A Skeptic’s Review of Peter Attia’s “Outlive”

Going into this, I’d only heard of Dr. Peter Attia in passing. I had a loose association in my mind between him and keto diets and nutrition-in-quotes podcasts, and I’m generally extremely skeptical of any physician in this space. There’s so much snake oil and it’s so easy to produce it if you’ve got some basic medical training. Light on facts and medical nuance, heavy on “buy my vitamins.”

So this was supposed to be a scathing review of yet-another “wellness” doctor promoting their bullshit to the laypublic.

It was supposed to show you the vast differences between Graham Walker, a practicing emergency physician for 16 years who cares deeply about reading the scientific literature and understanding its nuance, and Peter Attia, a physician who didn’t finish his residency and now mis-interprets scientific studies and talks nonsense to promote his podcast and anything else he’s hawking at the moment.

But my review will not work out the way I’d expected it to. I found Outlive to be a deeply personal, courageous, and vulnerable look at a broken man who was uber-focused on optimizing every part of his life except his actual enjoyment of it. And I ended up seeing a lot of Dr. Attia in myself — and I’m sure a huge number of other physicians with similar personalities and phenotypes. You should read it.

This review will of course contain plenty of criticism —?where Peter I think is a bit blinded by theory and not actual practice — but overall, I have to say I pretty much agree with the guy’s ideas.

As I said: I’d highly encourage everyone to read Outlive. The main reason I even picked it up was because my personal trainer told me it was available for free on Spotify, so I may be the target demo — active middle-aged man trying to stave off disease and illness at the gym. I really enjoyed the audiobook; Attia himself narrates it and has a calming yet engaging voice. But if you start Outlive, you must promise to finish it. Only reading the first third or half of the book (focused more on Attia’s theories on physical health) will entirely lead you astray to the actual conclusions he makes at the end.

TL;DR (Too Long; Didn’t Read):

If you boil it down to the pure basic message, it’s this (which I entirely agree with):

There are no (or very few) shortcuts in life, and to truly achieve “health” or “wellness” or “longevity,” you’ve gotta put in work (time + effort). The often-American desire for a pill for everything simply will not cut it.

Other themes from Attia:

• Our genes and biology have not kept up with our environment (plentiful and highly-processed food, sedentary lifestyle)?—?Graham's comment: agreed.
• Preventing (or delaying inevitable) disease is way better and cheaper than treating or managing it — Graham's comment: no argument there.
• Exercise is critical to everything. We all need frequent strength and cardio exercise. —?Graham's comment: there’s no point to all his other blood tests and optimizations if you're not going to exercise.
• The culture of medicine is still in a “treat the disease” mindset; Attia argues it must pivot to “prevent the disease” instead — Graham's comment: yes, but way easier said than done by physicians
• The core, central features of all the solutions boil down to common, simple things that medicine spends little time on: exercise, diet, sleep, stress reduction, and mental health. — Graham's comment: these are all central to maintaining health

My general criticisms:?

• Most of Dr. Attia’s medical recommendations are not accessible to the vast majority of Americans, and if anything his patients are going to be generally way healthier than the average American, as they can afford his $150,000 annual fee.
• Surprisingly, he frequently talks about how the environment of humans has changed quite rapidly, but doesn’t recognize that these are systematic, structural problems that could be addressed in American society. Instead, he really focuses on personal responsibility of both doctors to fix all these problems and patients to own the changes as well.
• If anything I think Peter Attia expects too much of individual doctors and individual patients; while I agree with most of his recommendations, they are completely impossible to achieve in today’s society. There are not enough doctors in the world to reverse the caloric excess or sedentary lifestyles of humans.?(How have other countries and societies dealt with this? They've just chosen to have better food options and a better social safety net so that healthier choices are built into their citizens' lives, meaning there's not nearly as much need for Attia's "Medicine 3.0.")
• I would love to live in a Peter Attia world where I have infinite resources and infinite time to see a very limited number of patients and optimize the needs of every single one — but I wish he would acknowledge the impossibility of this task. I also wish he'd touch on the ethical implications of having a doctor take this deep focus of a focus on one single person.

Let's get started with a deeper look at the book.

Attia’s Medicine 3.0

Attia starts off talking about medical practice, and how it needs to evolve — Medicine 3.0, as he calls it. He also mentions that medicine needs to do a better job of acknowledging risk (and both sides of it — risk of inaction and risk of action), but I think he has a major selection bias with his wealthy patient population.

As an ER doctor, I see all-comers. (Admittedly, this is my bias.) From day of life 2 to year 110. And I can tell you right now, patients have extremely variable levels of interest in going through all the risks and weighing them closely. It often correlates strongly with education level and health literacy. But when we need to come to a decision, medicine already does a risk assessment with the patient. It’s called shared decision-making. If the patient wants to hear my whole spiel about doing the CT scan, I give it to them. If they just want me to decide, I do so. You have to meet the patient where they’re at.

As Attia writes:

Medicine 3.0 demands much more from you, the patient: You must be well informed, medically literate to a reasonable degree, clear-eyed about your goals, and cognizant of the true nature of risk. You must be willing to change ingrained habits, accept new challenges, and venture outside of your comfort zone if necessary. You are always participating, never passive.

There could not be more unreasonable of a definition for “Medicine 3.0.” Peter Attia argues that it's entirely medicine's fault here and that medicine must evolve. Sure, but look at his definition above: Medicine 3.0 requires an informed and medically-literate patient? Are physicians responsible for that, too? From where will this health literacy spring eternal? Attia wants medicine to advance — and I do too — but he has a deep, deep selection bias at play by seeing his tiny sliver of the population.

On Healthspan and Longevity Strategy

Attia says we need to focus way more on quality of life years —?years where you’re healthy, doing the things you want — and I fully agree. This is “lifespan” vs “health span.” And on his general strategy of doing our best to massively delay or prevent the inevitability of aging and the diseases that come with it, I couldn’t agree with Peter more in theory.

(I should also mention that Peter really uses some fantastic analogies throughout the book that drive his points home, except when he’s talking about driving his race car around the track which rapidly shatters the everyman illusion.)

Attia acknowledges upfront that there is no greater risk for disease and morbidity and mortality than age. This is something a lot of quacks blindly ignore — and the fact that he calls it out clearly was really reassuring to me. He also acknowledges that health span and lifespan are connected: if you can improve your health span, you’ll also improve your lifespan. I see this every day in the ER: the 90 year-old who falls down and broke her hip coming back from yoga class or the 3 mile walk she does every day? She’s probably going to be just fine. The 90 year-old with diabetes and multiple comorbidities who breaks her hip? She has an extremely high mortality.

Peter says this early in the book, but I wish he’d remind people of it even more:?

I now consider exercise to be the most potent longevity “drug” in our arsenal, in terms of lifespan and healthspan. The data are unambiguous: exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention.

As I’ve said before: If exercise was a pill, it would cost you millions of dollars a year: almost everything in physical, mental, and emotional health and wellness is better with exercise. And it just so happens that it’s free.

Outlive’s Focus on Biological Pathways

The one area that really irks me the most in Outlive is so much emphasis on chemicals and molecules in our bodies. While we often use our understanding of physiology and pharmacology in the practice of medicine, I feel like Dr. Attia jumps to conclusions too frequently and exudes too much confidence and pretends his molecular pathway hypotheses are definitive when they are not. While we think “if we block or add molecule X it will have effect Y in the body” it often, frustratingly just doesn’t work that way. Countless times we find a molecule or a gene or a target in a mouse, say “Eureka!” After we find the same chemical in a human, and then in actual clinical trials, it just doesn’t work out.?(Or similarly, we might find a drug that's highly effective at reducing cholesterol levels, but it doesn't seem to actually be effective at reducing heart attacks, strokes, or deaths –?aka, the things people actually care about.)

I’d imagine Peter would counter by asking me, “What’s the harm in the absence of better evidence,” and if it’s something simple like exercise or diet changes, there’s probably admittedly little harm. But when you don’t have good evidence for your claims, I worry about heading dangerously close toward promising something you can’t deliver — and that’s what charlatans and health gurus do.

The Crisis of Abundance

Chapter 6 is one of my favorites, for a few reasons —?it raises public knowledge about NASH/NAFLD which I’ve found shockingly few patients have heard of, despite it being the leading indication for liver transplants.

I also enjoyed Chapter 6 because I emphatically believe what Attia says: we have all taken in too many calories, causing insulin resistance, and that leads to a TON TON TON of badness in the body. (I will also admit to being a big fan of Jason Fung’s work on intermittent fasting.) Additionally, this chapter was a nice kick in the pants to me as I gained weight like almost everyone during the past 4 years (being an ER doctor during a global pandemic was my excuse, what was yours?)

Two more thoughts:

1. Attia does a DEXA fat scan on his patients annually, and a 2 hour glucose test, where he measures their glucose and insulin every 30 minutes. This is a prime example of how skewed Attia’s view is of healthcare; he seemingly wants Medicine 3.0 to be widely adopted, but is then totally clueless that massive numbers of Americans could never afford the cost or the time required to do all of his testing. (1 in 4 Americans don't even have ANY sick leave and 1 in 14 don't even have health insurance.)
2. On the flip side, I fully agree with Peter that medicine for some reason has chosen to measure TSH levels for thyroid disease but not routinely measure insulin levels, despite both potentially evaluating for serious endocrine diseases. This is his sweet spot and where he really shines in Outlive: pointing out his insider knowledge of medicine yet trying to push the field forward as an outsider.

The last thing I will say is what I’ve learned as an ER doctor for the past 16 years: do not get diabetes. Almost every other disease is worse or more prevalent or higher-risk if you have diabetes, and I am not exaggerating when I say that easily half of my patients I see in the ER have it. It is that bad of a disease. (They’re not necessarily in the ER due to their diabetes, but due to the other diseases that track along closely like heart disease, kidney disease, etc.)?

For people with type 1 diabetes, they obviously have no say in the matter as they are dependent on external insulin, however many if not most patients with type 2 diabetes can improve or even reverse their diabetes with aggressive lifestyle changes. I’m not saying it’s easy, especially in America — but I’m saying it’s certainly biologically possible.

And that’s just the first 6 chapters! Please let me know if you found this useful; I took notes over the entire book and can do a Part 2/3 if people like this.

Part 2: https://www.dhirubhai.net/pulse/part-2-more-meat-potatoes-skepticism-peter-attias-graham-walker-md-dslzc/

Part 3: https://www.dhirubhai.net/pulse/part-3-my-review-attias-magnum-outlive-opus-graham-walker-md-jqfuc/