Over the past few months, I’ve had dozens of patients come in to see me after reading Peter Attia’s book Outlive and wanting to have a comprehensive preventive cardiovascular evaluation as part of their longevity journey.
If you aren’t familiar with him, Dr. Attia is a Johns Hopkins trained physician who has a clinical practice focused on the applied science of longevity1 and a popular podcast with deep dives on diverse topics like cancer screening, building muscle, metabolic health, and cultivating happiness.
The book and the podcast are both really interesting and of high quality - I read the book and listen to the podcast from time to time - and I’ve certainly learned a lot from his content.
And judging from Attia’s audience, his message is resonating, although not with everyone. You may have come across the New Yorker profile that I read as basically a critique of his philosophy and approach.
I have a lot of thoughts on Dr. Attia’s approach to longevity, how he interprets the medical evidence, and his book, but I’ll save those thoughts for a different time, because today I want to talk about his big picture points and how they’re being received by the people coming into my clinical practice.
So I know that I am seeing a skewed sample of people, but it’s been fascinating to me what the people who were motivated to make an appointment after reading Outlive are hoping to get from the medical system.
And unfortunately, I think that many of the people who are inspired by Attia’s approach are totally missing his point.
A new way of thinking about healthcare - Medicine 3.0
One of the themes in all of his content is the concept of the failure of the current healthcare system for preventing chronic disease and decline.
Attia describes his philosophy and approach as “Medicine 3.0” and argues for a fundamental shift in how people interact with the medical system.2
Medicine 3.0 is premised on acting early to delay the onset of what he calls the “Four Horsemen of Chronic Disease:” cancer, atherosclerotic cardiovascular disease (ASCVD), neurodegenerative disease (think Alzheimer’s and other dementia), and metabolic dysfunction (the precursor to type 2 diabetes, which increases the likelihood of the other 3 horsemen).
And so I’ve had quite a few people come to see me and say that they’re “ready for Medicine 3.0” and want a healthcare provider who practices with that mindset.
The way Attia uses it, that means understanding your current health status across the different domains of health and then taking action, either with lifestyle interventions (diet, exercise, sleep) or pharmaceutical interventions (prescription medications and supplements).
It’s metricized, proactive, and aggressive when it comes to screening for and treating early stages of chronic disease.
And so when I see these patients, particularly given my familiarity with Attia’s content and approach, I’m consistently struck by how I don’t think that most people understand the actual point.3
One of Attia’s biggest insights - exercise is the most potent longevity “drug” that we have
Perhaps the most consistent theme across all of Attia’s content is the profound way that fitness impacts our lifespan.
He talks a lot about things like VO2 max, muscle strength, and muscle mass as being the most important metrics for our longevity journey.4
VO2 max is a measure of cardiorespiratory fitness, while muscle strength and mass are self explanatory.
Trying to achieve elite age-adjusted levels of VO2 max or muscle strength requires a huge amount of time for most people, and also requires more intense workouts than many are willing to do.
What I like about using metrics like these as a marker of how things are going is that they provide an objective assessment of whether you’re doing “enough” exercise.
Many patients want to know what the minimum amount of activity that they can do to be healthy is - using objective standards for cardiovascular fitness and muscle strength inverts that concept, where the results matter and the inputs are just a means to get there.
It’s not about how much time you spend in the gym, it’s about what you have to show for it.
So if you’re exercising for two hours a day, but your VO2 max stinks and your grip strength is lousy, something about your approach needs to change even though you’re dedicating a huge amount of time to fitness.
And - more importantly - if you aren’t exercising much, or you’re doing it inconsistently, and your muscles are weak and you can’t walk up a few flights of stairs without stopping, then it doesn’t matter what supplements you’re taking.
Many of the patients coming in and asking about Peter Attia’s Medicine 3.0 cardiovascular screening tests come in with excuses about why they aren’t doing as much exercise as they should rather than a detailed description of how they’re getting their Zone 2 cardio in or what their VO2 max was on recent testing.
Early and aggressive preventive care often requires prescription medications
Attia talks a huge amount about screening for atherosclerotic cardiovascular disease (colloquially known as heart disease) early on with tests like a coronary CTA and coronary artery calcium score.
People commonly get this point and often come in asking for these tests.
But the most important part of a medical test isn’t whether or not you get it, it’s what you do with the information.
If you’re a patient in Peter Attia’s practice, an elevated coronary calcium score almost always results in a medication to lower LDL-cholesterol/apolipoprotein B.
That’s because getting lipid numbers to the targets that halt heart disease in its tracks is hard - if not impossible - for people to get do with diet alone.
My own clinical experience is that most people are unrealistic about how much they can change their diets5 and dishonest with themselves about how sustainable that plan is anyway.
And so that means that once we screen you for heart disease and we find early stages of something, it is highly likely that medication is going to be the recommended treatment.
But too often people get their calcium score and then negotiate about the recommended treatment plan. Or they have no interest in taking a medication and so that discussion is a nonstarter.
It strikes me as bizarre.
That’s the whole point of Medicine 3.0 - screen early and treat aggressively for things that we know the root cause of.
I’m consistently perplexed by the idea that someone would want to screen for heart disease and then not act on the results.6
Yet that’s where many of these conversations end up.
The operative concept in “acting early” is taking action
The heart disease screening gets to a core disconnect I’ve observed with my patients - the ability to persuade yourself away from taking action.
My observation is that the a major reason why people spin their wheels and never take action is at least partly because of analysis paralysis - they are too preoccupied with trying to anticipate every detail about the specifics of a topic that can’t separate the details from the broad strokes or the big picture.
I’ve seen this with exercise, where questions about “what’s the best type of exercise for me to do?” or “how much exercise should I be doing?”7 can quickly morph into detailed questions about treadmill velocities, elliptical resistance, and problems with the leg press machine in your gym that don’t really matter.
I’ve seen it with medical therapy, where questions about common side effects and treatment targets can go down a path of “what if I have side effects with rosuvastatin or my LDL only goes down to 75 plus I don’t want to do an injectable medication and also what if my blood sugar goes up and should I take coenzyme q10?”
A corollary to this point is that it’s really easy with any of these topics - exercise, heart disease, sleep, nutrition, you-name-it - to start down a path of investigating the topic for yourself and end up unable to get out of a rabbit hole.
Part of the reason you go to a professional, whether it’s a personal trainer, therapist, or physician, is that you want their opinion about the right next step.
The philosophy of medicine 3.0 requires taking action - early, preventive steps to treat chronic disease - and so it never makes sense when someone is inspired to see me because of that philosophy but then doesn’t want to apply it to their own health.
Major in the major, and minor in the minor
One of Attia’s common refrains is “major in the major, and minor in the minor.”
Most chronic disease prevention is straightforward - control blood pressure, blood sugar, and cholesterol. Don’t smoke. Don’t carry too much weight. Get regular exercise.
Attia’s philosophy is a difference of degree but not kind. He doesn’t have magical potions that make you instantly younger.
He applies a metricized, systematic approach to fitness, nutrition, sleep, and medications.
The fact that he has so much content and much of it goes into extreme detail about topics that impact all of our lives makes it hard for people to stay focused on the plot.
And so if you’re obsessing about the right type of band to buy for blood flow restriction training or the optimal magnesium supplement dosing and formulation, but your LDL-C is 160mg/dL and you are prediabetic, you are totally missing the forest for the trees.
Major in the major, and minor in the minor.
He describes longevity as improving lifespan (how long we live) and healthspan (how well we live). My read is that it’s just a different way of marketing something that we describe to patients in the traditional healthcare system as feeling better or living longer
If you want to dive into the Medicine 3.0 concept - start here. TL;DR: Medicine 1.0 is pre-scientific thinking. Medicine 2.0 is where we currently are - germ theory is widely accepted and the gold standard of evidence is the randomized controlled trial. But we suck at preventing chronic disease because we intervene too late and don’t address root causes early on. Hence the need to shift to medicine 3.0.
If you are a patient of mine and you’re reading this - I am probably not talking about you. Some of my patients really get it, but lots of people do not.
Technically, it seems that muscle strength trumps muscle mass, but muscle mass seems to provide a buffer against an injury or immobility, so it’s worth building muscle in addition to just getting stronger.
I also think that if you can’t make a diet change forever, there’s not much point in making it for a short period of time. If you think that being a completely whole foods, plant based, no processed food, zero sugar human isn’t a sustainable path for you lifelong, I don’t really understand the point of trying it to see if your bloodwork improves on it. You’re just going to go back to what you were doing before, and we’ll be right back where we started.
One of the most common reasons why people don’t want to act is because action requires a statin prescription. But statins are better than you’ve been told on the internet.
As we discussed above, it’s not about the amount of exercise, it’s about the results of the exercise.