Important Insights from Outlive by Peter Attia
Heart Good, Brain Good
I’ve just read Dr Peter Attia’s book, Outlive: The Science & Art of Longevity. For me, there were a few essential takeaways that have already changed my behavior and approach. I’ll start with the main one.
One cannot have good brain health without also having good cardio-metabolic health
I’ve always hated cardio. As someone who grew up ice skating and skiing at great speeds with thrilling levels of yaw, camaraderie, competition and more, I’ve found the prospect of walking or jogging or tread-milling and stair-climbing utterly boring and un-engaging.
I told myself I didn’t really need that kind of exercise because when I did strength training or mountain bike riding or whatever else, I always included bursts of very high-intensity exertion.
But those bursts are actually VO2 max training (exercise that improves the amount of oxygen you can uptake in a burst). VO2 max is important, but not sufficient for cardiovascular health.
It seems your brain requires steady-state cardio to achieve certain levels of perfusion and much more.
Related to this, here’s a great video spotlighting Wendy Suzuki. It really drives home the concept.
The high stakes of using or losing your brain & body’s flex-fuel system
When you don’t do any steady-state cardio, your brain and body actually lose the ability to efficiently tap into your own fat reserves for energy. Instead, as you begin to exert yourself, you burn up the glucose in your system, and when that fuel source is gone, you’re exhausted—out of energy.
Actually, it’s worse than merely being out of energy. This inability to run on anything but glucose means you are metabolically unhealthy, and this is one of the first dominos of disease, including insulin resistance (which creates chronic inflammation in your brain and body) and neurodegenerative disease.
Your brain needs to be able to run on fat or glucose, and being sedentary means it rarely if ever runs on fat.
Someone who does steady-state cardio routinely (like walking in a Zone 2 state for at least 3 hours per week, minimum) will tap into their fat stores almost immediately when they begin walking or steadily swimming, etc. Their brains and bodies burn fat or glucose as needed. This greatly improves their metabolic health, cardiovascular health, and brain health.
If a hybrid car only ever ran on the gas system, the battery health would swiftly deteriorate. And if it only ever ran on electricity, the fuel system would deteriorate. Our biology is way more complicated and nuanced than a hybrid car, but you get the idea. Our health requires using the flex-fuel system—every single day. It’s simply how we’re built and how we’re meant to function.
Sadly, boring-ass cardio training is fundamental and indispensable. The brain is mostly cardiovascular tissue. It’s the primary user of blood and metabolic energy in one’s system.
Attia convinced me that steady-state cardio is as essential as sleep. As with sleep mode, our brains and bodies can only perform certain functions in cardio mode.
So goddammit, I have to start doing cardio—consistently. My initial aim is to do a Zone 2 walk for a minimum of 30 continuous minutes per day, every day. I hope to work up to doing 30 minutes 2x per day. Eventually, it may take more than walking to put me in Zone 2.
Attia considers exercise the single most important intervention or improver of human health. He used to think it was diet, but he now sees exercise as the single most important lever.
Unlike exercise protocols, which are largely similar for most people, he sees diet as totally individual, and he convinced me of that. Being totally individual, the only way to truly know whether your diet is working for you personally is to look closely at things like your blood test results, glucose monitor results, stool and urine testing results, etc.
Heart disease & brain disease are linked, and one has to avoid both to avoid either longterm
Here’s another thing that crystallized for me while reading the book.
Since cardiovascular disease runs in my family, I’ve been afraid of developing it, but I assumed it was a late-in-life thing, and I didn’t fully make the connection between vascular disease of the heart and vascular diseases of the brain, which leads to neuro-degeneration and dementia.
It turns out cardiovascular disease (CVD) begins as early as your teen years, and I should have tested all along for the signs, and followed specific protocols. In the book, Attia talks about going to his doctor in his mid-30s, getting a calcium score that was ‘normal’ and being told he was all good. Knowing what he knows now, he would advise his mid-30s self to take specific immediate actions.
Attia talks about the ways our medical system doesn’t really do prevention or long-term strategic thinking. Heart disease may be the most glaring example of this. Nothing is done until you’ve already developed it or dropped dead. And all the while, atherosclerosis is also compromising your brain health.
So the book has helped me realize that if I want to have a healthy brain for as long as possible, I’ll need to bring heart health into that plan. It’s long past time to schedule my own calcium test, etc.
The Importance of Emotional Health
The chapter about emotional health is one of the most important, in part because it makes the book something more than a Silicon Valley health optimization scheme. I’m sure that chapter will land differently with different people, but it definitely landed for me.
Attia talks about his longstanding issues with becoming enraged, which is something that people often deal with after head trauma of any kind at any age.
In Attia’s case, one of the wellsprings for this rage was the feeling of all-encompassing, profound, and enraging powerlessness—in his childhood. Childhood trauma linked to powerlessness means that any incident of powerlessness, no matter how trivial, can trigger overwhelming rage.
Just today, I overheard someone screaming with the entirety of his being at a stranger simply because he had been preempted at a stop sign. And I thought how powerless he must have been made to feel as a child, and I felt sympathy for him.
The rage that people with head trauma experience is more complex, in part because it can also involve things like a loss of cortical control, but the feeling of being disempowered within your own brain can be profoundly enraging. Yet another insult to the injury.
Attia mentions a couple of specialty clinics where one can go for weeks or months at a time to work through emotional traumas. He also recommends a book for men called I Don’t Want to Talk About It. I’m reading that now.
On a related note, I was recently listening to an interview with Mark Hyman, and he said that when they do a new patient intake at the Ultra Wellness Center, they look at the ACE score (Adverse Childhood Events) and have patients include forms of therapy in their treatment plans because, in his experience, people with high ACE scores won’t heal if they focus entirely on the physical.
So: If want brain good, must have heart good. Cardiovascularly. Emotionally.
Onward.
Brainwave is a newsletter about brain health, a personal blog about my own journey, and an informational resource for people whose symptoms haven’t resolved after a concussion or mTBI. I aim to present this information in a clear and concise way, spelling out what’s backed by science and what remains unknown. Nothing here is meant as a substitute for professional medical advice, diagnosis, or treatment. I am not a physician or a healthcare practitioner of any kind; I’ve had a lot of sports-related head trauma and had to learn this stuff the hard way. If you found this information helpful or know someone who might benefit from it, please share and subscribe to Brainwave.