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Longevity

Want to live to 100 and enjoy the ride? ‘Healthspan’ is the way.

David Holt October 20, 2022

Some people have accomplished so much in their lives, it seems as if they must be more than one person. And some of these got off to a slow start. As a teenager growing up in Toronto ON, Peter Attia, was, in his own words, a “screw-up.” He was always goal-oriented, but he had only one goal – to become a professional boxer, which he knew was almost impossible, especially in Canada.

To get fit, he and a small group of friends trained six days a week in a grimy underground adult gym, but otherwise he wasn’t motivated, certainly not by school. Then, a single grade-12 teacher turned him around and he was accepted at Queens University. He ended up with two undergraduate degrees, one in math and one in engineering. From there he went to Stanford medical school in California and emerged as a star cancer surgeon – the hardest specialty he could find.

These days Attia admits that a lot of his perfectionism was driven by a negative emotion – an inferiority complex, which he hopes not to pass on to his own children.

Then he pivoted again, leaving medicine to join the McKinsey Consulting Group where he specialized in the business of healthcare, where – believe it or not – his training as a doctor was not an asset. Even before completing his medical training, Attia had become disillusioned with medicine, certainly with the lack of focus on prevention.

In the United States and Canada we spend a tremendous amount of money and effort to extend that period of chronic disease at the end of life, he wrote. “This is not much of a strategy. It was often too late and too often didn’t seem to impact how much longer or better a person could live. It was only after the birth of my daughter, two years after I left medicine altogether, that I became obsessed with the idea of trying to figure out how to live as long and live as well as possible so that I might spend as much time with her as I can.”

Meanwhile, he kept working out and studying human biology. When he returned to medicine, he became obsessed with the science of aging. This lead to his fascination with longevity and its handmaiden, “healthspan”– improving quality of life and not simply its length.

His training in math and engineering gave him an advantage over many medical researchers. His strong grasp of probability and statistics helps him to look closely at the underlying data to see the strengths and weaknesses of research.

This can lead to potential interventions that are based on leading-edge science. The popular term for these interventions is “hacking.” The problem is that assessing probabilities in the face of uncertainty is not second nature, even to most scientists. The correct conclusions, which may simply be best guesses, are often counter intuitive.

Still, he cautions that while there is a lot of gold among so-called “bio-hackers,” there is even more misinformation and disinformation based on shoddy science and promoted with an agenda that is more about sales than improving health.

Always on the frontier, Attia started using himself as a guinea pig, but only after “doing the research,” as we say nowadays. (But in his case, this actually means something.) Never one to do anything halfway, he is now a leading expert on both longevity and “healthspan,” a relatively new and more subtle concept.

His current practice allows him to work with fewer clients, so can spend more time learning, thinking, and even paying experts to do research – and he has a long list of mentors and advisors. Meanwhile many doctors are struggling to keep up with their caseload, which, as he learned as a resident and a cancer surgeon, leads to a high stress load. There is little time to explore the frontiers of medicine, and the long hours and stress often compromise sleep, which impairs memory, judgment, and the biochemistry of a healthy life. The doctors we rely on for life and death decisions are often running on fumes.

LIFESPAN: LIVING LONGER

Besides genetics, a lot depends on the “social determinants of health,” which are also beyond your control, at least in the early years.

The most important questions are simple. Did you grow up in a family that provided love and emotional support, as well as the basics like secure housing, clean clothing, and healthy food? Could you play outdoors in clean air with green spaces nearby? Did you have a circle of friends and supportive teachers? To paraphrase Einstein, did you feel you were living in a friendly universe?

As Attia points out, most little children have amazing flexibility and core strength. Deep squats are not a problem, and in fact many yoga poses are stuff that kids do naturally. But even in the first year of school, he says, they start to lose that flexibility as they are taught to sit still and watch the teacher. Then, even in our 20s, we begin to lose components of our biological resilience.

Still, genetics is not destiny. The new science of epigenetics has revealed that genes turn on and off in response to external factors such as diet, stress, and the chemicals that enter our bodies day in and day out. For example, identical twins raised apart may have very different lives and health outcomes.

Attia is now in his late forties. His many followers, including those in their 90s and above, are living proof that healthy aging is possible. He recommends smart strength training, for example, which reverses the natural loss of muscle mass while minimizing risk of injury. Yet there are trade-offs. At some point, he realized that training hard in one or more areas could damage your long-term health. For example, he’s still a powerlifter, but after a few long-term injuries he’s cut down on the weight and the intensity of his training. Overtraining can also lead to “athlete’s heart,” which poses its own added risk for cardiovascular disease and premature death.

HEALTHSPAN: LIVING BETTER

“Healthspan” is a relatively new concept. The essence is that as the decades go by, we gradually lose abilities like strength, flexibility and biochemical efficiency – our cells don’t work as well. Then, in the last decade of life, we take a deeper dive.

Today, in the developed world, many of us can expect to live to be 80 years old, with an overall health peak at age 40, says Attia. This means that at age 70 many of our health metrics will be half of what they were at age 40. Then we will die at age 80, after a steep decline in our health. The way to improve healthspan is to shift this entire curve to the right, so you live longer and healthier, with the drop-off happening quickly at the end.

Longevity is a balance of lifespan and healthspan. Ever the math guy, Attia explains that increasing lifespan means delaying the onset of “the four horsemen” of cardiovascular and cerebrovascular disease (heart attack and stroke), cancer, and accidental death, which together account for about 80% of deaths in a non-smoking population.

Enhancing healthspan means avoiding (or at least delaying) three categories of decline:

Cognitive decline—reduced executive function (concentration and self-control), processing speed, and memory. Alzheimer’s disease is an extreme version of this decline.

Physical decline—reduced stability, flexibility, mobility, strength, muscle mass, bone density, aerobic function, anaerobic function, functional movement, freedom from pain, and sexual function.

Emotional decline—reduced mindfulness, social support, sense of purpose, fulfillment, and relationships.

STRATEGY & TACTICS

In medicine, strategy is more relevant in some practices than others. Sometimes, it’s just “take a test, receive a treatment.” Healthspan is more complex. To improve healthspan, you need an overall strategy that embraces all categories you want to address, and not just a list of tactics. Much of his strategy comes from studying centenarians (those who are 100 years of age or more), who make up only 0.4% of the population.

To put it all together, Attia focuses on the following categories, sometimes using his own preferred terminology: “nutritional biochemistry” (derived from food and eating habits), exercise, sleep, distress tolerance, emotional health, and “exogenous molecules” – drugs, nutritional supplements, and hormones.

LIFE LESSONS

Here’s the strategy.

First, choose the right parents! In other words, start with good genes. This is said with a certain irony, but it is commonplace in anti-aging medicine.

Centenarians tend to die from the same things as the rest of the population (the “four horsemen”), but their vulnerable age starts much later than for the average human — even if they have poor health habits. This is the power of genetics. For example, centenarians tend to be more efficient at processing glucose, no matter what their diet.

So, two, start your healthspan program early to delay the onset of chronic disease. As a cheat, consider that phenotype (your body type and composition) tends to follow genotype, your DNA.

Three, learn about the key genes, about 10 or so, that influence healthspan, and how you can influence them with good health habits.

For example, high muscle mass, especially in the lower body, has multiple benefits. Anyone in decent health can train for this at any age. Besides improving the biochemistry of “glucose disposal,” this helps you maintain agility and reduce the risk of injury as you go about your day.

TRAIN FOR A CENTURY

Attia promotes the concept of the “centenarian decathlon” or even the “centenarian Olympics,” where you would like to be able to perform 10 or 18 key movements at a certain level at a given age, say 100. This comes from the concept of “backcasting,” which he borrowed from professional poker player Annie Duke. You look ahead to a certain age, and then project yourself backwards from that age. For healthspan, you project yourself into the future and ask: what are my health goals for a given age, say 100, and therefore how do I manage myself from now until then?

Attia would like to be able to do basic activities like walk up and down stairs easily while carrying a 30lb. bag in each hand; pick up a grandchild and hold him or her over his head; and be able to move easily into a standing position using just one point of contact, such as one hand and arm.

These are all complex, dynamic movements that require strength, balance, and flexibility. Stairs can be steep and curved (Attia, of course, wants to be able to walk them backwards) and young children are squirmy and unpredictable. This is far from repeating sets and reps in your local gym or workout area. To accomplish these goals, you need to get started training these “functional movements” in a disciplined way decades earlier.

This training also helps to prevent injuries, including falls. Seniors are much more likely to fall than younger people. Even a moderate injury can trigger a downward spiral, a loss of mobility – and pain. Then you exercise less, sleep poorly, and become susceptible to a rapid decline. Another adage of anti-aging medicine: “if falling in the elderly were considered a disease, it would be designated an epidemic.”

While many of the markers you want to measure as you age come only from specialized blood tests (preferably given by an anti-aging specialist), some are less formal. These include grip strength and leg strength; but, even here, measurements are about efficiency, not size.

NUTRITION

Eating and nutrition is an especially difficult subject because it is not just about what you eat and how much. It’s also about timing and must be tailored to the individual and their unique biology and lifestyle. It’s not just about someone’s preferred theory. There are many roads to Rome. In Attia’s case, he has tried many approaches, including keto, and is a believer in fasting.

“I don’t like to talk about it,” Attia says. “Nutrition is like religion, politics, and guns — it’s so charged. Instead, I see the subject through a biochemical lens. Moreover, a lot of nutrition science is unreliable. I teach a Phd-level course on that.”

As you plan your own personal approach to food — what you eat, when you eat, and how much — the key is to get unemotional about food, he says. “It’s just a bunch of molecules that impact enzymes and hormones. Once you figure out what works for you, then you can get emotional about food again.”

SLEEP

Like nutrition, sleep is also about quantity, quality, and timing. Generally, sleep occurs when brain waves slow down. Moreover, the brain rotates through five stages of sleep over 90 minute cycles. The deepest, slowest-wave sleep seems to be especially important for the brain to consolidate memories and eliminate chemicals that have accumulated during waking consciousness.

Stress, lack of exercise, and interruptions all take a toll on a healthy sleep. “When I finished residency, my testosterone was very low,” Attia says. “Later, once my sleep started to improve, my testosterone level and my memory started to improve.”

MIND AND BODY

Distress, stress as we usually think of it, has many possible origins. It is more about how our mind interprets events than the events themselves. We all have different triggers and some people just naturally handle tough stuff better than others. The damage is done when stress hormones like cortisol, which are designed to provide a burst of quick energy, keep flooding the body long after the initial stimulus.

Getting a good sleep is key for most people, although the science here is still in its infancy. Nutrition is also a factor, as insulin resistance (pre-diabetes) makes us more susceptible to stress. To reduce stress, Attia recommends meditation and, potentially, psychotherapy, and certain drugs and supplements.

IN THE END

Attia is old enough to have learned some key lessons in recent years. One is that as people age, time becomes more precious – it is relished. Also, in practical terms, if your improved health habits buy you one more year of life, new interventions may appear that will help you live longer and better. This could be a compounding relationship.

In recent years, he has become more focused on emotional health, including positive relationships. “If this is suboptimal, it’s not a life worth living,” he says. He’s also learned that some self-inflicted suffering is part of life. This you must accept, learn from, and then move on. This is easier said than done.

The birth of his daughter was a game changer. This gave him a practical reason to want to live long and well: to spend quality time with his children and grandchildren.

NOTES

THE LIFESPAN CALCULATOR

Lifespan is determined by many factors: your current age, your overall health, your health habits, your environment, your ability to tolerate mental distress – and, overwhelmingly, your genetics. You can take a quiz on a life span calculator on the Internet, where you plug in data about your age, health, and lifestyle and a program spits out your probable lifespan and recommends actions you can take to increase that number. These quizzes are based on science, but they are still just guesses. The more sophisticated the calculator and the more data you plug in, the better the guess.