Outlive by Peter Attia, MD Summarized

I read Outlive, you may not need to. Here is my brief summary.

If you listened to Peter Attia on the Tim Ferriss Show (#661), you have most of what you need to know. If you need to dig into the biological details, then get the book. If you need to do a deeper dive into a specific concern to you, such as cancer or heart health, then read the book. However, if you are like me, mostly healthy, and just want to get some actionable items, then this summary may be enough.

Attia’s core thesis is that exercise is the biggest lever for longevity. I was planning on putting together an outline of his exercise guidance, but the great YouTube channel Productivity Game beat me to it.

Book Summary: Outlive by Productivity Game  (YouTube)

You can access the supporting exercise videos from the book on his site – no password is required.

For heart health, Attia likes the Apolipoprotein B (ApoB) marker more than LDL. I see on Ulta Lab Tests, this test only costs $35. I’ll order one later this year. Whenever the cholesterol topic comes up, comments can get heated. I don’t know what the truth is. I’m just passing this info along.

Attia used to love low-carb ketosis and fasting. Now he promotes high protein and is less enamored with fasting. I questioned this point in an earlier post. Don’t eat a few hours before bed and keep your blood glucose in a safe range. Maybe use a continuous blood glucose monitor for a few weeks to learn what foods can spike your glucose and then avoid those.

Probably the only thing in the book that surprised me was learning about Attia’s issues with anger. His emotional health journey is covered in the final chapter.

One thing I noticed that was missing from this book was a discussion on the longevity benefits of dietary fiber.

For me, I’ll take these actions:

  1. Add the ApoB test to my next blood panel. I suspect it will be fine.
  2. Increase my Zone 2 cardio and then work on my VO2 Max. This should be easier to do outdoors now that the weather is improving in Seattle.
  3. Continue testing if higher protein will improve my DEXA score and recoverability. I should know by winter if this makes any difference.
  4. Incorporate some of the movement exercises he shared on his video page.

Part of me thinks his core thesis that exercise is the biggest lever in longevity is really selection bias. People with high VO2 Max and strength are likely those folks that already lean, have good sleep, have dietary discipline, and are energetic. I explain my position on selection bias in The Problem With Boot Camp Training. Despite my skepticism, I see the end goals of strength and cardio fitness as worthy goals, even if it doesn’t add additional longevity.

This is not a book I’ll be keeping for reference. I’ll be passing my copy along, either to a friend or to the library.



Add yours

  1. My wife is less enamoured with exercise than I am. She certainly doesn’t overthink it like I am prone to do. In her words, I worry so much about living longer and the right type / amount of exercise required to do it, that I may yet die from the stress brought on by the worrying.
    As she rightly said, in a world where there are countless children who do not live to see adulthood, I should consider myself fortunate to have reached so far, and anything else is a bonus.
    Yet Mr Attia, in terms of over thinking and worrying about these things, is like me, but on steroids. I wonder just how much his deep dive into this topic, and his ever changing approach, based on the “latest science” is actually negatively impacting on him in terms of his ultimate goal?

  2. @Stuart – Attia does have a practice and makes an income from people that want their health questions answered. I don’t view that as worrying or overthinking. He pivots when he sees new data. That is a rare trait in health influencers.

  3. Thanks for the review. I actually just started the book today, but have noticed the shift to more protein in some of his recent videos, and admit I have raised my protein intake a.little – ~130 grams/day. Not overly high, but any more is a PITA.

    I agree @Stuart – I waver between tracking, monitoring, planning and a few simple actions that I can just do and forget about.Sometimes I get a little mental over it, and that can’t be good.

  4. MAS,
    Attia may well follow the science, but sometimes the science and real world application don’t always marry up well.
    He went from being an extreme endurance athlete to scaling it back when it was theorised that there was an reverse J curve with too much / too intense cardio and mortality. He still however promoted zone 2 work for between 45 minutes and an hour, which he personally did on an indoor bike trainer or on an incline treadmill. This inspired me to do the same ( I tend to do most of my cardio indoors) and typical me, I worried whether I should do an hour ( Was 45 minutes enough? Would I be missing out if I didn’t put in my that extra 15 minutes per session? Could I get away with 50 minutes? Etc).
    Since then Attia has decided that there is no reverse J curve and has increased his cardio to up to two hours on week days and several hours at a time at weekends. He, I think still partially wears his “performance” hat, despite saying that everything is geared towards longevity. An indication of that was on a Q&A video he did, where someone asked if they could vary cardio machines to relieve boredom. His answer was that yes they could, but performance would suffer / not be as good as a result. If your goal is longevity only…who cares?
    I went the other way. His anal retentive approach to it, I decided was not sustainable. I go no longer than 40 minutes ( that’s including a 5 minute warm up) on a cardio piece, and most often only 35.
    I do believe in the reverse J curve idea between too much cardio and longevity benefits popularised by James O’Keefe and Carl Levie. O’Keefe’s thoughts on keeping it minimal and just then get out and move more seem far more reasonable. If you had to go to the lengths that Attia goes to, hours on an indoor bike, just to see some benefit, in my opinion you would start to question the process. Those extra years would almost be taken up via exercising.
    This is where the 80/20 rule comes into play. You’d get most of the results and the low hanging fruit from 30 minutes of cardio, most days. Attia is clearly after the remaining few percent, but I still wonder if his “obsessive search is misguided.

  5. @Stuart – I suspect you are correct.

    I think he has a selection bias problem, but I’m willing to try some of his ideas while rejecting others.

    My guess is if Attia were advising a patient on how to get taller, he would recommend they play more basketball, because the best basketball players are the tallest. LOL.

  6. MAS,
    When it comes to his exercise for longevity prescriptions, Attia reminds me of one of those authors on sites like T Nation and Men’s Health etc, who write about the benefits of weight training for general health for the normal working man with a family, then who proceed to lay out a program that, in reality an Olympia level bodybuilder might baulk at.

  7. @Stuart – The more I think about, the more I see it.

    If one follows all his exercise recommendations, by definition, they would have to have already been in great health. He can filter out 99% of the population.

    I recall Charles Poliquin wouldn’t take on a new strength client unless they showed him 6 months of training logs first. I’m certain he is a smart fellow, but that act absolutely increased his odds of having success.

  8. Would living an extra, say, five years really matter much in the end? 🙂

  9. Aaron Ashmann

    May 12, 2023 — 6:28 pm

    Jim, yes it would…. we could be at escape velocity for longevity within 40 years. Imagine that the first treatments might allow us to function like a centarnarian and live to 100-110..The next treatments might turn back the clock. 5 years could mean a lot.

  10. Aaron, I see your point. I think Kurzweil has a similar outlook. I guess I personally don’t feel that a longer life is a better life. I’m good with my 77 years +/- a few years. I don’t think I need escape velocity. Of course, I’m not 77 yet. 🙂

  11. I have a single “life rule” that has served me well:
    Always be looking for the point of diminishing returns and when you find it, stop there.

  12. @Grubby, that is a great rule for life applicable across the board, thanks for sharing

  13. Loved the book and certainly learned a lot from it. I will also ask my doctor for additional bloodwork although in the world where insurance rules, some of it may not fly.
    I hate to bring up this example, but certainly there are cases where the the rules don’t apply. My mother in law. She didn’t start going to the doctors until her early 60s, when she had a minor stroke, then another minor stroke. She recovered perfectly with no effort whatsoever. Never exercised in her life. Has been smoking since 18 and still continues to do so at the age of 72. Nothing seems to phase her. She eats very very little so maybe caloric restriction is the only thing she does, and not even on purpose. Her diet is terrible, I found expired food in her fridge on many occasions. She is very thin and hardly has any muscle on her at all. Leads very sedentary lifestyle. So how do you explain that? Probably amazing genes. Her dad just passed away at the age of 96 and her mom is still alive and lives on her own at the age of 94. She is on some blood pressure medications, but again, is able to function, smoke and lead pretty much independent lifestyle as before. So there… some of us have to make an effort, and some are just lucky like that.

  14. @Bunny – I don’t ask doctors for permission to get blood work. I pay out of pocket for whatever tests I desire. I found that I can get a better price than their “covered” price.

    I use Ulta Lab Tests which uses Quest Diagnostics. There are others. Look for discount codes to save even more.

  15. Thanks for the review. Alas, I had already purchased the book, so I will eventually work my way through it. My initial impression is that it provides a lot of scientific background for his ideas, but has fewer specifics than I was expecting in terms of diet and exercise.

    Attia is an interesting guy, and obviously smart. He does have a habit of going all in on a particular intervention, and then abruptly changing direction. That is a good thing, in that he clearly changes his position when given new or compelling information. But it can be disconcerting if you are treating him as a guru who has a proven formula.

    I have mixed feelings about his Zone 2 cardio advice. I am convinced of the overall health value of doing a significant amount of daily/weekly physical activity. But I am skeptical that it has to be prescribed as precisely as he does.

    He personally does most of his Zone 2 on a stationary cycle. In part, I think that is because of his past history as an endurance bicyclist: this is an exercise modality he is comfortable with. Plus, he can exercise at a precise watt output, which allows him to keep is blood lactate level at exactly 2 mmole/liter, which he feels is optimal.

    I guess that is OK, BUT… humans did not evolve while riding bicycles, We evolved by walking and running, a load bearing activity, which is not the case for cycling. Cyclists are known to develop problems with low bone density, which I haven’t heard him mention. Also, it is hard to imagine our primate ancestors keeping their blood lactate at a precisely controlled level as they went about doing hunter-gatherer activities. I’m sure their heart rates and lactate levels varied widely according to the activities being done.

    A lot of his exercise advice also hinges on the correlation between VO2max and all cause mortality. What this misses is that a significant part of having high VO2max comes down to genetics (at least 50%). So when you pick up an association like this, you can’t be sure how much is due to good genetics, and how much comes from lifestyle or exercise interventions.

    Before reading Attia’s stuff about Zone 2 cardio, I had read a number of articles by researchers at NTNU (Norwegian University of Science and Technology). They have a research group that strongly supports the idea of improving health and longevity by improving VO2max. But they favor interval work, specifically their “Norwegian 4X4” protocol instead of steady state, longer duration exercise. Basically, they want you to do 4 x 4 minute intervals where you exercise at 85-95% of you maximum heart rate, followed by 3 minutes rest. With warmups, the exercise program takes about 35-40 minutes, not all that short. The reasoning and data they cite for recommending this protocol makes sense, and they will tell you that the program is well tolerated by subjects.

    So a couple years back, I gave it a try, doing this 2 sessions a week. Initially, it was a fun challenge. But after 4 or 6 weeks, I started to burn out on it. I cut back to once a week, and then gave up on it entirely. Turns out that repeatedly pushing your heart rate to 90%, and holding it there for 2.5 to 3 minutes is pretty uncomfortable, if you do it on a regular basis. I didn’t find it sustainable for the long haul.

    I was later amused to note that they did a long term study (called Generation 100) where one group was given the 4X4 protocol. That group’s results were not quite as outstanding as the researchers obviously were hoping for. Poor compliance with the exercise protocol was cited as an issue. Apparently, 4×4 wasn’t as well tolerated as they initially claimed. Seems you really need the supervision of a trainer to regularly push yourself that hard. (Shades of High Intensity Strength Training).

    At least Zone 2 is something I feel I can regularly do. It is mild enough that I can put on the TV and stream episodes from NetFlix or Amazon Prime to help pass the time. Finding the time to do 4 to 6 hours of that stuff, is of course still a problem. I think I will settle for trying to get in about 1.5 to 2.5 hours a week (2 or 3 45 minute sessions).

  16. @Greg – Thanks for the comment.

    The more I think about Outlive, the more issues I have with it. I think there is a strong selection bias when it comes to exercise. Those that can recover faster have a more positive feedback loop than those that don’t. They exercise more. Did the exercise itself provide the benefit or was it the fact they are fast recovers? Attia is pushing that it is the exercise. I’m not convinced. I might do a follow up post later this year.

  17. Im a little confused by some of the comments here. (Just finished the book myself) From Reading the comment above, i get the impression that attia recommends zone 2 training to increase vo2 max, but as i understood it from the book, he Does specific vo2 max training, like the norwegian 4×4 described.
    Also as i understand his focus on exercise, has a lot to do with the quality of your Life, and avoiding injuries, and less on longevity. (Especially the huge amount, i Think he recommends 3-4 hours of zone 2 training, to get the proper benefit)

    Or did i misunderstand?

  18. @Morten – It’s been several months since I read the book and although I like a lot of the book, I didn’t find his exercise portion to be persuasive to me.

    Maybe I will do a follow-up post, but I don’t think he understands selection and survivorship bias when measuring health results from exercise. I don’t exercise as much as he does, because I don’t recover as well. Forcing an “Attia volume” on me, would not increase my health. It would make me more prone to injury.

    Being able to recover faster is a result of something “under the hood”, not the exercise itself. Someone with perfect genetics, health, and recoverability that enjoys exercise will thrive with his volume of exercise. But was it the exercise? I’m doubtful it is the main lever. I suspect it is secondary.

    Having muscle, grip strength, and a higher VO2 max will improve the quality of the life – even if it doesn’t extend lifespan. I think Attia was clear on that. That makes perfect sense.

  19. Shouldnt zone 2 training, be low enough intensity, that it doesnt really require any recovery? I feel that was the bulk of his training regimen. Resistance, vo2 max, and stability training, where all much lower and more reasonable in quantity.

    Would You say, that because of genetics, You would never be able to get yourself to a level, where You could bike 4 hours a week, in zone 2? (To me this should be the area with least risk of injury)

    Thinking now, i cant remember what was important about zone 2 training, other than, it targeted some musclefibers that resistance training didnt, but why that was important, i Will have to reread?

  20. @Morten – I meant the total volume of exercise that Attia does, not just the Zone 2. I may need to go into greater detail on a new post, but I think some of his recommendations such as box squats have greater risk than reward. Have a 50-year-old (or older) twist an ankle or worse on a missed box jump. Unlike a 20 year old that can shake it off and be back at the end of the week, they might be out for weeks or months.


  21. Sure i Can agree to that, but doesnt he also State multiple times, that there is no one size fits all? (I Think the box squats was recommended as an alternative to normal weighted squats)

    Im not saying anything of what has been posted above is wrong, i just had a completely different understanding of his recommendations, afterwards.

    It should be noted that i went through it as an audio book, and i guess the Way he explains it himself, tone of voice, etc. could make a difference

  22. Just reheard some parts, is it the parts where he mentions cutting risk of all mortality caused, when You go up a quartile? (So You are no longer in the bottom 25% of your age group)

  23. @Morten – In addition to reading Outlive, I also have watched or listened to Attia in interviews (related to Outlive) and his own podcast. I’m lumping all that information together.

    I would have to look it up, which I can’t do at this time, but I though the box jumps were related to plyometrics, not strength itself.

  24. Arh, yeah that makes sense, thinking about it, i actually cant remember box jumps being mentioned in the book, nor plyometrics. (I mixed it up with step ups, on a box…)

    The book was the first i ever heard of him, so i have the luxury of only my memory being the limit 😉

  25. @Morten – Now I’m starting to question my own memory on the box jumps. I’m 70% certain I heard him talk about them, but I’d have to do some digging to confirm. I do not think they were mentioned in the book.

  26. Dont do it for my sake atleast, i guess atleast the book is sort of accurate, even though he might be saying other things through other channels.

  27. @Morten – Now I’m starting to think I imagined he mentioned box jumps. If I do a follow-up post, I’ll cite any references. Thanks for the feedback.

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