Outlive: The Science and Art of Longevity

Outlive: The Science of Art & Longevity (2023) written by American physician Peter Attia with journalist Bill Gifford, focuses on how humans can live longer and live longer for better. By drawing on a wide body of science, anecdotes, and personal stories, Attia communicates complex biological processes to a general audience. The crux of Attia’s argument is that we need to maximize both chronological lifespan (age) and healthspan (quality of life), which represent the two key components of longevity. Attia believes that modern medicine (Medicine 2.0) is ill-equipped to help us achieve our longevity objectives. Instead, he argues that people need to take control of all aspects of their health to craft a strategy that works for them based on science. He believes only a new way of thinking about medicine—Medicine 3.0—can help people do this.

Outlive was a Sunday Times and New York Times Bestseller. While it has generally received positive feedback, there has been some criticism that Attia puts anecdotal evidence above scientific findings, and that some of his tools (e.g., exercising for several hours each day and perspectives on diet) are out of reach for most people.

This guide uses the 2023 Random House Books edition.

Plot Summary

Outlive is divided into three parts. The first part focuses on the science of longevity. Attia notes that his interest in longevity research began when he was a medical resident at Johns Hopkins Hospital, where he saw both fast and slow deaths. Slow deaths, which include the “Four Horsemen” diseases (metabolic dysfunction, cancer, neurogenerative diseases, and heart disease), especially bothered him. He could not fathom how Medicine 2.0 kept catching these diseases only when they were embedded within the human body and much more difficult to reverse, mitigate, or treat. He slowly realized that Medicine 2.0 focused too heavily on treatment over prevention. Attia’s goal with Medicine 3.0 is to focus on prevention.

Attia also introduces his three-part approach to longevity. The first part is objective, which is the reason(s) behind why someone wants to extend their lifespan and healthspan. People can tailor their longevity objectives to meet their own needs. The second part is strategy. Attia underscores that strategy needs to be based on scientific evidence. The final part is tactics. Tactics are the tools people use to achieve their lifespan and healthspan goals.

Attia focuses on strategy in Part 2. Specifically, he discusses the biological mechanisms that predispose people to the Four Horsemen diseases. He also discusses how each disease progresses, Medicine 2.0’s current approach for treating them, how this approach is failing, and where Medicine 3.0 can offer (better) alternatives. One of the key ideas in this section is that metabolic health is critically important to broader health. Poor metabolic health makes people more susceptible to the other Horsemen diseases. Attia also emphasizes that metabolic dysfunction, heart disease, neurogenerative diseases, and cancer do not just appear overnight. Instead, they slowly develop in the body, often for decades. Since Medicine 2.0 focuses on treatment, this approach often misses major icebergs (or symptoms) that something is terribly wrong within the human body. Recognizing these danger points is the first step to developing tactics that will reduce the risks of Horsemen diseases.

Part 3 focuses on five tactical domains that will help alter health. The first is exercise, which Attia considers to be the most powerful longevity drug. Exercise is not just one thing, so Attia breaks it down into the facets he believes need to be optimized to achieve longevity goals: aerobic efficiency and endurance, strength training, and stability training. The second is diet, which he prefers to call “nutritional biochemistry.” Here, he focuses on the different levers that people can manipulate to address whether they are overnourished or undernourished. Next, he focuses on quality and quantity of sleep, which is incredibly important to maintaining health more broadly. Many people sleep poorly, so Attia provides tools to help make one’s sleeping environment more conducive for sleep. Finally, Attia discusses emotional health, which he believes is the most important part of healthspan. He tells his own emotional health journey, stressing that it is good to ask for help and that living longer will not be better if you are unhappy. The fifth domain is exogenous molecules (e.g., drugs, hormones, and supplements). Attia touches on this domain throughout the book.

Outlive is a call to action for people to become captains of their own ship (i.e., health). While he does not tell people what to do, he provides key scientific knowledge and tools that people can use to create their own longevity playbook.