summarize this "Going into the fight with Foreman, Ali knew that time was on his side. The
longer he could keep his opponent riled up and wasting energy, while
avoiding getting knocked out himself, the better his chances of winning in the
long run. Unfortunately for us, time is definitely not on our side. Every
moment we are alive, our risk of disease and death is tugging at us, the way
gravity pulls a long jumper toward earth.
Of course, not every problem you face requires a strategy. In fact, many
don’t. You don’t need a strategy if your objective is, say, to avoid getting a
sunburn. Your straightforward tactical options are to put on sunblock, long
sleeves and pants, and perhaps a big hat, or to stay out of the sun altogether.
But we need a strategy in order to live longer and better, because longevity is
a far more complex problem than sunburn.
[*1]
Living longer means delaying death from all four of the Horsemen. The
Horsemen do have one powerful risk factor in common, and that is age. As
you grow older, the risk grows exponentially that one or more of these
diseases has begun to take hold in your body. Unfortunately, there’s not much
we can do about our chronological age—but what do we mean by “aging,”
exactly? It’s not merely the passage of time, but what is happening inside us,
beneath the surface, in our organs and our cells, as time passes. Entropy is
working on us every single day.
“Aging is characterized by a progressive loss of physiological integrity,
leading to impaired function and increased vulnerability to death,” wrote the
authors of an influential 2013 paper describing what they termed the
“hallmarks of aging.” They continued: “This deterioration is the primary risk
factor for major human pathologies, including cancer, diabetes,
cardiovascular disorders, and neurodegenerative diseases.”
The very process of aging itself is what makes us vulnerable to these
diseases, while also affecting our healthspan. Someone who drops dead of a
heart attack did not just get sick an hour earlier. The disease was working
inside them, silently and invisibly, for decades. As they grew older, their own
internal defense mechanisms weakened, and disease gained the upper hand.
We saw something similar in the COVID-19 pandemic. The virus infected
people across all age groups, but it killed older people in vastly
disproportionate numbers, precisely because it exposed and exploited their
existing vulnerability to disease and death: their weakened immune systems,
their cardiovascular and respiratory issues, and so on. Thus, our strategy must
account for the effects of aging, just as Ali took his own advancing years into
account as he searched for a way to defeat Foreman. Without the right
strategy, Ali would have almost certainly lost the fight.
This is why we can’t just skip ahead to the tactics, where I tell you what to
do. If you are tempted, my advice is to pause, take a breath, and settle in.
Without an understanding of the strategy, and the science that informs it, our
tactics will not mean much, and you’ll forever ride the merry-go-round of fad
diets and trendy workouts and miracle supplements. You’ll be stuck in a
Medicine 2.0 mentality, seeking a quick fix to your problems. The only way
to become an adroit tactician is to shift your mindset to Medicine 3.0, which
requires becoming a master strategist first.
In the chapters to come, we will be taking a deep dive into some of the
mechanisms underlying the aging process, and we will also be taking a very
close look at the inner workings of each of the Horsemen diseases. How and
when do they begin? What forces drive them—internal and external? How
are they sustained? Most importantly, how can they be delayed or even
prevented entirely? As we’ll see in the next chapter, this is how the
centenarians achieve their extraordinarily long lifespans: they delay or prevent
the onset of chronic disease, by decades compared to the average.
We will also be taking a more detailed look at healthspan—another one of
those overused buzzwords that has lost all meaning. The standard definition,
as the period of life when we are free from disease and disability, sets far too
low of a bar. If we’re not sick and housebound, then we’re “healthy”? I prefer
to use more pointed language—so pointed that it often makes my patients
uncomfortable.
Here’s another way to think of it. Lifespan deals with death, which is
binary: you’re alive, and then you’re dead. It’s final. But before that happens,
sometimes long before, most people suffer through a period of decline that, I
would argue, is like dying in slow motion. Certainly, that was the case for
Sophie, Becky’s mom. This can happen quickly, such as after a bad accident,
but usually it goes so slowly that we barely perceive the change.
I think about healthspan and its deterioration in terms of three categories,
or vectors. The first vector of deterioration is cognitive decline. Our
processing speed slows down. We can’t solve complex problems with the
quickness and ease that we once did. Our memory begins to fade. Our
executive function is less reliable. Our personality changes, and if it goes on
for long enough, even our sentient self is lost. Fortunately, most people don’t
progress all the way to frank dementia, but many people experience some
decline in their cognitive capacity as they age. Our objective is to minimize
this.
The second vector of deterioration is the decline and eventual loss of
function of our physical body. This may precede or follow cognitive decline;
there is no predetermined order. But as we grow older, frailty stalks us. We
lose muscle mass and strength, along with bone density, stamina, stability,
and balance, until it becomes almost impossible to carry a bag of groceries
into the house. Chronic pains prevent us from doing things we once did with
ease. At the same time, the inexorable progression of atherosclerotic disease
might leave us gasping for breath when we walk to the end of the driveway to
fetch the newspaper (if newspapers still exist when we are old). Or we could
be living a relatively active and healthy life until we fall or suffer some
unexpected injury, as Sophie did, that tips us into a downward spiral from
which we never recover.
My patients rarely expect this decline to affect them. I ask them to be very
specific about their ideal future. What do they want to be doing when they are
older? It’s striking how rosy their predictions tend to be. They feel supremely
confident that they will still be snowboarding or kickboxing, or whatever else
it is they enjoy doing now, when they’re in their seventies and eighties.
Then I stop them and explain: Look, in order to do that, you will need to
have a certain level of muscular strength and aerobic fitness at that age. But
even right now, at age fifty-two (for example), your strength and your
maximum volume of oxygen uptake (VO2 max) are already barely sufficient
to do those things, and they are virtually certain to decline from here. So your
choices are (a) surrender to the decline, or (b) come up with a plan, starting
now.
No matter how ambitious your goals are for your later years, I suggest that
you familiarize yourself with something called the “activities of daily living,”
a checklist used to assess the health and functionality of elderly people. The
list includes such basic tasks as preparing a meal for oneself, walking without
assistance, bathing and grooming, using a phone, going to the grocery store,
handling personal finances, and so on. Now imagine living your life without
the ability to feed or bathe yourself or walk a few blocks to meet friends for
coffee. We take these for granted now, but to continue to live actively as we
age, retaining even these minimal abilities, requires us to begin building a
foundation of fitness and to maintain it diligently.
The third and final category of deterioration, I believe, has to do with
emotional health. Unlike the others, this one is largely independent of age; it
can afflict outwardly healthy young people in their twenties, or it can creep up
on you in middle age, as it did with me. Or it can descend later in life.
Surveys show that happiness tends to reach its nadir in our forties (age fortyseven, to be exact), but as I learned through painful experience, middle-aged
distress often has its roots much earlier, in adolescence or childhood. And we
may not recognize that we are in danger until we reach a crisis point, as I did.
How we deal with it has a huge bearing on our physical health, our happiness,
and our very survival.
To me, longevity as a concept is really only meaningful to the extent that
we are defying or avoiding all these vectors of decline, simultaneously. And
none of these individual components of longevity is worth much without all
the others. To live to the age of one hundred without our mind and our body
intact is not something that anyone would willingly choose. Similarly, to have
the greatest quality of life, only to have it cut short at a young age, is also
undesirable. And to retain good health as we age, but without love and
friendship and purpose, is a purgatory I would not wish on my worst enemy.
The important distinction here is that while actual death is inevitable, this
deterioration that we’re talking about is less so. Not everyone who dies in
their eighties or nineties passes through the valleys of cognitive, physical, or
emotional destruction on the way there. They are preventable—and I believe
that they are largely optional, despite their ever-increasing gravitational pull
over time. As we will see in later chapters, cognitive, physical, and even
emotional deterioration can all be slowed and even reversed in some cases
with the application of the proper tactics.
The other key point is that lifespan and healthspan are not independent
variables; they are tightly intertwined. If you increase your muscle strength
and improve your cardiorespiratory fitness, you have also reduced your risk of
dying from all causes by a far greater magnitude than you could achieve by
taking any cocktail of medications. The same goes for better cognitive and
emotional health. The actions we take to improve our healthspan will almost
always result in a longer lifespan. This is why our tactics are largely aimed at
improving healthspan first; the lifespan benefits will follow.
Tactics
The key difference between Medicine 2.0 and Medicine 3.0 has to do with
how and when we apply our tactics. Typically, Medicine 2.0 steps in only
when something is acutely wrong, like an infection or a broken bone, with
short-term fixes for the immediate problem. In Medicine 3.0, our tactics must
become interwoven into our daily lives. We eat, breathe, and sleep them—
literally.
Medicine 2.0 relies on two types of tactics, broadly speaking: procedures
(e.g., surgery) and medications. Our tactics in Medicine 3.0 fall into five
broad domains: exercise, nutrition, sleep, emotional health, and exogenous
molecules, meaning drugs, hormones, or supplements. I will not be talking
much about molecules, because that would make this book twice as long as it
already is, but one thing that I will say is that I do not shy away from
pharmaceutical drugs because they are not “natural.” I consider many drugs
and supplements, including lipid-lowering medications, to be essential items
in our longevity tool kit, and I hope that in the not-too-distant future we will
have many even more effective tools at our disposal.
Drugs and supplements aside, our first tactical domain is exercise. Like
“healthspan,” exercise is another one of those overly broad blanket terms that
annoy me, because it can encompass everything from a walk in the park to a
hard bike ride up a mountain pass, a set of tennis, or a session in the gym
lifting heavy weights. These all count as “exercise,” but they obviously have
very different effects (and risks, by the way). So we will break down this thing
called exercise into its most important components: strength, stability, aerobic
efficiency, and peak aerobic capacity. Increasing your limits in each of these
areas is necessary if you are hoping to reach your limit of lifespan and
healthspan. Again, my goal is not to tell you how to lose weight fast or
improve the aesthetic quality of your midsection. We want to maintain
physical strength, stamina, stability across a broad range of movements, while
remaining free from pain and disability.
This is another area where my thinking has changed over time. I used to
prioritize nutrition over everything else, but 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. We also tend to feel better when we exercise, so it probably has
some harder-to-measure effect on emotional health as well. My hope is that
you will understand not only the how but the why of various types of exercise,
so you will be able to formulate a program that fits your own personal goals.
Our second domain is nutrition. I won’t be telling you to eat this, not that,
or prescribing a specific diet that everyone should follow, and I’m definitely
not taking sides in the pointless, never-ending diet wars pitting low carb
versus paleo versus vegan, and so on. We will avoid such religious discussions
in favor of biochemical evidence. The best science out there says that what
you eat matters, but the first-order term is how much you eat: how many
calories you take into your body.
How you go about achieving the Goldilocks zone here—not too much, not
too little, but just right—will vary depending on numerous factors. My goal is
to enable you to determine the best eating pattern for yourself. But please
keep in mind that none of the tactics we will discuss are set in stone; we seek
feedback from as many sources as possible to try to determine what works
and what doesn’t. A good strategy allows us to adopt new tactics and discard
old ones in service of our objectives.
Next is sleep, which I and many others had ignored for far too long.
Fortunately, over the past decade or so sleep has finally received the attention
it deserves. Today, we have a far better understanding of its importance, and
what goes wrong in the short and long term when our sleep is compromised
(spoiler: a lot). There is not much that can compare to the feeling of waking
up from a great night of sleep, feeling completely refreshed and totally
primed for the day. Good sleep is critical to our innate physiological repair
processes, especially in the brain, while poor sleep triggers a cascade of
negative downstream consequences, from insulin resistance to cognitive
decline, as well as mental health issues. I too used to be one of those people
who enjoyed pulling all-nighters and thought sleep was for people who had
nothing better to do. Long story short, I found out how wrong I was in very
dramatic fashion. I am now convinced that Not-Thin Peter’s biggest problem
was less what he ate than how little he slept.
Finally, we will explore the importance of emotional health, which I
believe is every bit as important a component of healthspan as the others.
This is an area in which I have very little professional expertise but a great
deal of personal experience. So while I do not have much hard experimental
data and studies to point to, as in the other chapters, I will be sharing my own
very long and painful journey to come to terms with things that happened to
me in the past and to correct my own behavior and heal the relationships that
I have damaged. If nothing else, it may serve as a cautionary tale—and a prod
to get you to consider the state of your own emotional house, if warranted.
I will discuss my journey in much more detail in chapter 17, but one
phrase from that period has stuck with me, almost like a mantra. It is
something that one of my therapists, Esther Perel, said to me early in our
work together.
“Isn’t it ironic that your entire professional life is predicated around trying
to make people live longer,” she mused, “yet you’re putting no energy into
being less miserable, into suffering less emotionally?”
She continued: “Why would you want to live longer if you’re so
unhappy?”
Her logic was undeniable, and it changed my whole approach to longevity."