summarize this "Several years ago, I flew to San Francisco to attend the funeral of
the mother of a good friend from college, whom I’ll call Becky. Because
Becky’s parents lived near Palo Alto, where I went to medical school, they
invited me to dinner many times. We often ate in their garden, which had
been beautifully planned and meticulously maintained by Becky’s mother,
whose name was Sophie.
I remembered Sophie as a vibrant, athletic woman who had seemed
ageless. But I hadn’t seen her since my wedding nearly fifteen years earlier.
Becky filled me in on what I had missed. Beginning in her early seventies,
Sophie had undergone a steep physical decline that began when she slipped
and fell while gardening, tearing a muscle in her shoulder. That soon
escalated into back and neck pain so severe that she could no longer work in
the garden or play golf at all, her two primary passions in retirement. She
simply sat around the house, feeling depressed. This was followed by a
descent into dementia in the last couple of years of her life, before she died
of a respiratory infection at age eighty-three.
At her memorial service, everyone agreed that it was a “blessing” that
Sophie hadn’t had to linger in that demented state for very long, but as I sat in
the pew, I reflected on the fact that she had spent the last decade of her life
being unable to participate in any of the activities that had given her pleasure.
Instead, she had been in considerable pain. Nobody mentioned that. We were
gathered to mourn Sophie’s biological death, but it saddened me even more
deeply that she had been robbed of the joy of her final years.
I often talk about Sophie with my patients, not because her tale is unusual
but because it is so sadly typical. We have all watched our parents,
grandparents, spouses, or friends undergo similar ordeals. The sad thing is
that we almost expect this to happen to our elders; and even with this
knowledge, relatively few of us take measures that might help ourselves avoid
that fate. Even for Becky, who had cared for her mother during her difficult
final years, the idea that she might end up in the same condition was probably
the furthest thing from her mind. The future, for most of us, remains a hazy
abstraction.
I tell Sophie’s story to help illustrate a fundamental concept in my
approach to longevity, which is the need to think about and plan for the later
decades of our lives—our seventies, eighties, nineties, or beyond. For many
people, like Sophie, the last ten years of life are not a particularly happy time.
They typically suffer from one or more of the Horsemen diseases and the
effects of the requisite treatments. Their cognitive and physical abilities may
be weakening or gone. Generally, they are unable to participate in the
activities they once loved, whether that means gardening, or playing chess, or
riding a bicycle, or whatever else in their life gave them joy. I call this the
Marginal Decade, and for many, if not most, it is a period of diminishment
and limitation.
I ask all my patients to sketch out an alternative future for themselves.
What do you want to be doing in your later decades? What is your plan for
the rest of your life?
Everyone has a slightly different answer—they might want to travel, or
continue playing golf or hiking in nature, or simply be able to play with their
grandkids and great-grandkids (top of my own list). The point of this exercise
is twofold. First, it forces people to focus on their own endgame, which most
of us might prefer to avoid thinking about. Economists call this “hyperbolic
discounting,” the natural tendency for people to choose immediate
gratification over potential future gains, especially if those gains entail hard
work. Second, it drives home the importance of healthspan. If Becky wants to
enjoy a healthy, rewarding life in her later years, and not repeat her mother’s
fate, she will have to maintain and hopefully improve her physical and
cognitive function every decade between now and then. Otherwise, the
gravitational pull of aging will do its thing, and she will decline, just as her
mother did.
Because I am a math guy, I like to visualize lifespan and healthspan in
terms of a mathematical function, as in figure 2 on the following page—one
of many graphs that I draw for my patients. The horizontal or x-axis of the
graph represents your lifespan, how long you will live, while the vertical or yaxis represents a kind of sum total of your physical and cognitive function,
the two age-dependent dimensions of healthspan. (Obviously, healthspan is
not really quantifiable, but bear with my oversimplification.)
The black line represents the natural trajectory of your life: You are born
at time zero, and for purposes of our diagram, we’ll say your physical and
cognitive health start out at 100 percent. You remain relatively robust until
about the fifth decade of life, at which point your cognitive and physical
health will likely begin a gradual but steady decline, until you die (healthspan
= zero) sometime in your sixties or early seventies. This would have been a
not untypical lifespan for someone born into a hunter-gatherer or primitive
agrarian tribe, provided they managed to avoid early death thanks to
infectious disease or another calamity.
Now look at the typical modern life course, represented by the shortdashed line on the graph, marked “Med 2.0.” You will live a bit longer,
thanks to the relative comfort and safety of our lives. But in midlife, you will
gradually begin to feel some changes. You will lose a bit of your youthful
strength and stamina. You might notice that you occasionally forget
passwords, or the names of people you meet, or the names of actors in
movies you watched long ago. Your friends and peers will begin to be
diagnosed with cancer, cardiovascular disease and related conditions like high
blood pressure, and diabetes or prediabetes. You will attend memorial
services for friends from school.
At a certain point, the decline begins to steepen. Eventually, sometime
around age seventy or seventy-five, give or take, your cognitive and physical
capacities will diminish to roughly their halfway point (represented by the
horizontal dotted line), which I sort of arbitrarily define as the point below
which you are no longer able to do the things that you want to do with ease.
You’re constrained, and bad stuff starts to happen more frequently and with
greater consequence. It’s one thing to break your femur in a skiing accident
when you’re forty and still strong and resilient; it’s quite another to break it
falling off a curb when you’re seventy-five and functioning at 25 percent of
your capacity. At the same time, your own risk of chronic disease is rising
exponentially.
This is where Medicine 2.0 steps in. We treat your heart disease, or
cancer, or whatever else afflicts you, prolonging your life by a few months, or
years if you’re lucky. This is when the lifespan/healthspan curve flattens out
horizontally to the right, representing this postponement of death. But now
look at where this occurs: when your healthspan is already compromised.
This means that we have delayed your death without significantly improving
your quality of life—something at which Medicine 2.0 is quite adept. This is
the Marginal Decade that most of us can expect, in our current system.
Now look at the long-dashed line on the graph. This represents your ideal
trajectory. This is what you want. Instead of beginning a slow decline in
midlife, your overall healthspan stays the same or even improves into your
fifties and beyond. You will be fitter and healthier at fifty-five and even sixtyfive than you were at forty-five and will remain physically fit and cognitively
sharp well into your seventies and eighties, and possibly beyond. You will
seem like someone a decade younger than the age on your passport, or
possibly two. There is much more space under this curve, and all that space
represents your longer, better life: more time being with your family,
pursuing your passions, traveling, or continuing to do meaningful work.
Moreover, when you do begin to decline, the descent is steep but relatively
brief. This is called squaring the longevity curve.
In this scenario, we live longer, and we live better for longer. We outlive
our life expectancy, and we also exceed society’s expectations of what our
later life is supposed to look like. Instead of a lousy Marginal Decade, we get
to enjoy what feels more like a “Bonus Decade”—or decades—when we are
thriving in every dimension. This is our objective: to delay death, and to get
the most out of our extra years. The rest of our lives becomes a time to relish
rather than to dread.
—
The next obvious question is: How do we accomplish this? How do we
lengthen our lifespan while simultaneously extending our healthspan? How do
we stave off death via the Horsemen while slowing or even reversing physical,
cognitive, and emotional decline?
What’s our plan?
This is where most people make a wrong turn. They want to take a
shortcut, right to the tactics: this is what to eat (and not eat), that is how you
should exercise, these are the supplements or medications you need, and so
on. There are warehouses full of books that purport to have the answers, but
the one you are reading now is not one of them. Instead, I believe this is
exactly where we need to hit pause and take a step back, lest we skip the most
important step in the process: the strategy.
Take another look at the Sun Tzu quote that opens this chapter: “Tactics
without strategy is the noise before defeat.” He was talking about war, but it
applies here as well. To achieve our objectives, we first need to have a
strategy: an overall approach, a conceptual scaffolding or mental model that is
informed by science, is tailored to our goals, and gives us options. Our
specific tactics flow from our strategy, and the strategy derives from our
objective. We know what the objective is by now, but the strategy is the key
to victory.
The big mistake people often make is to conflate strategy and tactics,
thinking they are the same. They are not. I like to explain this distinction
using one of the more memorable boxing matches of all time: Muhammad
Ali versus George Foreman, the famed “Rumble in the Jungle” that took
place in Kinshasa, Zaire, in 1974. Ali’s objective, obviously, was to win the
match against Foreman and regain his heavyweight title. The problem Ali
faced was that Foreman was younger, stronger, meaner, and favored to win in
devastating fashion. It’s hard to reconcile with the jovial guy who sells
countertop grills now, but back in the day George Foreman was considered
the meanest SOB who ever laced on boxing gloves. He was viewed as literally
invincible. The pundits all agreed that colorful and beloved as he was, Ali
didn’t stand a chance—which is why he needed a strategy.
Ali knew he had certain slight advantages over Foreman in that he was
faster, more experienced, and mentally tougher. He also knew that Foreman
was hotheaded and prone to anger. Rather than try to counter Foreman punch
for punch, Ali decided that he would attempt to induce the younger, less
seasoned fighter to wear himself out, leaving him frustrated and tired, and
thus vulnerable. If he could accomplish that, he knew it would be a more even
match. This was his strategy: make Foreman angry, and then let him flail
away until he had exhausted himself and Ali could mount an offensive.
From this strategy flowed the tactics that are now legendary: first, come at
Foreman with a series of lead straight rights, an obvious, even disrespectful
punch that was guaranteed to make Foreman mad. Nobody hits the
heavyweight champion of the world like that. Ali then let an enraged
Foreman chase him around the ring and press him up against the ropes,
wasting energy, while he concentrated on trying to minimize the damage he
absorbed—the famous “rope-a-dope.”
For the first few rounds, everyone thought Foreman was absolutely
crushing Ali, including Foreman. But because Ali’s strategy was to try to
outlast Foreman, he had trained himself to endure the abuse. By about the
fifth round, you can almost see Foreman realizing, Damn, I’m already gassed.
Meanwhile, Ali’s superior physical conditioning meant he had much more left
in the tank. He went on to win the match via a knockout in the eighth round.
The point is that the tactics are what you do when you are actually in the
ring. The strategy is the harder part, because it requires careful study of one’s
opponent, identifying his strengths and weaknesses, and figuring out how to
use both to your advantage, well before actually stepping in the ring. In this
book, we will apply this three-part approach to longevity: objective →
strategy → tactics."