcare. Not simply because his tactics for longevity are cutting edge and informed by the best science available—and they surely are. And not because those tactics won’t evolve as science progresses—for they surely will. No, Attia’s contribution will endure because his strategy is as timeless as it is revolutionary, and it will remain relevant as long as our objective is the extension of human health and lifespan. Medicine 2.0, as he calls it, is the conventional paradigm, the model I learned in medical school. It served us well when infection was our greatest threat, and still does against acute disease or trauma. But today’s top killers are chronic diseases that exploit the one factor current treatment paradigms neglect: time. Heart disease, cancer, dementia, and metabolic disease mock our feeble 9th inning attempts to medicate them away after an eight-inning head start. To put more than a modest dent in their devastation, Attia argues, we must attack from the other end of the timeline, long before these diseases manifest clinically—before the game even begins. This is Medicine 3.0, and it truly is revolutionary. To be clear, Outlive is not another sensational anti-establishment exposé on the failures, lies, and corruption of mainstream medicine. Rather, it graciously acknowledges Medicine 2.0’s success. But, noting its inadequacy against modern diseases, Attia has cleverly “back-casted” and reverse engineered a new strategy forward—and it is brilliant. If we do achieve significant improvement in human health and longevity, absent some miraculous sci-fi discovery, it will be because we followed the strategies presented in Outlive, even if its tactics are refined over time. This book is important. It’s carefully compiled, meticulously fact-checked, thoughtfully organized, and masterfully presented. It’s cutting edge, yet careful in its claims. Passionate, yet explicitly non-dogmatic. Deeply personal, yet rigorously clinical. Speaking of personal, I must comment on the final chapter. Those of us who consider Peter superhuman may be surprised—and relieved, perhaps—to learn that he battles the same insecurities and weakness that beset the rest of us mortals. His candid account of recent struggles with emotional health is as inspiring as it is moving and provides precious layers of meaning and perspective to all that comes before it. If chapters 1 through 16 are the how, chapter 17 is the why. Whether serendipitous or providential, that his crisis manifested in time to consummate the finished project is fortuitous for us, as it changes the entire work in a compelling—and beautiful—way. Since discovering The Drive in 2018, I’ve considered Attia’s podcast the most comprehensive and reliable resource for all things health and longevity. It changed the way I live, and how I practice medicine. Going forward, Outlive will be my primary textbook. Thank you, Peter.

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Outlive: The Science and Art of Longevity Hardcover – March 28 2023

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• Print length 496 pages
• Language English
• Publisher Harmony
• Publication date March 28 2023
• Dimensions 18.42 x 3.81 x 23.55 cm
• ISBN-10 0593236599
• ISBN-13 978-0593236598
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About the author, excerpt. © reprinted by permission. all rights reserved., product details.

• Publisher ‏ : ‎ Harmony (March 28 2023)
• Language ‏ : ‎ English
• Hardcover ‏ : ‎ 496 pages
• ISBN-10 ‏ : ‎ 0593236599
• ISBN-13 ‏ : ‎ 978-0593236598
• Item weight ‏ : ‎ 635 g
• Dimensions ‏ : ‎ 18.42 x 3.81 x 23.55 cm
• #1 in Physiology Books
• #1 in Physiology (Books)
• #1 in Medical Anatomy

About the authors

Bill gifford.

Bill Gifford is a veteran magazine writer and editor who writes about extraordinary athletes and cutting-edge health science. After growing up mostly in Washington, D.C., he returned after college to become a staff writer for the legendary Washington City Paper, for a salary paid in beer, rice and beans. He then moved to Philadelphia to write and edit for Philadelphia Magazine for several years. Continuing north along I-95 to New York, he worked as features editor and then "editor-at-large," the world's best job title, for Men's Journal. His freelance work has appeared in Outside magazine, where he is a longtime contributing editor, as well as Bicycling, Wired, Bloomberg Businessweek, Slate, and others, as well as in Best American Sportswriting. His first book, Ledyard, is a biography of the 18th-century explorer, writer, entrepreneur and bon vivant John Ledyard. His latest, Spring Chicken, is a personal investigation into the science of aging.

Peter Attia MD

Peter Attia, MD, is the founder of Early Medical. He received his medical degree from the Stanford University School of Medicine and trained at the Johns Hopkins Hospital in general surgery. He also trained at the NIH as a surgical oncology fellow at the National Cancer Institute, where his research focused on immune-based therapies for melanoma. He serves on the editorial board for the journal Aging. He is the host of The Drive, one of the most popular podcasts covering the topics of health, medicine, and longevity.

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Book Review: Outlive the Science and Art of Longevity by Peter Attia and Bill Gifford

Reading Outlive changed my view of Peter Attia – even before hitting the bombshell plot twist in the final chapter.

As a fan of his podcast, I was fully expecting this book to be a factual, practical, and detailed dive into healthy aging strategies. No nonsense about biological immortality, just solid advice for reaching 100 in robust health.

It did not disappoint.

Yet, alongside this, the driven and serious side of Attia’s on-screen persona crumbled, revealing a nuanced, rich and – at times – vulnerable individual beneath. Anecdotes, failures, moving stories of friends and loved ones and intense self-reflection bought the detailed coverage of the diseases that kill us, nutrition, exercise, and sleep to life.

Fresh Perspectives

Reducing my copious notes to just five takeaway points for this review of Outlive was a challenge.

Themes include the abject failure of the current medical system, the unstoppable rise in metabolic syndrome, a fresh perspective on exercise and the significance of preventative health screening.

I’ll be revisiting the sections on chronic disease. They are information-dense to the point where reading them in a single session became overwhelming. The practical advice from the more general sections is actionable. Peter outlines a framework of principals. You can then apply this to nutrition, toxins, sleep, exercise, and emotional health.

Five Take Aways from my Review of Outlive: The Science and Art of Longevity by Peter Attia

The five key takeaways below are points that triggered deep thinking or perspective change while I was reading Outlive.

They cover varied topics, though won’t sum up the entire book. After this section, you’ll find my thoughts on the plot twist referenced above – though without any spoilers.

There is one final actionable takeaway there.

Outlive by Peter Attia #1: Metabolic Syndrome as a Train

There are stations on the train line linking excess sugar consumption and death.

This starts with insulin resistance, goes through non-alcoholic fatty liver disease, then NASH / diabetes. As the train travels, your risk of death from one of the four horsemen (cancer, heart disease, stroke, and neurological diseases) rapidly increases.

Even if you are lucky enough to dodge these bullets – the accumulated damage to your blood vessels, neurones and cell signalling pathways is immense.

Most people are already on this train. The SAD (Standard American Diet) almost guarantees that the slow journey from healthy to metabolically compromised is underway.

Early symptoms, up to NAFLD and pre-diabetes are reversable. Lifestyle changes are required. They begin with taking personal responsibly for your health outcomes. As many as one in four people have NASH (nonalcoholic steatohepatitis), which happens when NAFLD progresses. Untreated, this can lead to cirrhosis.

Attia is careful to point out that obesity and metabolic health are nuanced – though not one and the same:

“But not everyone who is obese is metabolically unhealthy, and not everyone who is metabolically unhealthy is obese. There’s more to metabolic health than meets the eye”.

The big takeaway here is that the standard diet (not just in the US, but worldwide) is directly linked to the progression of metabolic syndrome . And that metabolic syndrome directly causes chronic health conditions that will massively reduce the quality of your life, and eventually kill you.

#2 – A Perspective Flip of Stability Training

Anyone familiar with Peter Attia will have high expectations of the chapters on exercise.

They did not disappoint, the information was so rich, I’ll need to revisit it for specifics.

It turned out, I was thinking about ‘Stability’ all wrong.

This is a core component of what Attia calls the ‘Centurion Olympics’. He has set a list of goals for his 100 th birthday. Then worked backwards through the decades to see what training is required.

Strength training (for muscles), Vo2 max (circulatory) and Zone 2 (endurance) are components, along with stability training.

I thought my planking and core workouts – along with stretching and squats – ticked this box.

Peter disagrees.

Stability starts with the feet, providing a stable platform (yours probably don’t). It then includes good form in situations where major muscles are activated. Squats, stepping blindly from a height and lifting weights are all included.

Without that good form, we are at risk from injuries – especially in later life. We lose the good form as children, and without specialist training, getting it back is a challenge.

If you are unclear how dangerous setbacks which force inactive periods are in later life, then Outlive contains stories which bring this phenomenon to life. Reoccurring references are made to ‘Sophie’s mum’, an active / healthy older person whose end started with a simple injury. This triggered a period of inactivity, causing a rapid spiral into frailness and eventually death.

#3 – Medicine 2.0 vs Medicine 3.0: Treating Underlying Causes, Not Symptoms

Whack-a-Mole medicine was already on my radar.

It is a major theme in Outlive. Attia calls legacy medical care ‘Medicine 2.0’. He is scathing of it in that intense, serious way that only Peter can pull-off. Imagine that stare, his BS detector fully activated on his YouTube videos… now multiply and repeat it in different contexts throughout the book.

I’m sure you get the idea.

Peter is disgusted with the universal practice of medicating symptoms without examining underlying causes. Add inflexible testing levels – for example treating a condition at 100 units per ml of blood, yet totally ignoring signs at 99 units – and the disfunction is obvious. Poor population-level screening for chronic diseases is yet another failure.

The case for upgrading from Medicine 2.0 to Medicine 3.0 is compelling. That said, challenging the behemoth of the medical establishment is no trivial task.

My takeaway from this is that moving from Medicine 2.0 to 3.0 is a personal choice .

Get tested, get personal monitoring, set goals, and change your behaviour to avoid future conditions. Don’t wait to develop symptoms, get them treated – then return to the doctor a year later with new symptoms triggered by the same underlying problem that was untreated the first time around.

#4 – Outlive Review: Nutrition is Far from Solved

Information about diet and eating habits is both detailed and nuanced.

If you were expecting information on keto or low carb / high protein options, you’ll find them discussed. This is in a wider context of ‘what works for you’ and nutritional biochemistry.

Attia uses the terms ‘overnourished’, and ‘undernourished’.

Polarising terms are avoided completely. For me, nutrition is as tribal as politics . Factions strongly believe that anyone not following their specific regimen is either stupid or misguided. Information in this chapter contradicts every fanatic at some point – from vegan through to carnivore. I felt that Peter handled this skilfully, and as with the other chapters, there are hidden gems along the way.

The single biggest take-away is that nutrition is way too complex, and confounded by far to many individual and environmental factors to be considered ‘solved’ .

Once you understand this, seeking the ‘correct’ diet for healthy aging becomes favouring one narrative over the others.

Instead, you can think of this in terms of your nutritional biochemistry – working backwards from there while keeping an open mind as our understanding of food improves.

 “Diet and nutrition are so poorly understood by science, so emotionally loaded, and so muddled by lazy thinking that it is impossible to speak about them in nuanced terms…” (Chapter 14, Nutrition 3.0)

In the second chapter on nutrition, Attia covers dieting strategies including restricting calories, restricting specific foods, and eating during a specific time window. The pros and cons of each will help you choose what mix of strategies work best for your own goals.

#5 – Vo2 Max Training and Healthy Lifespan

Exercise information in Outlive is excellent.

It covers the why of each form of exercise, and the biological pathways involved in the beneficial effects. Zone 2 training (moderate cardio) was explained in detail – including how it boosts mitochondrial function.

When it comes to Vo2 Max, I’m behind the curve.

My circuit training does leave me out of breath and with an elevated heart rate. Honestly, it is more like a Zone 4 or high Zone 3 than Max. Yet training at maximum capacity and all-cause mortality are significantly correlated. Adding endurance multiplies the health benefits. Peter goes ‘Rucking’, which involves hiking and running with a 60-pound rucksack on his back.

I’m adding Vo2 Max training to my routine. There is a test site at a local university, I want to get two to three months training under my belt before getting tested. Watch my Age Well Times blog for the results.

After reading the exercise chapter, you’ll have a great understanding of why Vo2 Max, resistance training, stability training and Zone 2 exercise are important.

Without each of these, you’ll be leaving healthy aging benefits on the table.

Outlive Review: The Final Chapter Plot Twist

I’m not going to include spoilers.

What I will say is that you won’t see Peter Attia in the same light once you complete Outlive. And you might apply the same kind of perspective flip to others.

After all, once you find out why Peter is so intense, so serious and frequently angry – it not only becomes understandable, you’ll wonder why you never considered why in the first place. Next time you meet someone that seems unreasonable, or even out of line, the same logic is easy to apply.

There is one more takeaway from this chapter. Peter has a developed a technique for when his anger flares: Do the opposite of what the red mist of anger tells you to do. If you feel like lashing out (verbally), compliment, if you feel like walking away – dive in (and so on).

I love this idea, and am actively looking for opportunities to use it. While I’m not a hugely angry person, I certainly have the potential for a sharp tongue in my tetchy moments!

Outlive Review: Final Thoughts:

With sky-high expectations, I was wondering whether Outlive would stand out from the huge list of longevity and healthy aging books out there.

It beat those expectations.

Your views will be challenged, from their framework through to the tiny details. This is a practical book, though the ‘art’ in the title is there for a reason. There are no clear answers in longevity. By working backwards from our final decades, we can plan for a robust future – and minimise our chances of a slow, painful decline.

Reading Outlive has real potential to make you healthier.

Reading the final chapter of Outlive might just make you a better person.

As usual I don’t include commercial links here at the Age Well Times. This is to satttay unbiased in my book reviews.

If you enjoyed this review, I’d genuinely appreciate a share on your favourite social media platform .

Please join me on Twitter – @MarkAWT

Here is Peter’s Podcast Channel on YouTube

And Peter’s Twitter: @PeterAttiaMD

More Detailed Book Reviews Covering Longevity and Healthy Aging:

• Life Force: By Tony Robbins and Peter Diamandis
• Cheating Death by Rand McClain
• The Collagen Cure

Mark’s Blog

Biological Age Test Results: 8 Years Younger

The Day I Ghosted a Personal Trainer (and why I can’t relate to ripped fitness advice)

The Brick Wall of Ingrained Health Beliefs (why the Age Well Times is not for Everyone)

Ageotypes, Sex and Individual Differences in Longevity

Yamanaka Factors and Longevity Research

Metformin and longevity.

Jimmy Carr on Healthy Aging

Inversion and Healthy Aging

CBT-I and Longevity Habits

Longevity on a Budget

Creatine and Healthy Aging

Coenzyme Q10 and Longevity

Bryan Johnson – The SAD Challenge

Cheating Death: Book Review

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Outlive: The Science and Art of Longevity

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#1 NEW YORK TIMES BESTSELLER • OVER ONE MILLION COPIES SOLD • A groundbreaking manifesto on living better and longer that challenges the conventional medical thinking on aging and reveals a new approach to preventing chronic disease and extending long-term health, from a visionary physician and leading longevity expert   “One of the most important books you’ll ever read.”—Steven D. Levitt, New York Times bestselling author of Freakonomics AN ECONOMIST AND BLOOMBERG BEST BOOK OF THE YEAR Wouldn’t you like to live longer? And better? In this operating manual for longevity, Dr. Peter Attia draws on the latest science to deliver innovative nutritional interventions, techniques for optimizing exercise and sleep, and tools for addressing emotional and mental health.   For all its successes, mainstream medicine has failed to make much progress against the diseases of aging that kill most people: heart disease, cancer, Alzheimer’s disease, and type 2 diabetes. Too often, it intervenes with treatments too late to help, prolonging lifespan at the expense of healthspan, or quality of life. Dr. Attia believes we must replace this outdated framework with a personalized, proactive strategy for longevity, one where we take action now, rather than waiting.   This is not “biohacking,” it’s science: a well-founded strategic and tactical approach to extending lifespan while also improving our physical, cognitive, and emotional health. Dr. Attia’s aim is less to tell you what to do and more to help you learn how to think about long-term health, in order to create the best plan for you as an individual. In Outlive , readers will discover:   • Why the cholesterol test at your annual physical doesn’t tell you enough about your actual risk of dying from a heart attack. • That you may already suffer from an extremely common yet underdiagnosed liver condition that could be a precursor to the chronic diseases of aging. • Why exercise is the most potent pro-longevity “drug”—and how to begin training for the “Centenarian Decathlon.” • Why you should forget about diets, and focus instead on nutritional biochemistry, using technology and data to personalize your eating pattern. • Why striving for physical health and longevity, but ignoring emotional health, could be the ultimate curse of all.   Aging and longevity are far more malleable than we think; our fate is not set in stone. With the right roadmap, you can plot a different path for your life, one that lets you outlive your genes to make each decade better than the one before.

About the Author

Peter Attia, MD , is the founder of Early Medical. He received his medical degree from the Stanford University School of Medicine and trained at the Johns Hopkins Hospital in general surgery. He also trained at the NIH as a surgical oncology fellow at the National Cancer Institute, where his research focused on immune-based therapies for melanoma. He serves on the editorial board for the journal Aging . He is the host of The Drive , one of the most popular podcasts covering the topics of health, medicine, and longevity.   Bill Gifford is a veteran journalist and author of the New York Times bestseller Spring Chicken: Stay Young Forever (Or Die Trying) . His work has appeared in Outside, Scientific American, Bloomberg Businessweek, Men’s Health, and numerous other publications.

Praise for Outlive: The Science and Art of Longevity

“ Outlive completely transformed my approach to growing old. Peter Attia is among the most brilliant people I’ve ever met, and he’s succeeded in packing a life’s worth of insights into this book. It promises to be one of the most important books you’ll ever read.” —Steven D. Levitt, New York Times bestselling author of Freakonomics “In Outlive, Peter Attia explores the science of not just prolonging life, but also prolonging aliveness. Attia makes the crucial connection between overall health and relational health.” —Esther Perel, New York Times bestselling author, psychotherapist, and podcast host of Where Should We Begin? “Finally, there is a modern, thorough, clear, and actionable manual for how to maximize our immediate and long-term health. Firmly grounded in data and real-life conditions, Outlive makes obvious which actions we all need to take, and just as important, what all we need to pay attention to in order to live a long, vital life. As the most accurate and comprehensive health guide published to date, Outlive is not just informative, it is important.” —Andrew Huberman, PhD, professor, Department of Neurobiology at Stanford University School of Medicine, creator of the Huberman Lab podcast “Dr. Peter Attia is my doctor and also my friend. He is a specialist in longevity and someone I trust with my life. What separates him from others is his pursuit of quality of life from all angles—physical, emotional, mental, relational, and spiritual health. This incredible book is a call to action and a reminder to always participate, and never be passive. It will arm you with the tools you need to live a long, meaningful, and fulfilling life.” —Hugh Jackman “In Outlive, Peter Attia has delivered the definitive look at the complex subject of longevity. Comprehensive and rigorous, Outlive is full of surprising insights into the diseases of aging that will likely kill most of us, and the tactics and techniques that can help us live longer and in better health. Attia’s writing surprises and delights us, while provoking a new way to think about longevity.” —Siddhartha Mukherjee, author of the Pulitzer Prize winner The Emperor of All Maladies and the New York Times bestseller The Song of the Cell

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Children’s Books

The Children’s Fantasy Novel That Flew Off Britain’s Shelves

“Impossible Creatures” has prompted comparisons to Tolkien, Lewis and Pullman, but action, not awe, is Katherine Rundell’s strong suit.

Cover illustration for “Impossible Creatures.” Credit... Ashley Mackenzie

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By Laura Miller

Laura Miller is a books and culture columnist for Slate and the author of “The Magician’s Book: A Skeptic’s Adventures in Narnia.”

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IMPOSSIBLE CREATURES , by Katherine Rundell. Illustrated by Ashley Mackenzie.

Katherine Rundell, a fellow of St. Catherine’s College at Oxford, belongs to that university’s longstanding tradition of combining scholarship — her biography of John Donne, “Super-Infinite,” won the Baillie Gifford Prize — with writing beloved children’s fiction. “Impossible Creatures,” Rundell’s sixth novel for middle grade readers, became an instant best seller in her native Britain when it was published last year and has garnered numerous awards, including the Waterstones Book of the Year.

The novel begins as Christopher Forrester is packed off to stay at his grandfather’s estate at the foot of a steep hill in Scotland, little realizing that the hill contains a portal to a magically sequestered portion of the world called the Archipelago, islands inhabited by creatures from assorted mythologies. In a parallel story, Mal Arvorian, a girl born in the Archipelago and able to fly thanks to an enchanted coat, investigates signs that the islands’ magic, or glimourie, is fading. This endangers all the unicorns, mermaids, kankos and other fabulous creatures — including her pet, a baby griffin — who need glimourie to survive. Mal enlists Christopher in a journey to find the source of the diminishment. Soon, their party expands to include a surly ship’s captain, an oceanographer and a talking horned squirrel who serves as navigator.

The first book in a series, “Impossible Creatures” marks a departure for Rundell. Her previous novels have their fanciful elements, but this is her first work of fantasy. Oxford’s history of producing illustrious children’s fantasy authors has prompted comparisons of Rundell to J.R.R. Tolkien, C.S. Lewis and Philip Pullman, but fantasy doesn’t feel like a natural fit for her. Rundell’s true antecedent is Robert Louis Stevenson, another author of thrilling yarns presented in confident, richly colored yet sleek prose.

In Rundell’s “The Explorer,” children survive a plane crash in the Amazon rainforest by building a raft and learning how to eat tarantulas. The heroine of the sublime “Rooftoppers” discovers a secret community of orphans living on the rooftops of Paris, including a boy who never sets foot on the streets and makes a waterproof tent out of pigeon feathers. In “The Good Thieves,” a professional pickpocket and two circus performers help a girl burgle the mansion of a mobbed-up robber baron in Prohibition-era New York.

Such doings may be improbable, but they’re not impossible, and much of the delight to be found in Rundell’s novels comes from the ingenuity and resourcefulness of her child characters when faced with the daunting constraints of reality. “Children have been underestimated for hundreds of years,” an old woman argues in “Impossible Creatures,” articulating a common theme in Rundell’s work. Another is the stifling demands of decorum, especially when imposed on Rundell’s wild, tomboy girls. Mal’s great-aunt and guardian (like many of Rundell’s protagonists, she’s an orphan) forbids “an immense, book-length list of things,” prohibitions Mal routinely defies. Christopher’s father (his mother is dead) is afraid of almost everything.

These complaints barely register before the plot of “Impossible Creatures” kicks into gear with a hired killer forcing Mal from her home and Christopher plunging through a passage in a lake and into the Archipelago. All this happens so hastily that the wonder of Rundell’s premise never has a chance to fully bloom.

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