Outlive: The Science and Art of Longevity

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.

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Medicine 2.0 treats everyone as basically the same, obeying the findings of the clinical trials that underlie evidence-based medicine. These trials take heterogeneous inputs (the people in the study or studies) and come up with homogeneous results (the average result across all those people). Evidence-based medicine then insists that we apply those average findings back to individuals. The problem is that no patient is strictly average.

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In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing.

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Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live—the quality of your years. This is called healthspan, and it is what Tithonus forgot to ask for. Healthspan is typically defined as the period of life when we are free from disability or disease, but I find this too simplistic. I’m as free from “disability and disease” as when I was a twenty-five-year-old medical student, but my twenty-something self could run circles around fifty-year-old me, both physically and mentally. That’s just a fact. Thus the second part of our plan for longevity is to maintain and improve our physical and mental function.

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This is called compression of morbidity, and it basically means shrinking or shortening the period of decline at the end of life and lengthening the period of healthy life, or healthspan.

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For example, doctors have traditionally relied on two tests to gauge their patients’ metabolic health: a fasting glucose test, typically given once a year; or the HbA1c test we mentioned earlier, which gives us an estimate of their average blood glucose over the last 90 days.

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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.

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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.

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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.

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My goal is to create an actionable operating manual for the practice of longevity. A guide that will help you Outlive. I hope to convince you that with enough time and effort, you can potentially extend your lifespan by a decade and your healthspan possibly by two, meaning you might hope to function like someone twenty years younger than you. But my intent here is not to tell you exactly what to do; it’s to help you learn how to think about doing these things.

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