It’s almost hard to believe, but in the 1950s doctors were frequently portrayed in TV commercials for cigarettes. Back then, smoking wasn’t just seen as cool and glamorous—it was positively health-enhancing
Fast-forward to today, and Americans have been sold on a dizzying number of health trends: from grapefruit diets and Weight Watchers to Pelotons and Pilates. The health industry churns through information and fads faster than anyone can possibly keep up. As soon as you’re gearing up to start a juice cleanse or go on a Costco rampage for keto-friendly ingredients, a new diet, a new drug, or a new piece of equipment shows up promising to be the real key to your health.
One person who consistently cuts through all that noise is Dr. Peter Attia. His new book, Outlive: The Science & Art of Longevity, is a blueprint—based on the best available science and data—for what really matters to live a healthy life, and a longer one.
Attia is a Stanford- and Johns Hopkins-educated, NIH-trained physician who is at the forefront of some of the most important conversations around health and longevity in medicine today. His work is at the center of a new industry that has been booming in Silicon Valley for the past several years. Tech giants like Jeff Bezos, Peter Thiel, Sam Altman, Larry Page, and Brian Armstrong have poured billions into start-ups that research human life extension.
But Attia doesn’t think longevity should be the purview of the wealthy. He says there are so many everyday changes—from how we eat, move, and sleep, to our emotional health—that can add years to all of our lives.
I spoke to Attia about the major factors preventing us from living longer, healthier lives, emotional health, and about the question that underlies this whole subject: what does the good life look like?
Listen to the whole conversation here, or read an excerpt from our chat below. — BW
On the “average American”:
BW: Peter, a lot of us have a sense that Americans are just way less healthy than people in other countries. And this is true by so many different measurements, right? We’re the 11th wealthiest country in the world, but we’re rated number 35 in terms of our overall health. Over a third of people in this country are considered obese, which is an incredible statistic. Roughly 60 percent of Americans live with a chronic health condition, and when compared to other peer nations, we have the highest rate of avoidable or preventable deaths. That’s just the tip of the iceberg. However, I think the simplest way to measure overall health is just to look at life expectancy, and we don’t perform well there, either. In fact, the United States ranks at number 51. The average life expectancy in America is around 77 years old. In Japan, where life expectancy is the highest, it’s almost 85 years old. And there are 50 other countries between us and Japan. So, Peter, explain it to me: why are Americans living shorter lives, and less healthy lives, than billions of other people in the world?
PA: First of all, the derivative is probably more troubling than everything you’ve said. In other words, it’s not just that our life expectancy is 77 years, it’s that it’s 77 and falling. I think we’re now standing in the third year of declining life expectancy in the United States. Now, part of that can be attributed to Covid, except that Covid sort of affected everybody in the world, although you could argue it disproportionately affected, at least in developed nations, the United States, because of its impact on those with a chronic condition, which you’ve already alluded to. But secondly, you have these deaths of despair, and that’s really where the United States is getting hammered in the life expectancy data. Last year was the first year we surpassed 100,000 deaths due to accidental overdose—virtually all of those due to opioids—and when you compare all deaths of despair, which includes everything from alcohol-related death, acute alcohol toxicity to chronic liver failure, to auto fatalities, to opioid poisoning and suicide, the rate at which those deaths of despair are increasing is about 20 percent per year. I don’t know that that’s a uniquely American situation, but I think we would score very high relative to the rest of the world. Now, as it pertains to some of these other things, there are obvious explanations in some regard. I’m sure you’ve spent time in Europe and you probably appreciate that when you’re in Europe, you live a very different life to the life you would live in the U.S. When you’re there, you’re walking much more. You’re typically cooking much more. You’re buying groceries in smaller amounts. There is less processed food, and there’s just no doubt that those things play an enormous role.
BW: And you’re working less, or at least the people that live there are working less than Americans, on average.
PA: Yes. When I contrast my life and the life of everybody I know here with all of my friends who live abroad, there is a difference in the level of societal stress. Part of that, as you said, is perhaps magnified through how much we work. But I think it goes deeper than that.
On Medicine 2.0 and our broken healthcare system:
BW: Let’s dive into the specific things you think are preventing us from living our longest and healthiest lives. Let’s start with the big picture, which is our healthcare system. You begin your book by describing a recurring dream you had while you were in med school at Johns Hopkins. Tell us a little bit about that dream.
PA: That was actually in residency. I slept much better in med school, but the dream was basically that I was trying to catch eggs that were being dropped from a roof three or four stories up. I had a padded basket, so as long as the egg would hit the basket, I was fine. But invariably the eggs would come down at too great a frequency, or I simply couldn’t get to them in time. Invariably, they would hit the ground. And this was kind of a frustrating and weird dream, which had obvious implications. I didn’t put two and two together until many years later, when I looked back and realized exactly what it meant. Frankly, I was surprised that the answer wasn’t obvious to me. In other words, the way out of this miserable dream wasn’t clear.
BW: Well, I don’t want to steal the punchline, but what was the conclusion of the dream?
PA: I’m sure anybody listening already knows it without stating it, which is you have to go up to the rooftop and basically take the eggs away from the guy who’s tossing them over the edge.
BW: So rather than focusing on catching the eggs at the bottom with the padded basket, you have to stop the guy who’s throwing them off. The problem is that it seems to me like the guy throwing the eggs off the top of the building is like the entire structure of our healthcare system. So, I hope this isn’t too broad a question, but why is our healthcare system so reactionary?
PA: I think there are many problems with our healthcare system. The first is that risk ownership is broken. There is no incentive on the part of a payer who has a relatively short window in which they own your life, i.e., own your risk, to do anything for prevention. For example, let’s say you’re 25 and you have type 2 diabetes, high blood pressure, bad lipids, anything like that—none of that is going to matter in the next ten years. There is nothing you can do. You could smoke. You can do whatever you want. By the time you’re 35, you’re still fine. Well, the portability of health insurance is such that if I’m your carrier, or your employer for that matter, because remember, you’re either covered by your employer or you’re covered by a carrier—they’re not going to be around in 40 years when the consequences of that come to bear. So that creates an enormous perverse incentive, which is “How little can I spend now, because all I care about is right now.” So that’s a big part of it. Now, that’s a slightly U.S.-specific example, and I think in some ways, we are a victim to the amazing success of what I describe as “Medicine 2.0” in the book.
BW: Let’s talk about Medicine 2.0.
PA: Medicine 2.0 was such a remarkable success story for our species. It catapulted us out of misery in the late nineteenth century and early twentieth century by finally coming up with a way to treat and nearly eradicate infectious diseases. Communicable diseases and trauma is an all but guaranteed cause of death. If you think about it, Bari, in the span of 50 years, we doubled human life expectancy. From an evolutionary perspective, that’s unprecedented, unheralded, and remains the most remarkable achievement of human civilization. And the playbook for Medicine 2.0, which was largely based on treating infections, was to treat the problem when it shows up, for the most part. This became the piece that got more ingrained than the other part, which was we could vaccinate against polio and make it go away too. That’s the preventive piece. But the real piece was we treat, we treat, we treat. For example, we come up with a diagnosis. We put a number on it. We can bill for it. We have a drug for it, and away it goes! It turns out that playbook has reached its capacity and it’s not working for chronic diseases.
BW: You write in the book about how there are two broad ways to die: the short way and the long way. Our current medical system, which you called Medicine 2.0, is very good at stopping the short way, like a bad infection, saving someone who’s bleeding out after a shooting, things that are acute sudden emergencies. However, this system is extremely bad at saving people who are suffering from the long way of dying, like from cancer, from diabetes, from heart disease, from neurodegenerative diseases, and chronic illnesses. Why is it that we’ve become so good at solving these short, sudden, potential deaths, but continue to fall so short when it comes to these long, chronic health issues?
PA: I think it’s just kind of an extension of what we talked about a second ago, which is there isn’t much you can really do in advance to prevent these fast deaths. Like if you get pneumonia, there’s no value in me giving you an antibiotic ten years before I think you’re going to get pneumonia. I kind of have to wait until you get pneumonia and then give you the antibiotic. Similarly, if you’re giving birth as a mother, there’s nothing I can really do nine months in advance of that. If you think about maternal and infant mortality, what it was like 200 years ago, it was insane. But once we had procedures, antibiotics, blood, all sorts of things to help reduce that to near zero, those things were instituted only at the moment of crisis or shortly before. The same is true with trauma, right? What we can do for people who are stabbed, shot at, in a car accident is remarkable, but there’s not a lot we’re doing ahead of time to prep for that. Unfortunately, the nature of those other diseases you mentioned—cardiovascular disease, type 2 diabetes, Alzheimer’s disease—those account for 80 percent or 90 percent of deaths today. Those diseases take decades. They move at such a glacial pace that even when a person dies suddenly of a heart attack—which we hear that story all the time: “This guy was completely fine and at 65, he just dropped dead.” I can promise you, if you looked at his coronary arteries for the last 30 years, this was developing.
On emotional health and resolving trauma:
BW: The last chapter of your book is devoted to the subject of what you call “emotional health.” Even though it’s the shortest section of the book, it was my favorite because it said this: “For all of these years I, Peter Attia, was taking a kind of Silicon Valley approach to longevity.” You were like this perfect humanoid trying to live until 120 and thought shorter lives were like an engineering problem that, with enough fine-tuning and science, could be solved. But it took many years, and two inpatient stays, and a lot of personal pain to realize, What good is it to live longer if you’re really unhappy? Talk to me about coming to that realization.
PA: It was a remarkable discordance between internal and external, between how I appeared and how I functioned at a superficial level, and how I felt and how I functioned internally or with those closest to me. Unfortunately, I was not able to fix this problem before it got so bad that it began to really hurt people around me, most notably my family. In 2017, I was really not left with much of a choice anymore. I effectively had no choice but to go and get treatment.
BW: And when you say treatment, most people hear that and they think, Is Peter a secret heroin addict or an alcoholic? But you were neither of those things. What do you mean when you say treatment?
PA: I ended up going to a place that deals with trauma. It was a facility for understanding how trauma leads to maladaptive behaviors. As you pointed out, when we think of that, we think of drug addictions or gambling addictions or alcohol addictions or sex addictions. But those weren’t my addictions. My addictions were much more socially acceptable, namely workaholism and perfectionism. It was sort of bathed in a constant state of anger, a simmering rage that just could not go away. And again, I got pretty far in life. I got to 45 because the perfectionism and workaholism had produced good results, and most people didn’t see this simmering rage that came along with it, and the detachment, the selfishness, the lack of connectivity and all of the interpersonal pain that I was basically giving to everyone in my wake. At that point, my selfishness in my behavior was escalating to a point where my wife couldn’t take it anymore. My closest friend, who I write about in the book, a guy named Paul Conti, who’s a psychiatrist, basically said, “Look, I don’t think you have a choice anymore. I think you have to go and confront your past.”
On prioritizing longevity versus quality of life:
BW: There’s a man that you quote often in the book, Terrence Real, who wrote the book, I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression, and this topic, I think, is really important and really, really under-discussed. While women are twice as likely to be diagnosed with depression as men, male deaths represent almost 80 percent of suicides. Deaths of despair, the idea that we’ve already referenced in this conversation, is something that disproportionately plagues Americans. We had a writer called Jeff Bloodworth who wrote this beautifully moving essay for us recently in a piece called “My Best Friend Died from Loneliness,” and he was reporting that white, working-class men are committing suicide at alarmingly higher rates than other demographics. Why is this happening?
PA: I think historically, men are far less likely to seek help. Help might mean professional help, but help might just mean talking to their friends. I think back to my adolescence, to being in college, being in med school, and just all the periods in my life when I was sort of struggling, it never occurred to me to talk to anybody about it. Even when I was married, it’s not like I would talk about this stuff with my wife. So she’s watching this behavior, she’s watching this person spiraling out of control, but it would just never occur to me to talk to somebody. I do think that that might be a fundamental difference in socialization between men and women, and I think men are probably paying a greater price for that.
BW: We started this conversation by me asking you why some people live longer than others, and I want to end it by asking: Should people want to live a long life? What would make a long life worth living? And are we sometimes, or some people, obsessed with longevity for the wrong reasons?
PA: When I started this book back in 2016, it was really a book about how not to die. And when I ended this book, it was a totally different book. It was a book, I hope, about how to live. It goes back to one of the questions that psychotherapist Esther Perel proposed to me, which I referenced twice in the book, which is what is the purpose of living longer if the quality of your life is piss-poor? And she was referring to it in terms of the quality of your relationships, both with others and yourself. So, to answer your question, should people want to live longer? I think it depends on what they can do with that time. If the answer is “I want to live longer so I can sit and suffer in misery,” then I don’t think the answer is yes. If the answer is “I want to live ten years more so that I can get to know my grandchildren more, play a bigger role in their lives, and be a mentor to more people and do more good in the world,” then I think the answer should be yes.
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