Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. As an integrative functional medicine doctor (anti-aging doctor), I do a lot of reading and research on longevity. Some of my favorite books include:

Lifespan by David A. Sinclair, PhD

Lifeforce by Tony Robbins

How Not To Die by Michael Greger, MD 

Chronic by Steven Philllips, MD and Dana Parish

The Better Brain Solution by Steven Masley, MD

The Longevity Diet by Valter Longo, PhD

The Longevity Economy by Joseph F. Coughlin

The Longevity Solution by Dr. James Dinicolantonio and Dr. Jason Fung

Age Later by Nir Barzilai, MD

An American Sickness by Elisabeth Rosenthal 

The Emperor of All Maladies by Siddhartha Mukherjee

And these are just a few! There’s more. Like the one I just finished this week called Outlive: The Science and Art of Longevity by Peter Attia, MD. This book sums up everything I’m trying to do in my practice at Performance Medicine, which is why I chose to do a book review for today’s Note. 

FYI: Dr. Attia is not only one of my favorite authors, but the host of my favorite podcast, The Drive (available on Spotify, Apple, Google, YouTube, Overcast, RSS).  

Let’s dive in.


Outlive: The Science and Art of Longevity


About the author: Peter Attia, MD (oncologic surgeon) is a Stanford/John Hopkins/NIH-trained physician. A real heavy hitter in the medical world. In a nutshell, “life” experiences led him down the path of researching longevity, and making a lifetime goal to figure out how to increase “health span”. 

About the book: Outlive is “a strategic and science-based approach to extending lifespan, while also improving our physical, cognitive, and emotional health.” Dr. Attia is a smart guy. For example, when he analyzes studies (which he does all the time on epidemiology), he uses a method called Mendelian Randomization. Note: Webster defines Mendelian Randomization as a method using measured variation in genes to interrogate the causal effect of an exposure on an outcome. (Did I mention the book is complex?) So, my challenge will be to keep things simple and practical. 


Medicine 3.0 


For the past 18 years, Performance Medicine has been teaching/educating people how to live better longer. The main focus being prevention of disease. I’ve studied this for years, and even completed a Board Certified Fellowship in anti-aging medicine (American Academy of Anti-Aging). Dr. Attia and I agree on a lot of things, especially on the direction that medicine is going.  

Dr. Attia calls his way of practicing medicine, Medicine 3.0 (also heavily focused on prevention). When looking ahead 10-20 years from now, what’s going to happen to you? This is an important question to ask. Based on what you are doing now, where is your health heading? In Outlive, Dr. Attia talks about the “four horsemen” of chronic disease. These are the four disease processes that are going to kill most of us.  

  • Cardiovascular and Cerebrovascular Disease 
  • Cancer 
  • Type 2 Diabetes (and it’s related metabolic dysfunction) 
  • Neurodegenerative Disease (like Alzheimer’s and Parkinson’s) 

Note: Neurodegenerative Disease is the one he really takes a deep dive on and the one I focus on the most at PM. In my opinion, it’s probably the worst one of the four horsemen. 




EXERCISE: When we’re talking about health span, we have to consider what we’re doing for exercise. That’s number one. As Dr. Attia puts it, “You better be fit by the age of 75, because if you’re not, it’s like falling off a cliff, once you reach that age.” 

Dr. Attia is an absolute fitness nut! He emphasizes fitness over everything. It’s funny because just the other night, I was watching the documentary, Limitless With Chris Hemsworth, on Disney + about longevity and how you can live longer. Hemsworth is a fitness nut, too, and in one episode he goes to the arctic, swims in cold waters, and then sweats in a dry sauna. Hemsworth really takes it to the limit in this series. He does a lot of research and talks to a lot of doctors about the Art of Longevity. Crazy as it sounds, but right there with him, swimming in the arctic and getting in a 192 degree hot box, was Dr. Attia! 

“Fitness is the key to prevention”, says Dr. Attia. And, I believe he’s right! My focus has  primarily been nutrition, but FITNESS is probably number one as far as how well you’re going to age. You have to move! In fact, his goal for all of us (and his personal goal) is to train like we’re going to run a marathon at age 100. That’s super interesting! 

  • For exercise, he focuses a lot on strength training, as well as endurance training. To him, both are equally important. 
  • For strength, he talks about hip hinges, step ups, and grip strength. Grip strength is probably the best overall measure of how fit you are. 
  • For endurance, he does a lot of work with the VO2 max, which is an endurance measurement. 

NUTRITION: According to Dr. Attia, the second most important thing for your health span is your DIET, i.e., what you put into your mouth! He’s not a fan of any one particular diet because the studies are misleading. When you have individual metabolisms, it’s hard to get a controlled study, but he leans toward Keto. He likes eating LESS calories, LOWER refined carbs, and FASTING. Note: As I have said before, sticking to Keto is very difficult. I’ve found that out in my practice. Very few people can stay in Ketosis, but it has great health benefits (i.e., weight loss, curing Type 2 diabetes, and helping cancer patients). 

Continuing with the diet story, Dr. Attia was in Ketosis for three solid years. He doesn’t do strict ketosis anymore, but he claims it saved life. He had a lot of risk factors for cardiovascular disease, and even as a marathon swimmer, his health was not where it should be. In the book, he tells the story of him finishing a swim from California to Catalina Island, which is 20 miles through the rough Pacific Ocean! When he gets to the Island, he has a cheeseburger and a coke, and his wife calls him fat! At that moment, a light bulb goes off in his head, and he decides to really start thinking about what he’s eating. That experience steered him towards the journey with Ketosis. 

Nutrition really boils down to energy balance. Calorie restriction and dietary restriction (low carb or time restricted diets, for example) are all very important. They are tools you can use to get where you want to go. Calorie restriction is the only thing that’s been proven to prolong life. Note: Dr. Attia takes a medicine called Rapamycin, which is a drug that mimics fasting. It has a lot to do with something called mTOR inhibition. To learn more about this, check out my podcast on Rapamycin.

Dr. Attia’s Nutrition 3.0 would be to: 

  1. Focus on your diet.
  2. Eat good fats.
  3. Get the vitamins and minerals you need.
  4. Eat protein. Getting enough protein in your diet is something I probably don’t talk about enough. It’s very important. 
  5. Drink little to no Alcohol. As far as your health goes, Dr. Attia believes there is no place for it. 
  6. Get good sleep. 

As far as your nutrition, everything he focuses on is about preventing diabetes. I agree with that.  A diabetic diet is basically a healthy eating plan that I would recommend to all my patients. Believe me, I’ve raised two diabetic children and treated thousands of diabetics over the years, and it’s amazing how nutrition changes everything! 


Cardiovascular Disease


In regards to cardiovascular disease, Dr. Attia focuses on two lipid numbers: the ApoB and Lp(a), both of which are on the Cleveland Heart Panel. According to Attia, you should work on getting your ApoB level lowered or at least evaluated. ApoB is a lipid measure that represents the size of all your LDL ( the bad cholesterol type particles). Lp(a) is a strictly inherited type of bad LDL particle that there’s not a lot you can do about. You also can’t do a lot about your HDL (the good cholesterol). Note: Exercise will raise your HDL a little bit, but a lot of it tends to be inherited. You can, however, lower your ApoB by various measures (including medicines, if needed).  

Dr. Attia is also a big fan of CT Calcium Scoring and CT Angiograms. CT Calcium scoring is a heart scan that tells you how much calcified plaque is in and around your coronary arteries. It’s a good predictor of coronary artery occlusion. CT Angiograms carry that a step further, if there is concern. Note: I order almost everybody a CT Calcium when they come to my clinic. The Cleveland Heart Panel and CT Calcium make a great starting place to assess a lot more than just your heart.  

Dr. Attia is big on looking at those lipid numbers, especially your insulin resistance numbers and your fatty acid analysis like EPA, DHA, and Linoleic Acid. Note: Linoleic acid is an inflammatory omega-6. You want the Omega-3’s to be high and the Omega-6’s to be low.


Neurodegenerative Disease 


Neurodegenerative diseases are so prevalent. The longer we live, the higher the risk of getting a neurodegenerative disorder. A list of the most common: 

  • Alzheimer’s disease and other memory disorders
  • Parkinsons’ disease
  • Huntington’s disease
  • ALS (Lou Gehrig’s disease)

In Outlive, Dr. Attia talks the most about Alzheimer’s, which is something dear to my heart because my grandmother and mother both died of Alzherimer’s. Certainly, Alzheimer’s and Parkinson’s are the two you think about the most. Is there a cure? NO, and the treatments are not that effective either (especially for Alzheimer’s). Can these diseases be prevented? The answer is YES, if you start early. 

Six million people in the United States have Alzheimer’s. One million have Parkinson’s (it’s probably even more than that). As a matter of fact, Parkinson’s is the fastest growing neurologic disease in our country. I see it all the time. This is why prevention is so important!

Dr. Attia talks about the importance of looking at the ApoE gene. This is something we check on the Cleveland Heart. It’s a risk factor for not only heart disease, but also Dementia and probably Parkinson’s, as well as Alzheimer’s. It’s a marker that you really want to know if you have it, or not. 

Women are more than twice as likely to have Alzheimer’s than men. Men are twice as likely to have Parkinson’s and Lewy Body Dementia than women. Note: if a woman gets Parkinson’s, it progresses much faster. Dr. Attia says one major factor in preventing these neurodegenerative diseases is bioidentical hormones, especially estradiol. As you know, evaluating and replacing your hormones safely is 90% of what we do at Performance Medicine. 

Dr. Attia is big on bioidentical hormone replacement. He talks a lot about the fallacies of the WHI study done many years ago. I’ve talked about this extensively myself. This study turned doctors and patients off of hormone replacement, falsely accusing them of causing breast cancer (which they don’t). As a matter of fact, he calls it the biggest crime of the last century, as far as women’s health goes. 

The theory of amyloid plaque in Dr. Attia’s opinion is wrong. There’s no doubt that the amyloid plaque is there with Alzheimer’s disease, but the plaque is why the Alzeheimer’s drugs don’t work. Dr. Attia, along with Dr. Bredesen (author of The End of Alzheimer’s), thinks that the amyloid plaque is the RESULT of the Alzheimer’s process, not the CAUSE of it. We want to have preventative measures that prevent the plaque from forming in the first place. Note: Tau is a small protein associated with multiple brain diseases. Women have more of the tau protein than men. If tau builds up in Alzheimer’s disease, it can damage brain cells essential for learning and memory. Tau can be very destructive. Very inflammatory. 

Oxidative stress and inflammation play a major role in the changes in the brain that cause Alzheimer’s disease. Reduced blood flow and blood-brain barrier (BBB) dysfunction are early findings in neurodegenerative disorders. Reduced blood flow? Think vascular disease. And a lot of it has to do with abnormal brain glucose metabolism. 

Alzheimer’s has been called Type 3 diabetes for a reason. If you’re a diabetic, you’re much more likely to get Dementia, than if you’re not. To prevent this, you need to think about things that decrease inflammation, oxidative stress, and mitochondrial dysfunction. Things like:

  • Diet.
  • Exercise.
  • Supplements. Especially Omega 3’s.
  • Sleep quality. 
  • Avoiding hearing loss. This leads to early dementia.
  • Avoiding depression and isolation. 
  • Flossing your teeth. He talks a lot about dental health in the book. 
  • Dry sauna. I try to use mine 4 times a week. A dry sauna can reduce your risk of Alzheimer’s by 65%, Dr. Attia says. That’s incredible! It can also reduce risk of cardiovascular disease by 50%. I’m big on dry saunas with a cold shower afterwards.
  • Lowering your homocysteine levels. Very important. People with the methylation mutation (MTHFR) have this inflammatory amino acid. Because a lot of us have this mutation, doctors need to be on the lookout. I check it on every Cleveland panel.
  • Monitoring your Vitamin D levels. This is important for everything healthwise.
  • Monitoring your hormone levels. As you age, you have to consider bioidentical hormone replacement, which is safe in the hands of a healthcare provider that knows what they’re doing. 
  • Emotional Health. Dr. Attia was very open about his struggle to control anger. His experience in rehab gave him time (and space) to work through emotional trauma that had occurred earlier in his life. He emphasizes the value of relationships. Note: I believe strongly that emotional health is vital to your overall health and happiness.

Remember, once these neurodegenerative diseases are diagnosed, it’s very difficult to reverse it, or even slow it down. You need to think about PREVENTION.


Final Thoughts 


Medicine is so far behind. Doctors are practicing from what Medicine was 20-30 years ago and patients deserve better. We need Medicine 3.0! Dr. Attia’s book ,Outlive, the Science and Art of Longevity is full of health wisdom. I highly recommend it to all who are willing to dive deeper into the why’s and how’s of their long-term health. 

If you are ready to take action, Performance Medicine is here for you. Come in and get a Cleveland Heart Panel so we can sort out your health and get you started on a journey to live better longer. Let’s live our lives like we are training for a marathon at age 100. 

Till next week.