Adding Ten Healthy Years to Your Life

My guest today, Peter Attia, makes a return visit to the podcast. He’s a physician who specializes in the topic of living a long, healthy life. It’s taken him seven years to collect and organize his insights into his first book. It’s called Outlive: The Science and Art of Longevity.

Peter ATTIA: Longevity is only half about length of life, we have to be just as concerned with quality of life.

Welcome to People I (Mostly) Admire, with Steve Levitt.

This is not your run of the mill self-help book. Peter is one of the smartest people I know, and this book represents the absolute cutting edge of scientific knowledge. The collective wisdom of Peter’s decades-long obsession with the question of living longer and better. Peter essentially explains how the human body works and what that implies for the steps you can take to slow down the aging process. In the time since I got my hands on the manuscript, I’ve changed many aspects of my daily routine, the way I exercise, how much I sleep. I’ve even gotten serious about flossing my teeth.

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LEVITT: Hey, Peter, it’s so great to have you back on the show.

ATTIA: Thank you so much, Steve, for having me back.

LEVITT: With most of my guests, even the best ones, I feel like a single episode is the exact right amount of time. But with you, I feel like we barely scratched the surface. I’ve known you for a long time. And when I first met you, you thrived on extremes: acts of physical exertion, extreme diets, extreme hobbies, all of which generate fascinating stories. But as we talked you were hesitant to relive those old stories. And I didn’t understand why until I read your new book, just published. It’s called Outlive the Science and Art of Longevity. And reading the book, I’ve realized that you have changed more in the last 10 years than just about anyone else I know. And I now understand why the last time you came on the show, you didn’t want to talk about the old Peter. You are clearly obsessed with this issue of longevity. You’ve studied the question with a passion and persistence that I’ve rarely seen anyone devote to any topic in my entire life. Has it always been a question you’ve cared about or did something happen along the way that put you onto this path?

ATTIA: Definitely has not been a lifelong question. In college I was a mechanical engineer student, math major, planning to do a Ph.D. in aerospace engineering. I didn’t even think medicine was remotely interesting until I had already finished college. And then even when I came to medicine, it was really through my interest in oncology. And I left medicine and then went to work for McKinsey and did credit risk stuff. All of this came back quite suddenly with the birth of my daughter. That was the first time I suppose — I’m guessing this is true for many parents — but that’s probably the first time I contemplated my own mortality and became interested in how to delay that.

LEVITT: In the book, you tell a story also about — it was almost so crazy, I couldn’t understand it. When you’re 27, they did the wrong operation or something? What’s that all about? That was so absurd.

ATTIA: Yeah, when I was in medical school, I had a really bad back injury, and I received horrible care. And the person who operated on me operated on the wrong side. It was a colossal set of missteps that involved — basically he didn’t even meet me or examine me prior to surgery. I think I’ve referred to that as the best, worst experience in my life because it’s about a year in my life that I lost with that operation and the subsequent operations that were needed to fix that operation. But in the process, I learned something very valuable which is what it means to lose your physical health. What it means to not be able to walk, what it means to be in so much pain that brushing your teeth is very difficult. It’s one thing if you experience something like that for a couple of days or weeks, but when you experience that for a year, it gets ingrained into your psyche. And there’s not a day that goes by where I’m not in a parking lot, where I’m so excited to be able to park as far away as possible to celebrate the fact that I can walk. ‘Cause I couldn’t walk for months. 

LEVITT: So you lived, you essentially lived your 99th year in your 20s.

ATTIA: That’s exactly right. I lived the last year of my life when I was 27. And I got to say this is a beautiful gift that will forever change how I approach my health.

LEVITT: So let’s lay some groundwork. You talk in your new book about medicine 1.0 and medicine 2.0. Can you explain what you mean by those two terms? 

ATTIA: Well, two events define the relatively slow transition from medicine 1.0 to 2.0. The first is kind of Francis Bacon’s codification of what science is and perhaps what the scientific method is. And that was the 17th century. And it’s important to understand that prior to that, the natural universe was really explained through things like the gods or bad humors. There were some people, like Hippocrates for example, who believed that nature was somehow involved in physical ailment, but nevertheless, there was no way to bridge the gap of what that actually meant. And of course, therefore no way to really offer some sort of treatment. But the really big boost for what allowed this transition into medicine 1.0 going to 2.0 was the advent of germ theory. So from a technology perspective, that would’ve been the development of the light microscope. And I would say that it’s the marrying of that type of technology and what it enabled, coupled with this new way of thinking that allowed us to go from really having no sense of what was causing illness to having, you know, a very good sense of it in the late 19th century. So you had this 200-year transition basically to go from medicine 1.0 to medicine 2.0, which is where we, I believe, are at the end of today; where we’ve developed amazing tools to basically do two things very well. One, remarkable success against all infectious and communicable diseases. And that’s been through sanitation, antibiotics, vaccinations. And then the second real success we’ve had is the treatment of acute care illness. So anything that has to do with critical care, broken bones, trauma. It’s really remarkable what we can do.

LEVITT: And so you would argue that medicine 2.0 has done really well at intervening near the end of life, extending life, but often at the cost of relatively low quality of life for those extra months or years that it delivers.

ATTIA: When it comes to chronic diseases. When you look at chronic conditions: type two diabetes, cardiovascular disease, cancer, neurodegenerative disease, that playbook doesn’t seem to work very well. All it does is slightly extend life, but with a reduction in quality of life. And given that this book Outlive is about longevity and longevity is only half about length of life, we have to be just as concerned with quality of life.

LEVITT: It’s interesting ’cause early on in medicine 2.0 when we went after infectious diseases, that was just a huge win, if you look at what killed people at the turn of around 1900, it’s a completely different set of illnesses than what kills people now. But if you look at it holistically with quality of life and quantity of life, the progress of medicine 2.0 has really slowed. Is that a fair statement?

ATTIA: It is. If you go back to 1900 and compare the mortality in the United States then to today, and you subtract out the top eight leading causes of death via infectious diseases, there has been no change in the adjusted mortality. In other words, we don’t live any longer today than we did 120 years ago, with the exception of the removal of infectious diseases. That’s a staggering statistic. Now, it’s also a bit misleading. It’s of course the case, I’m sure, that if people back then had lived long enough through those infectious diseases, they likely would not have survived some of the chronic diseases to quite the extent we do today. But I suspect that would only be a difference of a year or two. We wouldn’t be talking about a decade’s worth of difference. 

LEVITT: And so not to put all of the blame on medicine, though, I suspect there are many factors at work that have kept lifespan from increasing and behavioral changes have probably been really important. Obesity, for instance, being a great example, which was not common in 1900 and is of course very common today.

ATTIA: That’s right. And I think that’s the offsetting point there, is that, while modernity has brought many wonderful things in terms of the successes of medicine 2.0, in parallel it’s brought a lot of things that have increased our susceptibility to chronic diseases. So I think our success against infectious diseases has both allowed us to be living longer and therefore be more susceptible to chronic diseases. But an even greater factor has been all of the comforts of the modern world that, let’s be fair, I don’t think anybody is lobbying to go back and live in the year 1900. Certainly, I’m not. But with worse nutrition, with far less movement, with far more light and therefore less quality sleep, and probably more chronic stress, all of those things have conspired against the deterioration of our health.

LEVITT: Yeah. Okay. So what you call medicine 3.0, that’s what you espouse. It contrasts sharply with medicine 2.0. At a very high level, how would you describe medicine 3.0?

ATTIA: So the first is it’s much more about prevention and that word has lost most of its meaning because it is a buzzword within medicine 2.0 and outside of cardiovascular disease, where I think we do take steps to try to implement prevention, we really don’t have much of a prevention strategy. In fact, most traditional entities would argue there is no such thing as a cancer prevention, besides perhaps smoking cessation and maybe the reduction of obesity. And nobody’s really talking about the prevention of, say, dementia or Alzheimer’s disease. Another dimension is the idea of risk assessment. If you look at certain industries such as financial institutions, it’s well understood that risk management is a very important piece of success. And I would argue that’s just as important if you’re thinking about your own health. And that includes the risk of doing nothing.

So we often talk in medicine about the risk of doing something, but that’s not often contrasted with the risk of doing nothing. If we talk about using medications to lower cholesterol, people will often talk about, well, you know, that comes with this much of a side effect and this much of a risk; but what’s the risk of not doing something over a long enough time horizon? Which gets to really the third point, which is, most traditional ways of thinking about risk look at a very short-term time horizon, five to 10 years. When you study things over relatively short durations that are lifelong diseases, it’s very difficult to get meaningful answers. Something that’s very important to medicine 3.0 is understanding causality. And in the book, I use this example: Steve, if I said to you, “We’re going to institute a new policy, which is we’re going to tell people that it’s okay to smoke until their risk of lung cancer reaches 5 percent. But then we’re going to tell people to stop smoking.” I think everyone would look at me and say, “That’s a dumb idea.”

The fact that smoking is causally related to lung cancer doesn’t mean everybody who smokes is going to get lung cancer. Everybody’s got the story of their grandmother who’s 90 smoking two packs a day, and she’s totally fine. But we certainly know that smoking will dramatically increase your odds of it. And therefore, we don’t wait until your risk is a certain level before doing something about it. We say, stop right away, or don’t start. And now you want to apply that logic to say cardiovascular disease. Today we would use exactly that five- or 10-year risk model and say there’s no need to treat people preventatively until their risk crosses a certain threshold. And I would say, well, we know that smoking, high blood pressure, and ApoB are causally related to atherosclerosis, therefore they should be eliminated out of the gate. And again, it sounds like a subtle difference, but it’s actually an enormous philosophical difference.

LEVITT: One of the places this becomes clearest is around the treatment of diabetes. Could you walk through medicine 2.0 versus medicine 3.0 — how you think about diabetes?

ATTIA: Yeah. Type two diabetes, is a condition that is really defined by something called the hemoglobin A1C, which is a measurement that is taken in the blood that estimates the average blood glucose over the preceding three months, more or less. So the definition of type two diabetes is a hemoglobin A1C of 6.5 percent or higher. What happens if you reach that level? Nobody disagrees that it’s a bit of a four-alarm fire. Your risk of every chronic disease skyrockets; your risk of cancer, your risk of cardiovascular disease, your risk of Alzheimer’s disease, your risk of kidney failure, all of these things just go up significantly. And therefore we want to ameliorate those things. You know, it’s important to understand, a lot of people have type two diabetes. Very few people die from type two diabetes. Instead, type two diabetes raises their death rate from all these other diseases. So what happens if your hemoglobin A1C is 6 percent? Well, we call that pre-diabetes and we might institute or suggest some changes around diet and exercise. We might even use a drug called metformin, but we wouldn’t really institute much else and we wouldn’t really raise much concern. And if your hemoglobin A1C were 5.6 percent, we wouldn’t say anything because that’s even below the threshold of pre-diabetes.

LEVITT: So what you’re saying is the medicine 2.0 acts like when you cross over the line into diabetes, you’ve hit some huge cliff that’s a disaster when probably everything we know about the human body says it’s a continuous line from being totally healthy to being extremely diabetic. But the way the incentives and the rules of thumb work, we treat it like it’s a step function when really it isn’t.

ATTIA: And the treatment that you use once you cross that step function, is quite extreme and quite expensive. If somebody’s average blood glucose is say 120 milligrams per deciliter, which is not in the type two diabetes range, it is still elevated. The treatment for that is not medical, right? The treatment for that is nutritional, sleep related, stress related, and exercise related. You’re going to treat those with the big four, but you’re not going to treat it pharmacologically. And one of the challenges of medicine 2.0 is that its playbook is virtually all pharmacologic. I want to be really clear, I’m not anti-pharma; I just think that if pharma is your only tool, it’s like a general contractor who only has nails. Nails matter. They’re really important but sometimes you need a screw; (SL^laughs) sometimes you need a saw. It’s important to have lots of tools and all of our medical education was predicated on this one albeit important tool, but at the expense of what I would argue are 80 percent of the other tools out there, which is how do you use nutrition, how do you use sleep, how do you use exercise.

LEVITT: I think you’re going to rebel at this question, but let me ask it anyway. Roughly how many extra good years do you think a person could expect to gain from faithfully adhering to medicine 3.0 versus medicine 2.0?

ATTIA: It clearly depends on when one institutes these changes. It also probably requires some understanding that we don’t completely have of a person’s genetics and the subsequent exposures that they’re going to have in life to various elements that impact this. But I reject the point of view put forth by some that says, look, if you managed to avoid heart disease, you would only live an extra two or three years. And if you managed to avoid cancer, you would only live an extra two or three years. Because it assumes that all of these diseases exist in a silo but the reality of it is these diseases are so linked that if one does what you’re really suggesting, Steve, I think it’s more like a decade of life extension.

LEVITT: I love that you will say that because those are huge numbers. If people believe that, then it becomes incredibly difficult not to take you seriously, because who, faced with the possibility of having if not 10 extra years, 10 extra good years, wouldn’t say, “Hmm, I better pause for a second and think about what I’m doing that’s not giving me that.” I love that you believe that and are willing to say it. I think that’s really important.

ATTIA: I say to my patients that if all of the exercise I was doing shortened my life by a year, I would still do it because of that quality of life at the end. And I suspect that I feel so strongly about it because I’ve watched far too many people in the last decade of their life be so robbed of the things that you and I take for granted. Like, I think about what I did this weekend, Steve. My wife was at a volleyball tournament with my daughter. So it was just me and my two boys, who are five and eight. And everything I did with them was physical. And being able to get down on the ground and play and get up and run around and have the energy to do those things — yeah, it’s easy to do that when I’m 50, but I want to be able to do that when I’m 85, and that’s very hard. But I believe that’s what’s going to determine the quality of my life. It won’t be how much money I have. It won’t even be how fancy the vacations are that I might be able to take if I can’t physically be robust enough to enjoy them with whoever I’m with.

We’ll be right back with more of my conversation with Peter Attia after this short break.

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LEVITT: Now, as I listen to you talk about medicine 3.0, you’re not an economist by training, but almost everything that you’re saying and what you write in the book, it really resonates with my economic brain’s way of thinking. If I try to translate what you’re saying about medicine 3.0 into economic jargon, you’re saying that living the longest, healthiest life is a dynamic optimization problem under uncertainty. And empirically, if one studies the data as you have so carefully, it turns out that investment in health throughout the entirety of adulthood have huge marginal impacts on later life outcomes; far bigger impacts than people generally, or medicine 2.0 appreciates. Does that ring true to you? Is that kind of the way you think about the world?

ATTIA: Yeah, I would agree with that completely. The things that are required to capture or realize those gains you’re referring to require work today. And the work today comes at a cost because everything has an opportunity cost. And usually that’s time. Getting seven-and-a-half or eight hours of sleep instead of six and a half hours of sleep takes more time. Exercising takes time.

LEVITT: I mean you talked about risk and that really resonated ’cause one thing that I’ve always found strange is the only part of the Hippocratic Oath that I actually know, which is where they say, “Do no harm.” Which to an economist seems like an incredibly terrible credo in a world of uncertainty. I’m sure you agree with that, right?

ATTIA: Yeah, and as I’m sure you recall, Steve, in the book I go off on Hippocrates a little bit. First of all, that quote is actually incorrect. The actual quote is a little bit different and it’s been paraphrased into, “First, do no harm.” But if you show me one physician who has never done harm, I’ll show you a physician who has never done anything. We certainly don’t set out to do harm. And in the book I tell a very extreme story, which every doctor will have their example of. But I tell a story of a kid who came in, this was when I was the trauma chief one night, and he had been stabbed, just below his, xiphoid process. So right below the sternum he had been stabbed. And it was a teeny, tiny stab wound. It was probably about a half an inch. And you have no idea, Steve, which direction the blade went in, or even how deep it was. But in that location there are really bad outcomes.

And so he’s in the emergency room and he’s awake and he’s fine, and all of a sudden he’s not fine. So the thing you have to think about here is what’s the worst case scenario? And the worst case scenario is that knife has somehow penetrated either his heart or something around his heart that is allowing blood to bleed into his pericardium, which is the fibrous sack around the heart. And if that happens, the heart can’t expand. And that’s almost an immediate death. You’ve got about a minute until a person is dead. Which is not enough time to get him up to the operating room and do the right thing, open him up and explore. So you have to do something insanely dramatic called an E.R. thoracotomy where you, without anesthetizing him or doing anything, cut open his chest, pull his heart out, basically cut open the pericardial sac and relieve it. And then pump his heart until you get him to the O.R.  

LEVITT: If you’re wrong though, people think you’re crazy, right? You’re going to have a lot of explaining to do.

ATTIA: And if you’re right, you’ve saved his life. Now let’s be clear. There are other clues you would have to point you in that direction. You do have time to do an ultrasound of his chest. And even though ultrasounds are not very high resolution, they can suggest that there might be fluid around the heart. And of course, I did that and there was fluid around the heart and sure enough, had to do that thoracotomy, open him up. And once we took him to the operating room, we could actually see clearly what had happened, which was that little knife had hit his pulmonary artery and that pulmonary artery was bleeding into the pericardium. By the way, that’s a very easy thing to fix in the operating room. It was about two stitches, and that guy went home four days later totally fine. But you had to be willing to harm that patient to save his life. Fortunately, most examples in medicine are nowhere near that extreme. But there’s always some element of risk if you want to make a difference.

LEVITT: So I think the Hippocratic Oath, if he had been an economist, would be something more like, do no harm in expectation. That wouldn’t be a bad rule. A better rule would be: set marginal benefit equal to marginal cost, because that turns out to essentially be the answer to any optimization problem.

ATTIA: And medicine’s probably even more conservative, right? Medicine’s even more conservative, Steve. Even in medicine, you could say set marginal gain or marginal benefit to be in excess of marginal cost, but you have to acknowledge marginal cost.

LEVITT: One kind of study that you report on in the book that I wouldn’t have thought would be very useful, but you draw real insights from, are studies of people who live to be a hundred. So looking ex-post the people who live a really long time, what is it that we learn from those studies? 

ATTIA: So, if we ask the question: How much do your genes play a role in your lifespan? The answer is, it depends how long you live. So for people who live up to 75, 80-years-old, genes play very little effect. Your lifespan is almost uncoupled from your genetics into your eighth decade. But all of that changes in the ninth, 10th, 11th decade and beyond. At that point, it becomes almost purely a genetic game. So the joke in the gyroscience space is the single most important thing you can do to live to a hundred is pick the right parents. And so the question then becomes what genes are indeed responsible for extreme longevity? The disappointing insight is there are no really great longevity genes. There are a handful that uniquely stand out, but it’s not like there’s going to be a candidate gene, Steve, that once CRISPR is fully working, we’re just going to zap into everybody.

But the most important insight I took from studying that population is that they are completely at odds with medicine 2.0, and this gets back to strategy. Medicine 2.0’s strategy is how long can we help you live with disease? So once you have diabetes, once you have cancer, once you have heart disease, how much longer can we stretch out your life? centenarians don’t live that way. They just get all the same diseases the rest of us do 20 years to 30 years later. And once they get them, by the way, they’re just about as susceptible as the rest of us to them. All of their genes when you look at them, are basically genes that are chronic disease prevention genes. So they’re superpower is delaying the onset of chronic disease, full stop. And therefore that’s basically the insight that drives all of medicine 3.0. You have to live longer without disease, not stretch out the time you can live with a disease.

LEVITT: So I have pretty good genes. I think both my parents are still alive as they approach the age of 90. The good genes are helping me not get diabetes. But if I blow it and I get diabetes, then I’ve really blown it. In the nutshell, that’s kind of what you’re saying, right?

ATTIA: I don’t want someone listening to this who has type two diabetes to think it all hope is lost. ‘Cause the beauty of it is I think type two diabetes is completely reversible. So it’s not too late. But certainly once you’ve had your first heart attack, your risk of your second one goes way up. Now there’s a lot you can do to reduce that risk, but you’re never going to take it back to the risk profile that you had before you had a heart attack. So your parents approaching their 90s are getting into that rarefied air as they come up to abutting their 10th decade of life. And that would certainly suggest that you have that potential as well. But if you make a whole bunch of bad choices that really try to override that, the genes will only do so much for you.

LEVITT: So you think there are five areas of behavior that are under people’s control, which are the pillars of living long and living well. So let’s start with exercise. So you say that both aerobic exercise and strength training matter. And while that isn’t going to surprise anyone, I don’t think, I have to say I practically fell out of my chair when you presented the evidence of just how important exercise is.

ATTIA: I think your reaction was my reaction too, which was, of course, exercise matters. But you couldn’t believe the size of the impact and the consistency of it. The magnitude of the effect is not subtle. So the VO₂ max is a test that is easy to do. Not easy to do, it’s a miserable test to do, but it’s a simple test to do. It’s usually done on a treadmill or a bike and a person is exercised to exhaustion. So it is testing your maximum uptake of oxygen. And the only way to do that, of course, is to exercise you to the point where you can’t exercise anymore. And the bigger that number, the bigger your aerobic engine. Not surprisingly, the best endurance athletes in the world have the highest numbers there; namely cyclists, runners, and cross-country skiers. So at the most extreme level, if I take a person in the bottom 25 percent for their age and sex and compare them to someone in the top 2.5 percent for their age and sex, that’s a hazard ratio of about five. That’s a 400 percent difference in all-cause mortality. What that means is, at any moment in time, the person with the lower VO₂ max is 400 percent more likely to die in the upcoming year than the person in the top 2.5 percent. 

LEVITT: That’s crazy. Okay. So obviously the top 2.5 percent, they’re awesome, but what if you compare the top 25 percent to the bottom 25 percent? That’s just not that big of a difference.

ATTIA: So compare the people in the bottom 25 percent to the people in the 50th-to-75th percentile. Would we agree that’s a reasonable comparison, right?

LEVITT: Yeah, that’s going from being bad to a little bit above average.

ATTIA: Yeah, that has a hazard ratio of 2.75, so that’s 175-percent difference in all-cause mortality. I want to point out that’s a greater hazard ratio than smoking has. In other words, that creates a greater probability of death than comparing a non-smoker to a smoker.

LEVITT: Okay, so as amazing as the VO₂ max numbers are, even more shocking to me are the results around muscle mass and strength, which I would’ve suspected had nothing to do with longevity or a long, healthy life. But the data are totally the opposite. 

ATTIA: Tell me why that’s surprising to you, Steve. Why wouldn’t you have expected muscle mass or strength to matter? 

LEVITT: When I think of somebody healthy, I guess I think of someone who’s lith and youthful. And I don’t associate that with strength. I associate that with leanness. That was just my own prior.

ATTIA: No, that’s interesting. The data don’t suggest one needs to be a bodybuilder. But the difference between somebody in the top 25 percent of appendicular lean mass index versus somebody in the bottom 25 percent or even in the second quartile, is a difference of about a 20-percent mortality over a decade, starting in your mid-seventies versus a 50-percent mortality over a decade, starting in your seventies. Okay? That might translate to a difference of 15 pounds of muscle mass. So that’s not an enormous amount.

LEVITT: So you’re saying 15 pounds of muscle are the difference between a 50-percent chance of dying in the next 10 years for an older person versus 20 percent?

ATTIA: That’s correct. 

LEVITT: So more than a doubling of the death made over a decade from 15 pounds of muscle. 

ATTIA: That’s right. Muscle has two very important and quite distinct functions. The first is metabolic. And as we age, we naturally become more metabolically unhealthy. And muscle is a very important organ, right? It’s where we dispose of glucose. So this is our most important organ to put glucose to prevent us from getting insulin resistant and diabetic, which then of course feeds into all those other diseases. And then on top of that, it has all of these structural benefits. The other thing that I think I was really shocked to learn was if you take 65-year-olds — that’s not that old, by the way — if you take 65-year-olds, and subject them to a fall that is significant enough that it results in the break of their hip or femur, their mortality over the next 12 months is somewhere between 10 and 30 percent depending on the study. So how do we prevent people from falling? A part of it is just having enough muscle mass and enough strength to prevent yourself from falling when you lose your balance.

LEVITT: Let’s talk next about your second pillar, which was surprising and alarming to me, which was sleep. And I’ve always treated sleep as either a necessary evil or a luxury. It’s wasted time to be minimized.

ATTIA: And I shared that view. You know, for most of my life I viewed it as the old adage, I’ll sleep when I’m dead. Of course what I came to learn was that adage will speed up the shorten the length time it takes for you to be dead. Look, I think one of the simplest ways to explain this is to go through it through an evolutionary basis, which is that it’s not just that there’s no species we’re aware of that doesn’t sleep. That’s generally an important sign. When evolution conserves something across every species, it’s worth paying attention to. But the other thing is that why did it conserve it in us, given the clear risk that sleep poses. If on average, our species is to spend a third of its life unconscious — you’re not able to reproduce, you’re not able to forage for food, you’re not able to defend yourself against predators. And yet we still did it? You know, to me, it was that line of inquiry over a decade ago that really got me to pay attention to this. And as you point out, I think the data are quite consistent here. So Eve Van Cauter did a pretty elegant experiment where they took a group of subjects and sleep deprived them for just something like on the order of, I don’t know, about a week. So they took a normal group of subjects. They did something called the euglycemic insulin clamp, which is the gold standard for measuring insulin resistance. And these people were normal. And then they forced them to only sleep four and a half hours a night. And within one week, their glucose disposal fell by 50 percent. That’s effectively meaning they’re almost diabetic at that point. And I think the data are undeniable here that poor sleep, either in quantity or quality is causally related to poor health. I think in some areas it’s more clear than others. When it comes to Alzheimer’s disease, other forms of dementia and cardiovascular disease, chronic disruption of sleep is problematic.

LEVITT: Okay, so let’s talk about a third pillar, and that’s nutrition. And you know about as much about nutrition as anyone around. You founded and ran the Nutrition Science Institute, NuSI, for a number of years, but it’s my impression that while you believe diet plays a role in longevity, maybe you think it’s gotten too much emphasis relative to its actual importance. Is that a fair statement?

ATTIA: I think it is. I think people tend to over or underemphasize nutrition and the truth is it’s probably somewhere in the middle. And one of the challenges of nutrition is the lack of certainty we have. Unlike exercise and sleep, in nutrition, there aren’t that many things that we can say that are capital-T true. We know that too much nutrition and too little nutrition are catastrophic for our health. 

LEVITT: So by nutrition there you mean calories?

ATTIA: That’s right. We know that there are certain essential vitamins, minerals and nutrients that one must have for optimal health. The nutrient value of food today is not what it once was. So the manner in which food is grown, and this is everything from vegetables to all plant matter, all animal matter, we’re just in a less nutrient-dense environment. And therefore, probably even as we consume more calories, we’re not offsetting the nutrient deficit. But really the most important thing I take away from nutrition is you’re manipulating the total amount of energy intake. You want to manipulate protein, which are the building blocks for some of the most essential structures in our body, not the least of which is muscle. And we can also manipulate nutrition vis-a-vis energy balance for our metabolic health. And metabolic health is how does your body know how much to store, where to store, and how to go back and access it when it needs it.

LEVITT: Okay, so a fourth pillar of your approach is what you call exogenous molecules. That’s things like drugs, hormone treatments, and supplements. I really just want to ask you one question there, which is: Do you have an early opinion about the new weight loss drugs like ozempic? 

ATTIA: Yeah. In short, these drugs are very effective and in fact they’re more effective than any drugs we’ve ever seen in the past for the treatment of obesity. I would say that I have concern over these drugs that may or may not be warranted and only time will tell. We have used these drugs somewhat liberally with our patients over the past three years. But one thing we’ve seen unmistakably and repeatedly, is everybody’s resting heart rate goes up somewhere between about eight and 12 beats per minute at night. That may be nothing, Steve, but as a general rule, things that raise your resting heart rate by an average of 10-beats-per-minute aren’t good. And therefore I wonder what the implication of that is. The other thing, eventually, when you’re off the drug, your weight will drift back to your original weight. But that of course begs the question, which is, are you on these drugs for life? And as an economist, I think that’s an interesting question because the cost of that is staggering. These are drugs that are $8,000 a year, but they could be sometimes $16,000 a year. I would describe myself as probably not the most enthusiastic person about these drugs. But look, if I knew that over the long term they were not harmful, and if I thought that the costs were going to be a little more reasonable, I could be more excited.

You’re listening to People I (Mostly) Admire with Steve Levitt and his conversation with Peter Attia. After this short break, they’ll return to talk about Peter’s severe struggles with mental health.

*      *      *

The last piece of Peter Attia’s strategy for living a long, active life is emotional health. I’ve known Peter for a decade, but until I read the book, I had no idea he had suffered physical and sexual abuse as a child. No idea about his lifelong struggles with emotional health. It was shocking for me to read. I can imagine it’s not easy for him to talk about this topic, but I found what he wrote in the book so moving, so important that I at least want to bring up the topic.

LEVITT: Wow, through your own life story, you make such a powerful case for the importance of tending to one’s emotional health. It’s really interesting, in the book, what you say is, “This chapter is very different from the rest of the book because I go from being the doctor to being the patient.” And I just want to say, wow, I’m really sorry to hear about how much you had to suffer, and I’m really glad that you shared your story. One thing that makes your story so powerful to me is that based on outward appearances, you might seem to be the last person who is suffering. You’re a tough guy, a boxer. You have incredible career achievements, you’ve got an amazing wife and kids. And being around you is always energizing because you have a spark and a brilliance that I rarely encounter. And yet that exterior facade was hiding this just tremendous inner pain that you were suffering.

ATTIA: I would say that in many ways I lived different lives around different people. And my friends, and I count you as a friend, all but perhaps with maybe one exception, were probably largely unaware of any of the, I don’t know, turmoil, for lack of a better word. Whereas my wife was probably much more aware of it. She saw me at my worst. So my youngest son, who’s now almost six, he was born — and I almost missed his birth actually ’cause I was in New York. So this was a phase in my life when I was just traveling nonstop. I was probably away from home, I don’t know, 23, 24 days a month. And really was probably the worst version of me that ever existed just in terms of pure selfishness, pure grandiosity. And I remember going to New York, right when my wife was approaching the delivery date and she was like, “Why are you going to New York? I’m due in five days.” And I was like, “I’ll come home when you go into labor.” Which I barely did. I barely made it home for his birth. And then a few days later I was back on the road. And then there was this one particular moment. Five weeks after he was born, I was, of course, back in New York, and I get a call from my wife that she’s in the ambulance and they’re going to the hospital because our son had a cardiac arrest. And miraculously, she had been able to revive him; luckily she knew how to do C.P.R. on a five-week-old. And much to my disgust as I say this now, I didn’t go home, Steve, for 10 or 11 days. He was in the hospital for I think three or four more days. And I would call in every day and talk to the doctors and almost treated him and my wife like they were patients. I’ll talk to the doctor every day, figure out what tests are being done and ask questions it was just so detached I think is really the point. And I think that was one of many things that I did that just incredibly hurt my family. And ultimately I had a choice to make, which was like, what kind of person do I want to be? And if I don’t want to be this guy, then I have to figure out how to be a better guy.

LEVITT: So you ended up doing some inpatient treatment. The Peter I knew would never have gone inpatient treatment. How’d you end up in treatment?

ATTIA: Very reluctantly. So you’re absolutely right. That’s not something I would’ve ever signed up for but fortunately I just had a tiny bit of awareness left in me that I was really down to my last chance to salvage what was left of my relationship. My wife wasn’t being subtle in her disappointment and disdain for how I was behaving. And she basically begged me to go. One of my friends in particular, Paul Conti, who I write about, and he plays an important role in this story — he was watching the evolution of what was unfolding in my life in 2016 and 2017. And it was really Paul, who single-handedly forced this issue and forced me to confront this. And he did this not based on any knowledge of the underlying stories, but just based on the outward appearance of what he described as a person who just lived their life as a trauma victim. There was just no way I was going to get better without this type of immersive therapy.

LEVITT: But here’s the thing. You’re Peter Attia. You’re one of the smartest guys on the planet, and you know it, and in some sense, they broke you. Is that the right way to think about it?

ATTIA: They absolutely broke me. But look, I — first of all, I’m not any of those things that you said, although, it’s very kind of you to say them, but frankly, even if those things were true, Steve, it wouldn’t really matter. I don’t think these are necessarily the problems that people can fix on their own. I just thought, this is who I am. I am just a piece of shit. That’s the way it is. And there’s nothing that’s going to change that. That’s like saying my height is what it is. My skin color, my eye color, they are what they are. What became important over the next couple of years was first learning that wasn’t true. That I wasn’t a bad person. I was a person who did bad things. Many of those were coping mechanisms that needed to be unlearned. And it’s hard to unlearn coping mechanisms that have been partially very successful. And I think that is the thing that is hardest to accept. You see some people’s coping mechanisms are more outwardly negative. If I were to distill it down for me, performance-based esteem, perfectionism, anger, these were coping mechanisms that I had that could mostly be challenged into productive pursuits. Now, if my coping mechanism were gambling, Steve, I would’ve flamed out a long time ’cause, A, I probably wouldn’t have been very good at it. And even if you are good at it, eventually you’re going to lose, right? Whereas I think when it’s hard work and perfectionism and grinding that are your coping mechanisms, it’s easier for the world to give a pass to some of your negative characteristics. 

LEVITT: You have invested heavily in your emotional health. Maybe it’s the wrong way to think about, but, I’m just curious, are you able to put a rough number on, say, the hours a week that you’ve invested in prioritizing your emotional health since you’ve been working on it?

ATTIA: I had these two long stints where I went into residential care. So the first one was in 2017 and that was 14 days. And that’s 14 days of roughly 12 to 14 hours a day of treatment. And then the second time I went into residential care was in early 2020, and that was 21 days of the same intensive treatment. When I came out of that second treatment, because it was my second trip back, and that felt in some ways, like a failure, I realized this was the highest priority. The first time I went in, I wasn’t changing some of the underlying beliefs about myself. And that only happened in that second stint. And when I came out of that, I would say for the next six months, this was a five-hour-a-week project. I probably only do one to two hours a week now of quote-unquote therapy. But where the work translates to is in the behaviors. It’s how I try to act. It’s how I repair when I cause damage. One of the most important things I remember Terry Real saying to me was, “You’re not going to stop making mistakes. You’re not going to stop doing things that hurt your kids or hurt your wife. The difference is now you’re equipped to recognize it immediately and repair it immediately. And that’s the thing that matters.” I don’t know how to put a number on that from a time perspective other than to say I’m still making a whole lot of mistakes, but working, much better at recognizing and fixing them with everybody in my life. 

LEVITT: I’ve said it before, repeatedly, but don’t you think it’s absurd that the tools for managing one’s emotional health, which are possibly the most important determinant of living a long and fulfilling life — yet we don’t, as a society, try to systematically teach these skills to kids. Why isn’t emotional health one of the most central subjects in our K-through-12 curriculum?

ATTIA: You and I have talked about this before, and you will not get any argument out of me, Steve. I would go even more extreme and say, forget the impact emotional health can have on length of life. And by the way, the effect is huge. The number of deaths that are attributable directly or indirectly to despair are enormous. Deaths of despair being defined as suicide, overdose, or alcohol-related deaths. But let’s just take all that off the table. Let’s just talk in terms of quality of life. And to go back to the words of Esther Perel, who I quote in this chapter as my therapist, “What is the purpose of living longer if you’re so miserable?” What is point of this if your relationships stink? What is the point of this, if your kids hate you? What’s the point of this, if people think you’re a jerk? I know firsthand from having spoken to some of the most successful people in the world that a lot of them aren’t that happy. They’re stuck on this treadmill of having to prove themselves all the time. I worry that’s a recipe for getting to the end of your life and realizing you made a mistake. And I’m very guilty of this. I’m not going to sit here and suggest that I have figured this out. No, it’s going to be a struggle for me forever, just as it would be a struggle if I were an alcoholic who got sober but had to always be diligent and vigilant about maintaining sobriety.

Those are powerful words Peter finished with, and they keep echoing in my head. For many of us, there’s a lot of hard work and self-compassion required to heal old wounds. I think this conversation gave you a pretty good idea about how Peter thinks about the world. If you find it compelling, I strongly recommend his book. It’s called Outlive: The Science and Art of Longevity. Before I read the book, I never really bothered trying to fight the aging process. I thought it was hopeless. But knowing the facts, knowing that I might be able to squeeze 10 more good years out of my life. What an amazing motivator.

LEVITT: And now’s the time where we take a listener question. And as always, I’m joined by my producer Morgan.

LEVEY: Hi, Steve.

LEVITT: Hey, Morgan. 

LEVEY: So a listener named Ronie wrote to us from Brazil. Ronie recently was rejected from a lot of colleges and wants to know if you have any suggestions for dealing with rejection?

LEVITT: Well, I love the question, but I’m not sure I’m that qualified to answer it. Best I could hope to do would be to talk about how I deal with rejection. And in particular, the rejection that comes to mind because it’s the one that I get over and over is when I send my academic papers to journals and then they can either choose to publish them or not publish them, and my papers get rejected I would say at least two-thirds of the time. So over my life, I’ve had over 200 rejections of this kind. So I’ve had a lot of practice with it.

LEVEY: So how’d you deal with it?

LEVITT: So I definitely develop strategies because when you are young and getting started, it’s a really intense experience to get this kind of rejection. These are papers you might have worked on for six months or a year intensely. Papers you think are the most brilliant thing ever done, and then when you find out that’s not a shared opinion, it’s sometimes really hard to take. So you know, you send your paper off to a journal and you have to wait for a long time. Three months, six months, even a year before you get an answer back from the journal. And it comes in the form of a short letter from the editor. And he or she says either they’ll publish or won’t publish the paper. And then pages and pages of criticisms from what we call anonymous referees. People whose job it is to find all of the flaws in your work. And so my strategy then and now is that I don’t even look at the criticisms right away. I wait for a couple of days, a couple of weeks, even a couple of months until I’m no longer emotional about it. And only then do I look at the criticisms. And I think it’s a great strategy because then when I read the criticisms. I have to say I almost always agree with them. I don’t want to, but I catch myself saying, “Oh, that’s a good point.” Or “Why didn’t I think of that?” by separating out the hot moment where you’re angry about rejection from the slow down version where you’re ready to accept criticism. I think it’s really helped make my research much better because then I go back and I accept the criticism. I’m open to it and I change the papers, and my papers are much, much better.  

LEVEY: So that’s a sort of unique situation where you’re getting a lot of feedback as to why you were rejected, but what about situations where you don’t get that feedback, like applying to colleges? A college doesn’t tell you that they didn’t accept you ‘cause your G.P.A. was too low or you didn’t have enough extracurriculars, you just are told that you won’t be admitted to the university.

LEVITT: Well, I’ll say one thing to Ronie. I’ve been on the other side where I actually have to decide admissions, and I’ll tell you, it’s impossible to tell candidates apart in the end. I have no idea what I’m doing. It feels almost random who gets accepted and who doesn’t. So that can give someone like Ronie some solace. But let’s also be realistic if every school is saying they don’t want Ronie. It would be a mistake to totally brush off those rejections. If every school rejects you, there might start to be a message in that. And look, it doesn’t have to be a defeating message. It’s just saying that your preparation right now isn’t as good as you thought, and you need to either try something different or get a different kind of preparation. I think criticism is an integral part of real life. It’s so hard to learn unless people tell you what you’re doing wrong. So a way to put a positive spin on it is to think, well, if somebody’s telling me I’m doing something wrong, then I actually have a chance to get better.

LEVEY: Ronie, thanks for your question and good luck in the future. If you have a question for us, our email address is pima@freakonomics.com. That’s P-I-M-A@freakonomics.com. Steve and I read every email that’s sent and we look forward to reading yours. 

In two weeks, will be back with a brand new episode featuring music producer Rick Rubin. He founded Def Jam Records almost 40 years ago, and he’s been a powerful force in the music industry ever since, doing things in his own very unique way. He has a new book out about the creative process, and it’s one of the strangest things I’ve ever read.

RUBIN: I can remember when I started the whole endeavor about eight years ago, meeting with publishers and explaining how I envisioned the book, all of them said, like, “Yeah, but you’re going to tell stories about Johnny Cash and you’re going talk about Jay-Z?” And it’s like, no, that’s not what the book is. I never wanted it to be about me. I always wanted it to be about the process.

People I (Mostly) Admire is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and Freakonomics M.D. All our shows are produced by Stitcher and Renbud Radio. This episode was produced by Morgan Levey and mixed by Jasmin Klinger. Our production associate is Lyric Bowditch. Our executive team is Neal Carruth, Gabriel Roth, and Stephen Dubner. Our theme music was composed by Luis Guerra. To listen ad-free, subscribe to Stitcher Premium. We can be reached at pima@freakonomics.com, that’s P-I-M-A@freakonomics.com. Thanks for listening.

ATTIA: Yeah. And again, I say to my parent — uh, my parents. I say to my patients, I do say it to my parents as well, by the way. But I mostly say it to my patients ’cause my parents are sick of listening to me.