Outlive
CHAPTER 1 The Long Game
From Fast Death to Slow Death
Just because your parents endured a painful old age, or died younger than they should have, I say, does not mean that you must do the same. The past need not dictate the future. Your longevity is more malleable than you think. (Location 148)
Assuming that you’re not someone who engages in ultrarisky behaviors like BASE jumping, motorcycle racing, or texting and driving, the odds are overwhelming that you will die as a result of one of the chronic diseases of aging that I call the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction. (Location 152)
Changing that mindset must be our first step in attacking slow death. We want to delay or prevent these conditions so that we can live longer without disease, rather than lingering with disease. (Location 218)
Blood tests revealed worse problems than the ones I could see in the mirror. Despite the fact that I exercised fanatically and ate what I believed to be a healthy diet (notwithstanding the odd post-swim cheeseburger), I had somehow become insulin resistant, one of the first steps down the road to type 2 diabetes and many other bad things. My testosterone levels were below the 5th percentile for a man my age. It’s not an exaggeration to say that my life was in danger—not imminently, but certainly over the long term. I knew exactly where this road could lead. I had amputated the feet of people who, twenty years earlier, had been a lot like me. Closer to home, my own family tree was full of men who had died in their forties from cardiovascular disease. (Location 231)
Note:: Wow, this sounds very close to my own story. I eat (somewhat) healthy, workout pretty regularly, and overall, have little health concerns outside of asthma, which is being managed very well, currently. My Dad and his brothers passed away in the early-to-mid 50s from cardiovascular disease.
Millions of people are suffering from a little-known and underdiagnosed liver condition that is a potential precursor to type 2 diabetes. Yet people at the early stages of this metabolic derangement will often return blood test results in the “normal” range. Unfortunately, in today’s unhealthy society, “normal” or “average” is not the same as “optimal.” (Location 262)
Almost all “diets” are similar: they may help some people but prove useless for most. Instead of arguing about diets, we will focus on nutritional biochemistry—how the combinations of nutrients that you eat affect your own metabolism and physiology, and how to use data and technology to come up with the best eating pattern for you. One macronutrient, in particular, demands more of our attention than most people realize: not carbs, not fat, but protein becomes critically important as we age. Exercise is by far the most potent longevity “drug.” No other intervention does nearly as much to prolong our lifespan and preserve our cognitive and physical function. But most people don’t do nearly enough—and exercising the wrong way can do as much harm as good. (Location 267)
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. (Location 294)
It’s not “preventive” medicine; it’s proactive medicine, and I believe it has the potential not only to change the lives of individuals but also to relieve vast amounts of suffering in our society as a whole. This change is not coming from the medical establishment, either; it will happen only if and when patients and physicians demand it. (Location 298)
CHAPTER 2 Medicine 3.0
Rethinking Medicine for the Age of Chronic Disease
The trouble began with Hippocrates. Most people are familiar with the ancient Greek’s famous dictum: “First, do no harm.” It succinctly states the physician’s primary responsibility, which is to not kill our patients or do anything that might make their condition worse instead of better. Makes sense. There are only three problems with this: (a) Hippocrates never actually said these words,[*1] (b) it’s sanctimonious bullshit, and (c) it’s unhelpful on multiple levels. “Do no harm”? Seriously? Many of the treatments deployed by our medical forebears, from Hippocrates’s time well into the twentieth century, were if anything more likely to do harm than to heal. Did your head hurt? You’d be a candidate for trepanation, or having a hole drilled in your skull. Strange sores on your private parts? Try not to scream while the Doktor of Physik dabs some toxic mercury on your genitals. And then, of course, there was the millennia-old standby of bloodletting, which was generally the very last thing that a sick or wounded person needed. (Location 365)
Risk is not something to be avoided at all costs; rather, it’s something we need to understand, analyze, and work with. Every single thing we do, in medicine and in life, is based on some calculation of risk versus reward. (Location 389)
The shift from Medicine 1.0 to Medicine 2.0 was prompted in part by new technologies such as the microscope, but it was more about a new way of thinking. The foundation was laid back in 1628, when Sir Francis Bacon first articulated what we now know as the scientific method. This represented a major philosophical shift, from observing and guessing to observing, and then forming a hypothesis, which as Richard Feynman pointed out is basically a fancy word for a guess. (Location 424)
Toward Medicine 3.0
The banks’ problem was not all that different from the situation faced by some of my patients: their seemingly minor risk factors had, over time, compounded into an unstoppable, asymmetric catastrophe. (Location 455)
This is why I believe we need a new way of thinking about chronic diseases, their treatment, and how to maintain long-term health. The goal of this new medicine—which I call Medicine 3.0—is not to patch people up and get them out the door, removing their tumors and hoping for the best, but rather to prevent the tumors from appearing and spreading in the first place. Or to avoid that first heart attack. Or to divert someone from the path to Alzheimer’s disease. Our treatments, and our prevention and detection strategies, need to change to fit the nature of these diseases, with their long, slow prologues. (Location 459)
On the one hand, improved technology enables us to collect much more data on patients than ever before, and patients themselves are better able to monitor their own biomarkers. This is good. Even better, artificial intelligence and machine learning are being harnessed to try to digest this massive profusion of data and come up with more definitive assessments of our risk of, say, heart disease than the rather simple risk factor–based calculators we have now. Others point to the possibilities of nanotechnology, which could enable doctors to diagnose and treat disease by means of microscopic bioactive particles injected into the bloodstream. But the nanobots aren’t here yet, and barring a major public or private research push, it could be a while before they become reality. (Location 471)
But Medicine 3.0, in my opinion, is not really about technology; rather, it requires an evolution in our mindset, a shift in the way in which we approach medicine. I’ve broken it down into four main points. (Location 494)
First, Medicine 3.0 places a far greater emphasis on prevention than treatment. When did Noah build the ark? Long before it began to rain. Medicine 2.0 tries to figure out how to get dry after it starts raining. Medicine 3.0 studies meteorology and tries to determine whether we need to build a better roof, or a boat. (Location 496)
Second, Medicine 3.0 considers the patient as a unique individual. Medicine 2.0 treats everyone as basically the same, obeying the findings of the clinical trials that underlie evidence-based medicine. (Location 498)
Think of it as “evidence-informed” medicine. (Location 504)
The third philosophical shift has to do with our attitude toward risk. In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing. (Location 504)
The fourth and perhaps largest shift is that where Medicine 2.0 focuses largely on lifespan, and is almost entirely geared toward staving off death, Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life. (Location 528)
As I tell my patients, I’d like to be the navigator of your ship. My job, as I see it, is to steer you through the icefield. I’m on iceberg duty, 24-7. How many icebergs are out there? Which ones are closest? If we steer away from those, will that bring us into the path of other hazards? Are there bigger, more dangerous icebergs lurking over the horizon, out of sight? (Location 563)
Which brings us to perhaps the most important difference between Medicine 2.0 and Medicine 3.0. In Medicine 2.0, you are a passenger on the ship, being carried along somewhat passively. Medicine 3.0 demands much more from you, the patient: You must be well informed, medically literate to a reasonable degree, clear-eyed about your goals, and cognizant of the true nature of risk. You must be willing to change ingrained habits, accept new challenges, and venture outside of your comfort zone if necessary. You are always participating, never passive. You confront problems, even uncomfortable or scary ones, rather than ignoring them until it’s too late. You have skin in the game, in a very literal sense. And you make important decisions. Because in this scenario, you are no longer a passenger on the ship; you are its captain. (Location 565)