I’ve been reading a book written by Dr. Peter Attia called “Outlive - The Science and Art of Longevity.” At 500 pages, it’s not what I would call light reading, but it has opened my eyes to the concept of longevity, not just from the perspective of lifespan, but also from the standpoint of healthspan. In order words, it’s not just about living into your 70’s, 80’s and 90’s, but whether you can actually do the things you enjoy during those decades. He argues, quite convincingly, that the approach to medicine today, what he deems Medicine 2.0, is not constructed in a way that allows for early treatment against the “Four Horseman,” namely heart disease, cancer, neurodegenerative disease (Alzheimers or Dementia) and type-2 diabetes and related metabolic disorder. Medicine 2.0 takes a more reactive approach to treating disease, meaning that, unless you are exhibiting symptoms of any of these diseases, you’re not likely to receive care to treat them. He suggests that healthcare writ large should pivot from this approach to Medicine 3.0, which takes a more holistic view of your health, including tests that are not likely to be paid for under the current system, that will help identify the potential for developing these diseases and perhaps more importantly, putting a plan in place, regardless of age, to help either prevent or delay the onset of these deadly diseases.
As luck would have it, I have just seen the doctor for my annual physical. One of my concerns is that over the past three years, my total cholesterol has creeped up, this time over the 200 mark (203 to be exact) and while all of my other indicators, including levels of good and bad cholesterol, were in ideal ranges, I was a bit baffled by the result. I eat relatively well and exercise 5-6 days per week. I raised the concern, armed with my results for previous years and while he did not share my concern given the other metrics, he suggested that I get a calcium score test to “close the loop.” The test itself is essentially an MRI that is done at an imaging facility, with scores ranging from 0 (normal) to over 1,000. A score of 0 indicates a low risk of developing heart disease in the future. Scores of between 100-300 indicate a much higher risk as well as significant plaque deposits. This test happens to be relatively inexpensive, but is typically not covered by insurance, so I or anyone getting this test for evaluative purposes is going to have to pay for the test out of pocket. This is exactly the type of test (along with a slew of others) that can help identify issues early on so they can be addressed before they become more of a problem.
For now, Medicine 3.0 is elusive. Dr. Attia treats patients using this approach, but he doesn’t disclose how somebody becomes a patient. The book cites Hugh Jackman as a client, which suggests, at least to me, that his patients are likely ones of means who can pay for diagnostic tests that are not typically covered by insurance. But if you read the book, you can draw your own conclusions.
In any case, I’m not here to debate the merits of medicine 2.0 versus medicine 3.0. One of the more encouraging takeaways was that there are things that we can be doing right now to help ensure a longer healthspan, the most impactful of those being exercise. Sleep and nutrition are of course high on the list, but, to quote the book, “I now tell my patients that exercise is, full stop and hands down, the best tool we have in the neurodeneration prevention tool kit.” “Study after study has found that regular exercisers live as much as a decade longer than sedentary people.”
The book is about longevity, so the approach to exercise is perhaps a bit different than just say hopping on the treadmill and running. The good news for regular exercisers is that it’s relatively easy to incorporate the concepts of exercising for longevity. And the even better news for those who may not be exercising regularly is that it’s pretty easy to start.
I’m going to spend exactly one paragraph talking about the basic approach that I’ve laid out time and again. First, it’s much more important to establish a habit, even if it’s literally 5 minutes a day. I listened to a podcast recently which detailed the experience of a professional body-builder who after taking some time off, was ready to return to working out. He would get dressed, drive to the gym, walk in the door and work out for 5 minutes and then leave. As odd as that sounds, he was re-establishing his habit and routine. Getting dressed, driving to the gym or preparing to workout at home creates a mindset that you are ready to work. And of course, this should be done in consultation with your daily schedule, so you can specifically create a window of time that works for you on a given day.
Now back to the approach. I’m going to focus on cardio this week (strength training is hugely important as well, but I will cover that over the coming weeks). It’s a pretty fascinating framework, one in which Dr. Attia calls the Centenarian Decathlon, which equates to training yourself to be able to do the things you will want to be able to do when you are in your 70’s and 80’s (e.g., picking up a grandchild, hiking up a mountain, etc.). On the cardio side of things, there are two things to pay attention to as it relates to longevity. The first is training in Zone 2 and the second is VO2 Max.
Zone 2 training is defined differently depending on the activity you happen to be doing and your level of athleticism, but in general, you are in Zone 2 when you are able to exercise at about 75% to 80% of your maximum heart rate. In practical terms, this means that you can talk, but perhaps can’t or don’t want to hold a conversation. Zone 2 training builds endurance and should make up the bulk of your training. As a runner, Zone 2 training is critical for building endurance. If you’re just starting an exercise program, walking at a brisk pace is likely to put you in Zone 2, so there really aren’t any barriers to starting. The true health benefit (and here’s where the science and medicine come into play) is that Zone 2 training focuses on your slow twitch muscles which are rich with mitochondria. “Muscle is the largest glycogen storage sink in the body, and as we create more mitochondria, we greatly increase our capacity for disposing of that stored fuel, rather than having it end up as fat or remaining in our plasma. Chronic blood glucose elevations damage organs from our heart to our brain to our kidneys and nearly everything in between—even contributing to erectile dysfunction in men.” I had long ago realized the benefits of incorporating Zone 2 endurance training into my workouts as a way to improve performance, but of course, I had no idea of the additional health benefits and more importantly, the impact on longevity.
VO2 Max is a bit more difficult for the average person to measure. VO₂ max refers to the maximum amount of oxygen your body can absorb and use during exercise. It measures your aerobic fitness levels. If you have an Apple Watch and have run or walked outside, you may have noticed these metrics. The Apple Watch can estimate your VO2 levels, but to accurately measure VO2 max, you’ll need to be hooked up to machines on a treadmill or bike so that they can accurately read your oxygen input against your level of exertion. For the time being, I rely on the rough estimate from my Apple Watch though at some point, I would like to get the test done to see where my real VO2 Max lies and of course, to help verify the accuracy of the metric provided by my Apple Watch.
VO2 Max is displayed as a score, and whether it’s good or not really depends on your age.
The very good news is that VO2 Max can be improved regardless of your age. It will require working out at higher levels 1-2 times per week in addition to the work you are doing in Zone 2. A typical VO2 Max workout may look like this (using a treadmill as an example).
Start by warming up for 4 minutes at a jog.
Increase your speed to an interval that challenges you for 4 minutes; it’s sustainable, but not easy.
Jog for 4 minutes.
Repeat the workout 4-6 times.
Now if you’re just starting your fitness journey, this certainly sounds daunting, so I would suggest focusing your training in Zone 2 for 4-6 months. Additionally, even if you are “in good shape,” you may want to work up to the 4-6 intervals at 4 minutes over time. This could mean doing 2 sets of 4 minutes or 4 sets of 2 minutes, but it’s something that you will need to work up to.
In the coming weeks I’ll speak more to strength training, sleep, nutrition and mental well-being as things that we have control over in our quest to win the Centenarian Decathlon! Enjoy your week!
Great information Chris. I've been at it for decades and it has been my best friend for every situation. Could not agree more! Cheers.