- The Science and Art of Longevity

- Part 1

- Chapter 1: The Long Game: From Fast Death to Slow Death

- “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.” - Bishop Desmond Tutu

- Cancer doesn’t care how rich you are. Or who your surgeon is, really. If it wants to find a way to kill you, it will.

- Longevity does not mean living forever. Barring some major breakthrough that, somehow, someway, reverses two billion years of evolutionary history and frees us from time’s arrow, everyone and everything that is alive today will inevitably die. It’s a one-way street.

- The majority of people reading this book can expect to die somewhere in their seventies or eighties, give or take, and almost all from “slow” causes. 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.

- 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.

- 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.

- Striving for physical health and longevity is meaningless if we ignore our emotional health. Emotional suffering can decimate our health on all fronts, and it must be addressed.

- Chapter 2: Medicine 3.0: Rethinking Medicine for the Age of Chronic Disease

- “The time to repair the roof is when the sun is shining.” - John F. Kennedy

- “First, do no harm.” - Hippocrates

- 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.

1. Medicine 3.0 places a far greater emphasis on prevention than treatment.

2. Medicine 3.0 considers the patient as a unique individual.

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

- At the level of the individual patient, we should be willing to ask deeper questions of risk versus reward versus cost for this therapy—and for almost anything else we might do.

4. Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life.

- We want more out of life than simply the absence of sickness or disability. We want to be thriving, in every way, throughout the latter half of our lives.

- Health insurance companies won’t pay a doctor very much to tell a patient to change the way he eats, or to monitor his blood glucose levels in order to help prevent him from developing type 2 diabetes. Yet insurance will pay for this same patient’s (very expensive) insulin after he has been diagnosed. Similarly, there’s no billing code for putting a patient on a comprehensive exercise program designed to maintain her muscle mass and sense of balance while building her resistance to injury. But if she falls and breaks her hip, then her surgery and physical therapy will be covered. Nearly all the money flows to treatment rather than prevention—and when I say “prevention,” I mean prevention of human suffering. Continuing to ignore healthspan, as we’ve been doing, not only condemns people to a sick and miserable older age but is guaranteed to bankrupt us eventually.

- 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.

- Chapter 3: Objective, Strategy, Tactics: A Road Map for Reading This Book

- “Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.” - Sun Tzu

- The tactics are what you do when you are actually in the ring. The strategy is the harder part, because it requires careful study of one’s opponent, identifying his strengths and weaknesses, and figuring out how to use both to your advantage, well before actually stepping in the ring.

- You don’t need a strategy if your objective is, say, to avoid getting a sunburn. Your straightforward tactical options are to put on sunblock, long sleeves and pants, and perhaps a big hat, or to stay out of the sun altogether. But we need a strategy in order to live longer and better, because longevity is a far more complex problem than sunburn.

- Living longer means delaying death from all four of the Horsemen. The Horsemen do have one powerful risk factor in common, and that is age. As you grow older, the risk grows exponentially that one or more of these diseases has begun to take hold in your body.

- Aging is characterized by a progressive loss of physiological integrity, leading to impaired function and increased vulnerability to death. This deterioration is the primary risk factor for major human pathologies, including cancer, diabetes, cardiovascular disorders, and neurodegenerative diseases.

- Without an understanding of the strategy, and the science that informs it, our tactics will not mean much, and you’ll forever ride the merry-go-round of fad diets and trendy workouts and miracle supplements.

- I think about healthspan and its deterioration in terms of three categories, or vectors. The first vector of deterioration is cognitive decline. Our processing speed slows down. We can’t solve complex problems with the quickness and ease that we once did. Our memory begins to fade. Our executive function is less reliable. Our personality changes, and if it goes on for long enough, even our sentient self is lost. The second vector of deterioration is the decline and eventual loss of function of our physical body. This may precede or follow cognitive decline; there is no predetermined order. But as we grow older, frailty stalks us. We lose muscle mass and strength, along with bone density, stamina, stability, and balance, until it becomes almost impossible to carry a bag of groceries into the house. Chronic pains prevent us from doing things we once did with ease. At the same time, the inexorable progression of atherosclerotic disease might leave us gasping for breath when we walk to the end of the driveway to fetch the newspaper. The third and final category of deterioration, I believe, has to do with emotional health. Unlike the others, this one is largely independent of age; it can afflict outwardly healthy young people in their twenties, or it can creep up on you in middle age, as it did with me. Or it can descend later in life. Surveys show that happiness tends to reach its nadir in our forties (age forty-seven, to be exact), but as I learned through painful experience, middle-aged distress often has its roots much earlier, in adolescence or childhood. And we may not recognize that we are in danger until we reach a crisis point, as I did. How we deal with it has a huge bearing on our physical health, our happiness, and our very survival.

- Our tactics in Medicine 3.0 fall into five broad domains: exercise, nutrition, sleep, emotional health, and exogenous molecules, meaning drugs, hormones, or supplements.

- I used to prioritize nutrition over everything else, but I now consider exercise to be the most potent longevity “drug” in our arsenal, in terms of lifespan and healthspan. The data are unambiguous: exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention. We also tend to feel better when we exercise, so it probably has some harder-to-measure effect on emotional health as well.

- The best science out there says that what you eat matters, but the first-order term is how much you eat: how many calories you take into your body.

- Good sleep is critical to our innate physiological repair processes, especially in the brain, while poor sleep triggers a cascade of negative downstream consequences, from insulin resistance to cognitive decline, as well as mental health issues.

- Part 2

- Chapter 4: Centenarians: The Older You Get, the Healthier You Have Been

- “Whiskey’s a good medicine. It keeps your muscles tender.” - Richard Overton

- Never inhale smoke.

- The oldest person to have ever lived was 122.

- Despite the fact that female centenarians outnumber males by at least four to one, the men generally scored higher on both cognitive and functional tests.

- APOE can determine if you are going to get Alzheimer's disease.

- APOE e2 (and no e4) were about 30 percent more likely to reach extreme old age (defined as ninety-seven for men, one hundred for women) than people with the standard e3/e3 combination. Meanwhile, those with two copies of e4, one from each parent, were 81 percent less likely to live that long, according to the analysis.

- When we are slightly deprived of nutrients, or when we are exercising, FOXO3 tends to be more activated, which is what we want.

- A 2007 study found that older people who were put on a regular exercise program shifted to a more youthful pattern of gene expression after six months. This suggests that genetics and environment both play a role in longevity and that it may be possible to implement interventions that replicate at least some of the centenarians’ good genetic luck.

- Our goal is to live longer without disease.

- I think that the centenarians’ secret comes down to one word: resilience. They are able to resist and avoid cancer and cardiovascular disease, even when they have smoked for decades. They are able to maintain ideal metabolic health, often despite a lousy diet. And they resist cognitive and physical decline long after their peers succumb. It is this resilience that we want to cultivate.

- Chapter 5: Eat Less, Live Longer?: The Science of Hunger and Health

- “Scientists who play by someone else’s rules don’t have much chance of making discoveries.” - Jack Horner

- Rapamycin slows down the process of cellular growth and division.

- The job of mTOR is basically to balance an organism’s need to grow and reproduce against the availability of nutrients. When food is plentiful, mTOR is activated and the cell (or the organism) goes into growth mode, producing new proteins and undergoing cell division, as with the ultimate goal of reproduction. When nutrients are scarce, mTOR is suppressed and cells go into a kind of “recycling” mode, breaking down cellular components and generally cleaning house. Cell division and growth slow down or stop, and reproduction is put on hold to allow the organism to conserve energy.

- When resveratrol was subjected to the same sort of rigorous testing as rapamycin, as part of a National Institute on Aging program to test potential antiaging interventions, it did not extend lifespan in a similar diverse population of normal mice.

- Modern experiments have demonstrated, over and over, that reducing the food intake of lab animals could lengthen their lives.

- Discourses on the Sober Life by Alvise Cornaro #book

- Studies dating back to the 1930s have found that limiting caloric intake can lengthen the lifespan of a mouse or a rat by anywhere from 15 to 45 percent, depending on the age of onset and degree of restriction. Not only that, but the underfed animals also seem to be markedly healthier for their age, developing fewer spontaneous tumors than normally fed mice. CR seems to improve their healthspan in addition to their lifespan. You’d think that hunger might be unhealthy, but the scientists have actually found that the less they feed the animals, the longer they live. Its effects seem to be dose dependent, up to a point, almost like a drug.

- AMPK works to inhibit the activity of mTOR, the cellular growth regulator. Specifically, it seems to be a drop in amino acids that induces mTOR to shut down, and with it all the anabolic (growth) processes that mTOR controls. Instead of making new proteins and undergoing cell division, the cell goes into a more fuel-efficient and stress-resistant mode, activating an important cellular recycling process called autophagy, which means “self-eating” (or better yet, “self-devouring”).

- Autophagy represents the catabolic side of metabolism, when the cell stops producing new proteins and instead begins to break down old proteins and other cellular structures into their amino acid components, using the scavenged materials to build new ones. It’s a form of cellular recycling, cleaning out the accumulated junk in the cell and repurposing it or disposing of it.

- Chapter 6: The Crisis of Abundance: Can Our Ancient Genes Cope with Our Modern Diet?

- “Avoidable human misery is more often caused not so much by stupidity as by ignorance, particularly our ignorance about ourselves.” - Carl Sagan

- Signs of metabolic syndrome

1. high blood pressure (>130/85)

2. high triglycerides (>150 mg/dL)

3. low HDL cholesterol (<40 mg/dL in men or <50 mg/dL in women)

4. central adiposity (waist circumference >40 inches in men or >35 in women)

5. elevated fasting glucose (>110 mg/dL)

- Metabolism is the process by which we take in nutrients and break them down for use in the body. In someone who is metabolically healthy, those nutrients are processed and sent to their proper destinations. But when someone is metabolically unhealthy, many of the calories they consume end up where they are not needed, at best—or outright harmful, at worst.

- But if you continue to consume energy in excess of your needs, those subcutaneous fat cells will slowly fill up, particularly if little of that stored energy is being utilized. When someone reaches the limit of their capacity to store energy in their subcutaneous fat, yet they continue to take on excess calories, all that energy still has to go somewhere.

- Insulin is all about fat storage, not fat utilization.

- Evolution wants us to get fat when nutrients are abundant: the more energy we could store, in our ancestral past, the greater our chances of survival and successful reproduction. We needed to be able to endure periods of time without much food, and natural selection obliged, endowing us with genes that helped us conserve and store energy in the form of fat. That enabled our distant ancestors to survive periods of famine, cold climates, and physiologic stressors such as illness and pregnancy. But these genes have proved less advantageous in our present environment, where many people in the developed world have access to almost unlimited calories.

- Fructose isn’t the only thing that creates uric acid; foods high in chemicals called purines, such as certain meats, cheeses, anchovies, and beer, also generate uric acid. This is why gout, a condition of excess uric acid, was so common among gluttonous aristocrats in the olden days (and still today).

- I monitor several biomarkers related to metabolism, keeping a watchful eye for things like elevated uric acid, elevated homocysteine, chronic inflammation, and even mildly elevated ALT liver enzymes.

- Chapter 7: The Ticker: Confronting—and Preventing—Heart Disease, the Deadliest Killer on the Planet

- “There is some risk involved in action, there always is. But there is far more risk in failure to act.” - Harry S. Truman

- Cholesterol is essential to life. It is required to produce some of the most important structures in the body, including cell membranes; hormones such as testosterone, progesterone, estrogen, and cortisol; and bile acids, which are necessary for digesting food.

- Cholesterol is not a nutrient of concern for overconsumption.

- Fully half of all major adverse cardiovascular events in men (and a third of those in women), such as heart attack, stroke, or any procedure involving a stent or a graft, occur before the age of sixty-five. In men, one-quarter of all events occur before age fifty-four.

- Atlas of Atherosclerosis Progression and Regression, by Herbert C. Stary #book

- Evidence has piled up pointing to apoB as far more predictive of cardiovascular disease than simply LDL-C, the standard “bad cholesterol” measure. According to an analysis published in JAMA Cardiology in 2021, each standard-deviation increase in apoB raises the risk of myocardial infarction by 38 percent in patients without a history of cardiac events or a diagnosis of cardiovascular disease (i.e., primary prevention). That’s a powerful correlation. Yet even now, the American Heart Association guidelines still favor LDL-C testing instead of apoB. I have all my patients tested for apoB regularly, and you should ask for the same test the next time you see your doctor. (Don’t be waved off by nonsensical arguments about “cost”: It’s about twenty to thirty dollars.)

- If you have a history of premature heart attacks in your family, you should definitely ask for an Lp(a) test.

- In my clinical experience, about a third to half of people who consume high amounts of saturated fats (which sometimes goes hand in hand with a ketogenic diet) will experience a dramatic increase in apoB particles, which we obviously don’t want.[*8] Monounsaturated fats, found in high quantities in extra virgin olive oil, macadamia nuts, and avocados (among other foods), do not have this effect, so I tend to push my patients to consume more of these, up to about 60 percent of total fat intake. The point is not necessarily to limit fat overall but to shift to fats that promote a better lipid profile.

- Medicine 3.0 takes a much longer view—and more importantly seeks to identify and eliminate the primary causative agent in the disease process: apoB.

- The sooner you cut the head off the snake, the lower the risk that it will bite you.

- Chapter 8: The Runaway Cell: New Ways to Address the Killer That Is Cancer

- “You may have to fight a battle more than once to win it.” - Margaret Thatcher

- We need to try to detect cancer as early as possible so that our treatments can be deployed more effectively. I advocate early, aggressive, and broad screening for my patients—such as colonoscopy (or other colorectal cancer screening) at age forty, as opposed to the standard recommendation of forty-five or fifty—because the evidence is overwhelming that it’s much easier to deal with most cancers in their early stages.

- Contrary to popular belief, cancer cells don’t grow faster than their noncancerous counterparts; they just don’t stop growing when they are supposed to. For some reason, they stop listening to the body’s signals that tell them when to grow and when to stop growing.

- Metabolic therapies, including dietary manipulations that lower insulin levels, could potentially help slow the growth of some cancers and reduce cancer risk. There is already some evidence that tinkering with metabolism can affect cancer rates. As we have seen, laboratory animals on calorically restricted (CR) diets tend to die from cancer at far lower rates than control animals on an ad libitum (all-they-can-eat) diet. Eating less appears to give them some degree of protection. The same may hold true in people: one study of caloric restriction in humans found that limiting caloric intake directly turns down the PI3K-associated pathway, albeit in muscle (which is not susceptible to cancer). This may be a function of lowered insulin rather than lower glucose levels.

- She had concluded that a diet that reduced insulin and IGF-1 would aid in her treatment. So she worked out a regimen that consisted primarily of leafy vegetables, olive oil, avocados, nuts, and modest amounts of protein, mostly from fish, eggs, and poultry. The diet was just as notable for what it did not contain: added sugar and refined carbohydrates. All along, she underwent frequent blood tests to make sure her insulin and IGF-1 levels stayed low, which they did.

- This flies in the face of traditional practice, which is to try to get patients on chemotherapy to eat as much as they can tolerate, typically in the form of high-calorie and even high-sugar diets. The American Cancer Society suggests using ice cream “as a topping on cake.

- Too many cancers are detected too late, after they’ve grown and spread via metastasis.

- Out of dozens of different types of cancers, we have agreed-upon, reliable screening methods for only five: lung (for smokers), breast, prostate, colorectal, and cervical. Even so, mainstream guidelines have been waving people away from some types of early screening, such as mammography in women and blood testing for PSA, prostate-specific antigen, in men. In part this has to do with cost, and in part this has to do with the risk of false positives that may lead to unnecessary or even dangerous treatment.

- Typically encouraging average-risk individuals to get a colonoscopy by age forty—and even sooner if anything in their history suggests they may be at higher risk. We then repeat the procedure as often as every two to three years, depending on the findings from the previous colonoscopy. If a sessile (flat) polyp is found, for example, we’re inclined to do it sooner than if the endoscopist finds nothing at all. Two or three years might seem like a very short window of time to repeat such an involved procedure, but colon cancer has been documented to appear within the span of as little as six months to two years after a normal colonoscopy. Better safe than sorry.

- It’s possible that not screening early and frequently enough is the most dangerous option.

- Other cancers that are relatively easy to spot on visual examination include skin cancer and melanomas. The pap smear for cervical cancer is another well-established, minimally invasive test that I recommend my patients do yearly.

- Chapter 9: Chasing Memory: Understanding Alzheimer's Disease and Other Neurodegenerative Diseases

- “The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.” - Daniel J. Boorstin

- We set up another appointment for a week later to review her initial blood work. I rely as much as one can on biomarkers, so we run a comprehensive array of tests, but there are a few things that I immediately scan for when I get a new patient’s results back. Among them is their level of Lp(a), the high-risk lipoprotein that we talked about in chapter 7, along with their apoB concentration. A third thing that I always check is their APOE genotype, the gene related to Alzheimer’s disease risk that we mentioned in chapter 4.

- Alzheimer’s disease is perhaps the most difficult, most intractable of the Horsemen diseases. We have a much more limited understanding of how and why it begins, and how to slow or prevent it, than we do with atherosclerosis. Unlike with cancer, we currently have no way to treat it once symptoms begin. And unlike type 2 diabetes and metabolic dysfunction, it does not appear to be readily reversible (although the jury is still out on that). This is why, almost without exception, my patients fear dementia more than any other consequence of aging, including death. They would rather die from cancer or heart disease than lose their minds, their very selves.

- Plato believed that because advancing age seemingly “gives rise to all manners of forgetfulness as well as stupidity,” older men were unsuited for leadership positions requiring acumen or judgment. William Shakespeare gave us an unforgettable portrayal of an old man struggling with his failing mind in King Lear.

- While those of African descent are at an overall increased risk of developing Alzheimer’s disease, for unclear reasons, APOE e4 seems to present less risk to them than to people of Caucasian, Asian, and Hispanic descent.

- Alzheimer’s disease is almost twice as common in women than in men.

- Other reproductive history factors, such as the number of children the woman has had, age of first menstruation, and exposure to oral contraceptives, may also have a significant impact on Alzheimer’s risk and later life cognition. And new research suggests that women are more prone to accumulate tau, the neurotoxic protein we mentioned earlier. The end result is that women have a greater age-adjusted risk of Alzheimer’s, as well as faster rates of disease progression overall, regardless of age and educational level.

- While female Alzheimer’s patients outnumber men by two to one, the reverse holds true for Lewy body dementia and Parkinson’s, both of which are twice as prevalent in men. Yet Parkinson’s also appears to progress more rapidly in women than in men, for reasons that are not clear.

- These are clinically validated, highly complex tests that cover every domain of cognition and memory, including executive function, attention, processing speed, verbal fluency and memory (recalling a list of words), logical memory (recalling a phrase in the middle of a paragraph), associative memory (linking a name to a face), spatial memory (location of items in a room), and semantic memory (how many animals you can name in a minute, for example).

- Frontal and vascular dementias primarily affect the frontal lobe, a region of the brain responsible for executive functioning such as attention, organization, processing speed, and problem solving. So these forms of dementia rob an individual of such higher-order cognitive features. Alzheimer’s disease, on the other hand, predominantly affects the temporal lobes, so the most distinct symptoms relate to memory, language, and auditory processing (forming and comprehending speech)—although researchers are beginning to identify different possible subtypes of Alzheimer’s disease, based on which brain regions are most affected. Parkinson’s is a bit different in that it manifests primarily as a movement disorder, resulting from (in part) a deficiency in producing dopamine, a key neurotransmitter. While Alzheimer’s can be confirmed by testing for amyloid in the cerebrospinal fluid, these other forms of neurodegeneration are largely clinical diagnoses, based on testing and interpretation. Thus, they can be more subjective, but with all these conditions it is critical to identify them as soon as possible, to allow more time for preventive strategies to work.

- The more of these networks and subnetworks that we have built up over our lifetime, via education or experience, or by developing complex skills such as speaking a foreign language or playing a musical instrument, the more resistant to cognitive decline we will tend to be.

- People that have Alzheimer’s disease and are very cognitively engaged, and have a good backup pathway, they’re not going to decline as quickly.

- People with better movement patterns, and a longer history of moving their bodies, such as trained or frequent athletes, tend to resist or slow the progression of the disease as compared to sedentary people. This is also why movement and exercise, not merely aerobic exercise but also more complex activities like boxing workouts, are a primary treatment/prevention strategy for Parkinson’s. Exercise is the only intervention shown to delay the progression of Parkinson’s.

- Dancing appears to be more effective than walking at delaying symptoms of Parkinson’s disease, possibly because it involves more complex movement.

- The brain is a greedy organ. It makes up just 2 percent of our body weight, yet it accounts for about 20 percent of our total energy expenditure.

- Alzheimer’s is more likely to be diagnosed in patients who have suffered a stroke, which typically results from a sudden blockage of blood flow in specific regions of the brain.

- In all, some two dozen known risk factors for Alzheimer’s disease also happen to reduce blood flow, including high blood pressure, smoking, head injury, and depression, among others.

- Another compelling and perhaps parallel theory of Alzheimer’s disease says that it stems from abnormal glucose metabolism in the brain. Scientists and physicians have long noted a connection between Alzheimer’s disease and metabolic dysfunction. Having type 2 diabetes doubles or triples your risk of developing Alzheimer’s disease, about the same as having one copy of the APOE e4 gene.

- Insulin seems to play a key role in memory function. Insulin receptors are highly concentrated in the hippocampus, the memory center of the brain. Several studies have found that spraying insulin right into subjects’ noses—administering it as directly as possible into their brains—quickly improves cognitive performance and memory, even in people who have already been diagnosed with Alzheimer’s disease.

- A woman with one copy of e4 is four times more likely to develop the disease than a man with the same genotype.

- Our goal is to improve glucose metabolism, inflammation, and oxidative stress.

- One possible recommendation for someone like her would be to switch to a Mediterranean-style diet, relying on more monounsaturated fats and fewer refined carbohydrates, in addition to regular consumption of fatty fish. There is some evidence that supplementation with the omega-3 fatty acid DHA, found in fish oil, may help maintain brain health, especially in e4/e4 carriers. Higher doses of DHA may be required because of e4-induced metabolic changes and dysfunction of the blood-brain barrier.

- This is also one area where a ketogenic diet may offer a real functional advantage: when someone is in ketosis, their brain relies on a mix of ketones and glucose for fuel. Studies in Alzheimer’s patients find that while their brains become less able to utilize glucose, their ability to metabolize ketones does not decline. So it may make sense to try to diversify the brain’s fuel source from only glucose to both glucose and ketones. A systematic review of randomized controlled trials found that ketogenic therapies improved general cognition and memory in subjects with mild cognitive impairment and early-stage Alzheimer’s disease.

- In Stephanie’s case, she cut out not only added sugar and highly refined carbohydrates but also alcohol. The precise role of alcohol in relation to Alzheimer’s disease remains somewhat controversial: some evidence suggests that alcohol may be slightly protective against Alzheimer’s, while other evidence shows that heavier drinking is itself a risk factor for the disease, and e4 carriers may be more susceptible to alcohol’s deleterious effects. I’m inclined to err on the side of caution, and so is Stephanie.

- The single most powerful item in our preventive tool kit is exercise, which has a two-pronged impact on Alzheimer’s disease risk: it helps maintain glucose homeostasis, and it improves the health of our vasculature. So along with changing Stephanie’s diet, we put her back on a regular exercise program, focusing on steady endurance exercise to improve her mitochondrial efficiency. This had a side benefit in that it helped manage her off-the-charts high cortisol levels, due to stress; stress and anxiety-related risk seem more significant in females.

- Endurance exercise produces factors that directly target regions of the brain responsible for cognition and memory. It also helps lower inflammation and oxidative stress.

- Strength training is likely just as important. A study looking at nearly half a million patients in the United Kingdom found that grip strength, an excellent proxy for overall strength, was strongly and inversely associated with the incidence of dementia (see figure 8). People in the lowest quartile of grip strength (i.e., the weakest) had a 72 percent higher incidence of dementia, compared to those in the top quartile.

- There appeared to be no upper limit or “plateau” to this relationship; the greater someone’s grip strength, the lower their risk of dementia.

- I now tell patients that exercise is, full stop and hands down, the best tool we have in the neurodegeneration prevention tool kit.

- Sleep is also a very powerful tool against Alzheimer’s disease, as we’ll see in chapter 16. Sleep is when our brain heals itself; while we are in deep sleep our brains are essentially “cleaning house,” sweeping away intracellular waste that can build up between our neurons. Sleep disruptions and poor sleep are potential drivers of increased risk of dementia. If poor sleep is accompanied by high stress and elevated cortisol levels, as in Stephanie’s case, that acts almost as a multiplier of risk, as it contributes to insulin resistance and damaging the hippocampus at the same time. Furthermore, hypercortisolemia (excess cortisol due to stress) impairs the release of melatonin, the hormone that normally signals to our brains that it is time to go to sleep (and that may also help prevent neuronal loss and cognitive impairment). Addressing Stephanie’s difficulties with sleep was therefore urgent. Her divorce and her work situation were making it almost impossible for her to get more than four hours of uninterrupted sleep on any given night.

- Another somewhat surprising risk factor that has emerged is hearing loss. Studies have found that hearing loss is clearly associated with Alzheimer’s disease, but it’s not a direct symptom. Rather, it seems hearing loss may be causally linked to cognitive decline, because folks with hearing loss tend to pull back and withdraw from interactions with others. When the brain is deprived of inputs—in this case auditory inputs—it withers. Patients with hearing loss miss out on socializing, intellectual stimulation, and feeling connected; prescribing them hearing aids may help relieve some symptoms. This is just a hypothesis for the moment, but it is being tested right now in a clinical trial called ACHIEVE (Aging and Cognitive Health Evaluation in Elders) that is currently ongoing.

- Another surprising intervention that may help reduce systemic inflammation, and possibly Alzheimer’s disease risk, is brushing and flossing one’s teeth. (You heard me: Floss.) There is a growing body of research linking oral health, particularly the state of one’s gum tissue, with overall health. Researchers have found that one pathogen in particular, a microbe called P. gingivalis that commonly causes gum disease, is responsible for large increases in levels of inflammatory markers such as IL-6.

- The best interpretation I can draw from the literature suggests that at least four sessions per week, of at least twenty minutes per session, at 179 degrees Fahrenheit (82 degrees Celsius) or hotter seems to be the sweet spot to reduce the risk of Alzheimer’s by about 65 percent (and the risk of ASCVD by 50 percent).

- Other potential interventions that have shown some promise in studies include lowering homocysteine with B vitamins, while optimizing omega-3 fatty acids. Higher vitamin D levels have been correlated with better memory in e4/e4 patients but it’s difficult to know from the current literature if this means supplementing with vitamin D will reduce risk of AD. And as mentioned earlier, hormone replacement therapy for women during the transition from perimenopause to menopause seems promising, especially for women with at least one copy of e4.

- Our strategy should be based on the following principles:

1. WHAT’S GOOD FOR THE HEART IS GOOD FOR THE BRAIN. That is, vascular health (meaning low apoB, low inflammation, and low oxidative stress) is crucial to brain health.

2. WHAT’S GOOD FOR THE LIVER (AND PANCREAS) IS GOOD FOR THE BRAIN. Metabolic health is crucial to brain health.

3. TIME IS KEY. We need to think about prevention early, and the more the deck is stacked against you genetically, the harder you need to work and the sooner you need to start. As with cardiovascular disease, we need to play a very long game.

4. OUR MOST POWERFUL TOOL FOR PREVENTING COGNITIVE DECLINE IS EXERCISE. We’ve talked a lot about diet and metabolism, but exercise appears to act in multiple ways (vascular, metabolic) to preserve brain health; we’ll get into more detail in Part III, but exercise—lots of it—is a foundation of our Alzheimer’s-prevention program.

- Part 3

- Chapter 10: Thinking Tactically: Building a Framework of Principles That Work for You

- “Absorb what is useful, discard what is useless, and add what is specifically your own.” - Bruce Lee

- “Cancer, like insanity, seems to increase with the progress of civilization.” - Stanislas Tanchou

- Eventually cancer, as well as heart disease, type 2 diabetes, and dementia (along with a few others), became collectively known as “diseases of civilization,” because they seemed to have spread in lockstep with the industrialization and urbanization of Europe and the United States.

- This doesn’t mean that civilization is somehow “bad” and that we all need to return to a hunter-gatherer lifestyle. I would much rather live in our modern world, where I worry about losing my iPhone or missing a plane flight, than endure the rampant disease, random violence, and lawlessness that our ancestors suffered through for millennia (and that people in some parts of our world still experience).

- In Medicine 3.0, we have five tactical domains that we can address in order to alter someone’s health. The first is exercise, which I consider to be by far the most potent domain in terms of its impact on both lifespan and healthspan. Of course, exercise is not just one thing, so I break it down into its components of aerobic efficiency, maximum aerobic output (VO2 max), strength, and stability, all of which we’ll discuss in more detail. Next is diet or nutrition—or as I prefer to call it, nutritional biochemistry. The third domain is sleep, which has gone underappreciated by Medicine 2.0 until relatively recently. The fourth domain encompasses a set of tools and techniques to manage and improve emotional health. Our fifth and final domain consists of the various drugs, supplements, and hormones that doctors learn about in medical school and beyond. I lump these into one bucket called exogenous molecules, meaning molecules we ingest that come from outside the body.

- The obvious tactics we already know about to not die while driving: wear a seat belt, don’t text and drive (seemingly difficult for many people), and don’t drink and drive, since alcohol is a factor in up to a third of fatalities. Automotive fatality statistics also reveal that almost 30 percent of deaths involve excessive speed.

- A very high proportion of fatalities occur at intersections. The most common way to be killed, as a driver, is by another car that hits yours from the left, on the driver’s side, having run a red light or traveling at high speed. It’s typically a T-bone or broadside crash, and often the driver who dies is not the one at fault.

- We are most concerned about cars coming from our left, toward our driver’s side door, so we should pay special attention to that side. At busy intersections, it makes sense to look left, then right, then left again, in case we missed something the first time.

- When I evaluate new patients, I’m always asking three key questions:

- Are they overnourished or undernourished? That is, are they taking in too many or too few calories?

- Are they undermuscled or adequately muscled?

- Are they metabolically healthy or not?”

- But if they are also undermuscled, which is common, we want to be careful to make sure they are still getting enough protein, since the goal is not weight loss but fat loss coupled with muscle gain.

- The action part is their responsibility; not much of this stuff is easy. It requires them to change their habits and do the work.

- Our only goal is to live longer and live better—to outlive.

- Chapter 11: Exercise: The Most Powerful Longevity Drug

- “I never won a fight in the ring; I always won in preparation.” - Muhammad Ali

- More than any other tactical domain we discuss in this book, exercise has the greatest power to determine how you will live out the rest of your life. There are reams of data supporting the notion that even a fairly minimal amount of exercise can lengthen your life by several years. It delays the onset of chronic diseases, pretty much across the board, but it is also amazingly effective at extending and improving healthspan. Not only does it reverse physical decline, which I suppose is somewhat obvious, but it can slow or reverse cognitive decline as well. (It also has benefits in terms of emotional health, although those are harder to quantify.)

- If you adopt only one new set of habits based on reading this book, it must be in the realm of exercise.

- Even a little bit of daily activity is much better than nothing. Going from zero weekly exercise to just ninety minutes per week can reduce your risk of dying from all causes by 14 percent.

- Study after study has found that regular exercisers live as much as a decade longer than sedentary people. Not only do habitual runners and cyclists tend to live longer, but they stay in better health, with less morbidity from causes related to metabolic dysfunction.

- The benefits of exercise begin with any amount of activity north of zero—even brisk walking—and go up from there.

- It turns out that peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, is perhaps the single most powerful marker for longevity. VO2 max represents the maximum rate at which a person can utilize oxygen. This is measured, naturally, while a person is exercising at essentially their upper limit of effort.

- VO2 max is typically expressed in terms of the volume of oxygen a person can use, per kilogram of body weight, per minute. An average forty-five-year-old man will have a VO2 max around 40 ml/kg/min, while an elite endurance athlete will likely score in the high 60s and above. An unfit person in their thirties or forties, on the other hand, might score only in the high 20s on a VO2 max test.

- Muscle may be almost as powerfully correlated with living longer as a high V02 max.

- A ten-year observational study of roughly 4,500 subjects ages fifty and older found that those with low muscle mass were at 40 to 50 percent greater risk of mortality than controls, over the study period.

- Subjects with low muscle strength were at double the risk of death, while those with low muscle mass and/or low muscle strength, plus metabolic syndrome, had a 3 to 3.33 times greater risk of all-cause mortality.

- In numerous randomized clinical trials, exercise-based interventions performed as well as or better than multiple classes of pharmaceutical drugs at reducing mortality from coronary heart disease, prediabetes or diabetes, and stroke.

- Exercise strengthens the heart and helps maintain the circulatory system. It also improves the health of the mitochondria, the crucial little organelles that produce energy in our cells (among other things). That, in turn, improves our ability to metabolize both glucose and fat. Having more muscle mass and stronger muscles helps support and protect the body—and also maintains metabolic health, because those muscles consume energy efficiently. The list goes on and on, but simply put, exercise helps the human “machine” perform far better for longer.

- When we are exercising, our muscles generate molecules known as cytokines that send signals to other parts of our bodies, helping to strengthen our immune system and stimulate the growth of new muscle and stronger bones. Endurance exercise such as running or cycling helps generate another potent molecule called brain-derived neurotrophic factor, or BDNF, that improves the health and function of the hippocampus, a part of the brain that plays an essential role in memory. Exercise helps keep the brain vasculature healthy, and it may also help preserve brain volume.

- Both physical activity levels and muscle mass decline steeply after about age sixty-five, and then even more steeply after about seventy-five.

- Seniors with the least muscle mass (also known as lean mass) are at the greatest risk of dying from all causes.

- It is never too late to start; my mom did not begin lifting weights until she was sixty-seven, and it has changed her life.

- I will find a way to lift heavy weights in some way, shape, or form four times per week, no matter what else I am doing or where I might be traveling.

- The Centenarian Decathlon is the ten most important physical tasks you will want to be able to do for the rest of your life.

1. Hike 1.5 miles on a hilly trail.

2. Get up off the floor under your own power, using a maximum of one arm for support.

3. Pick up a young child from the floor.

4. Carry two five-pound bags of groceries for five blocks.

5. Lift a twenty-pound suitcase into the overhead compartment of a plane.

6. Balance on one leg for thirty seconds, eyes open. (Bonus points: eyes closed, fifteen seconds.)

7. Have sex.

8. Climb four flights of stairs in three minutes.

9. Open a jar.

10. Do thirty consecutive jump-rope skips.

11. Swim half a mile in twenty minutes.

12. Walk with a thirty-pound dumbbell in each hand for one minute.

13. Draw back and fire a fifty-pound compound bow.

14. Do five pull-ups.

15. Climb ninety steps in two minutes (VO2 max = 32).

16. Dead-hang for one minute.

17. Drive a race car within 5 to 8 percent of the pace I can do so today.

18. Hike with a twenty-pound backpack for an hour.

19. Carry my own luggage.

20. Walk up a steep hill.

- The full list is much longer, with more than fifty different items.

- In every case, you need to be doing much more now, to armor yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age.

- Chapter 12: Training 101: How to Prepare for the Centenarian Decathlon

- “It is impossible to produce superior performance unless you do something different from the majority.” - Sir John Templeton

- The three dimensions in which we want to optimize our fitness are aerobic endurance and efficiency (aka cardio), strength, and stability.

- For cardio, we are interested in two particular regions of this continuum: long, steady endurance work, such as jogging or cycling or swimming, where we are training in what physiologists call zone 2, and maximal aerobic efforts, where VO2 max comes into play.

- How we utilize different fuels, glucose and fatty acids, is critical not only to our fitness but also to our metabolic and overall health. Aerobic exercise, done in a very specific way, improves our ability to utilize glucose and especially fat as fuel.

- Typically, zone 1 is a walk in the park and zone 5 (or 6, or 7) is an all-out sprint. Zone 2 is more or less the same in all training models: going at a speed slow enough that one can still maintain a conversation but fast enough that the conversation might be a little strained. It translates to aerobic activity at a pace somewhere between easy and moderate.

- Our mitochondria can convert both glucose and fatty acids to energy—but while glucose can be metabolized in multiple different ways, fatty acids can be converted to energy only in the mitochondria. Typically, someone working at a lower relative intensity will be burning more fat, while at higher intensities they would rely more on glucose. The healthier and more efficient your mitochondria, the greater your ability to utilize fat, which is by far the body’s most efficient and abundant fuel source. This ability to use both fuels, fat and glucose, is called “metabolic flexibility,” and it is what we want.

- When we are exercising in zone 2, most of the work is being done by our type 1, or “slow-twitch,” muscle fibers. These are extremely dense with mitochondria and thus well-suited for slow-paced, efficient endurance work. We can go for a long time without feeling fatigued. If we pick up the pace, we begin to recruit more type 2 (“fast-twitch”) muscle fibers, which are less efficient but more forceful. They also generate more lactate in the process, because of the way they create ATP. Lactate itself is not bad; trained athletes are able to recycle it as a type of fuel. The problem is that lactate becomes lactic acid when paired with hydrogen ions, which is what causes that acute burning you feel in your muscles during a hard effort.

- If you know your maximum heart rate—not estimated, but your actual maximum, the highest number you’ve ever seen on a heart rate monitor—your zone 2 will correspond to between approximately 70 and 85 percent of that peak number, depending on your fitness levels.

- When starting people out, I prefer they rely on their rate of perceived exertion, or RPE, also known as the “talk test.” How hard are you working? How easy is it to speak? If you’re at the top of zone 2, you should be able to talk but not particularly interested in holding a conversation. If you can’t speak in complete sentences at all, you’re likely into zone 3, which means you’re going too hard, but if you can comfortably converse, you’re likely in zone 1, which is too easy.

- Mitochondria are incredibly plastic, and when we do aerobic exercise, it stimulates the creation of many new and more efficient mitochondria through a process called mitochondrial biogenesis, while eliminating ones that have become dysfunctional via a recycling process called mitophagy (which is like autophagy, but for mitochondria). A person who exercises frequently in zone 2 is improving their mitochondria with every run, swim, or bike ride. But if you don’t use them, you lose them.

- For some people, a brisk walk might get them into zone 2; for those in better condition, zone 2 means walking uphill. There are many different ways to do it: you can ride a stationary bicycle at the gym, or walk or jog or run around the track at the local high school, or swim some laps in the pool. The key is to find an activity that fits into your lifestyle, that you enjoy doing, and that enables you to work at a steady pace that meets the zone 2 test: You’re able to talk in full sentences, but just barely.

- About three hours per week of zone 2, or four 45-minute sessions, is the minimum required for most people to derive a benefit and make improvements, once you get over the initial hump of trying it for the first time.

- Four times a week, I will spend about an hour riding my stationary bike at my zone 2 threshold.

- A side benefit of zone 2 is that it also helps with cognition, by increasing cerebral blood flow and by stimulating the production of BDNF, brain-derived neurotrophic factor.

- Studies suggest that your VO2 max will decline by roughly 10 percent per decade—and up to 15 percent per decade after the age of fifty. So simply having average or even above-average VO2 max now just won’t cut it. We are planning for you to live for another thirty years, or forty. If you are only starting at 32 ml/kg/min now, at fifty, you can expect to be closer to 21 ml/kg/min at age eighty.

- The beauty of this is that VO2 max can always be improved by training, no matter how old you are.

- The tried-and-true formula for these intervals is to go four minutes at the maximum pace you can sustain for this amount of time—not an all-out sprint, but still a very hard effort. Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down to below about one hundred beats per minute. Repeat this four to six times and cool down.

- You want to make sure that you get as close to fully recovered as possible before beginning the next set. If you fail to recover sufficiently between sets, you will not be able to reach your peak effort in the working sets and you’ll consequently miss the desired adaptation. Also, be sure to give yourself enough time to warm up and then cool down from this intense effort.

- We lose muscle strength about two to three times more quickly than we lose muscle mass. And we lose power (strength x speed) two to three times faster than we lose strength. This is because the biggest single change in the aging muscle is the atrophy of our fast twitch or type 2 muscle fibers. Ergo, our training must be geared towards improving these with heavy resistance training. Daily life and zone 2 endurance work may be enough to prevent atrophy of type 1 fibers—but unless you are working against significant resistance, your type 2 muscle fibers will wither away.

- It takes much less time to lose muscle mass and strength than to gain it, particularly if we are sedentary.

- A study of twelve healthy volunteers with an average age of sixty-seven found that after just ten days of bed rest, which is about what a person would experience from a major illness or orthopedic injury, study participants lost an average of 3.3 pounds of lean mass (muscle).

- When we detect low or rapidly declining BMD in a middle-aged person, we use the following four strategies:

1. Optimize nutrition, focusing on protein and total energy needs (see nutrition chapters).

2. Heavy loading-bearing activity. Strength training, especially with heavy weights, stimulates the growth of bone—more than impact sports such as running (though running is better than swimming/cycling). Bones respond to mechanical tension and estrogen is the key hormone in mediating the mechanical signal (weight bearing) to a chemical one telling the body to lay down more bone.

3. HRT, if indicated.

4. Drugs to increase BMD, if indicated.

- You should at least check your BMD every few years. (Particularly if your primary sports are nonweight-bearing, like cycling or swimming.)

- It is much better to save and invest and plan ahead, letting your wealth build gradually over decades, than to scramble to try to scrape together an individual retirement account in your late fifties and hope and pray that the stock market gods help you out. Like investing, strength training is also cumulative, its benefits compounding. The more of a reserve you build up, early on, the better off you will be over the long term.

- Strength training is largely about improving your ability to carry things.

- The Comfort Crisis by Michael Easter #book

- “Carrying shaped our species,” he says. “Our ancestors carried often. It gave them robust functional strength and endurance that was likely very protective. But we’ve engineered carrying out of our lives, just as we have many other forms of discomfort. Rucking is a practical way to add carrying back into our lives.”

- A good goal is to be able to carry one-quarter to one-third of your body weight once you develop enough strength and stamina.

- Fundamentally I structure my training around exercises that improve the following:

1. Grip strength, how hard you can grip with your hands, which involves everything from your hands to your lats (the large muscles on your back). Almost all actions begin with the grip.

2. Attention to both concentric and eccentric loading for all movements, meaning when our muscles are shortening (concentric) and when they are lengthening (eccentric). In other words, we need to be able to lift the weight up and put it back down, slowly and with control. Rucking down hills is a great way to work on eccentric strength, because it forces you to put on the “brakes.”

3. Pulling motions, at all angles from overhead to in front of you, which also requires grip strength (e.g., pull-ups and rows).

4. Hip-hinging movements, such as the deadlift and squat, but also step-ups, hip-thrusters, and countless single-leg variants of exercises that strengthen the legs, glutes, and lower back.

- One of the standards we ask of our male patients is that they can carry half their body weight in each hand (so full body weight in total) for at least one minute, and for our female patients we push for 75 percent of that weight.

- We like to see men dead-hang from a pull-up bar for at least two minutes and women for at least ninety seconds at the age of forty.

- No discussion of strength is complete without mentioning concentric and especially eccentric loading. Again, eccentric loading means loading the muscle as it is lengthening, such as when you lower a bicep curl. It’s more intuitive when lifting something to focus on the concentric phase, such as curling the dumbbell with your biceps. This is the strength of a muscle getting shorter.

- Training eccentric strength is relatively simple. Big picture, it means focusing on the “down” phase of lifts ranging from pull-ups or pull-downs to deadlifts to rows; rucking downhill, carrying a weighted pack, is a great way to build both eccentric strength as well as spatial awareness and control, which are important parts of stability training.

- Next is pulling, which is closely related to grip strength. Pulling motions are how we exert our will on the world, whether we are hoisting a bag of groceries out of the car trunk or climbing El Capitan. It is an anchor movement. In the gym, it typically takes the form of rows, where you’re pulling the weight toward your body, or pull-ups. A rowing machine, something I love to use for VO2 max training, is another simple and effective way to work on pulling strength.

- The final foundational element of strength is hip-hinging, which is what it sounds like: You bend at the hips—not the spine—to harness your body’s largest muscles, the gluteus maximus and the hamstrings. (I repeat: Do not bend your spine.)

- Chapter 13: The Gospel of Stability: Relearning How to Move to Prevent Injury

- “The loftier the building, the deeper the foundation must be laid.” - Thomas à Kempis

- The missing X factor that explains why so many people just stop moving is something else: injury. That is, older people tend to exercise less, or not at all, because they simply can’t. They have hurt themselves in some way, at some point in their lives, and they just never got back on the horse. So they continued to decline.

- My first commandment of fitness: First, do thyself no harm.

- We have to break out of the mentality that we must crush all our workouts every single time we go to the gym—doing the most reps, with the heaviest weights, day after day.

- A technical definition might be: stability is the subconscious ability to harness, decelerate, or stop force. A stable person can react to internal or external stimuli to adjust position and muscular tension appropriately without a tremendous amount of conscious thought.

- In my practice, we don’t like to push much strength training, including many of the assessments I’ve discussed, such as dead hangs and weighted step-ups, until we have established some modicum of stability. We don’t think it’s worth the risk. Just as in engineering, it’s worth the extra time to build a solid foundation, even if it delays the project a few months.

- DNS (www.rehabps.com)

- Postural Restoration Institute (PRI) (www.posturalrestoration.com)

- Twice a week, I spend an hour doing dedicated stability training, based on the principles of DNS, PRI, and other practices, with ten to fifteen minutes per day on the other days.

☆ Stability training begins at the most basic level, with the breath.

☆ How we breathe is who we are.

☆ Breathing reflects our mental state and affects it.

☆ If our breathing is off, it can disrupt our mental equilibrium, creating anxiety and apprehension; but anxiety can also worsen any breathing issues we might have. This is because deep, steady breathing activates the calming parasympathetic nervous system, while rapid or ragged breathing triggers its opposite, the sympathetic nervous system, part of the fight-or-flight response.

☆ Researchers found that combining a breathing challenge (reducing the amount of oxygen available to study subjects) with a weight challenge reduced the subjects’ ability to stabilize their spine. In real-world terms, this means that someone who is breathing hard (and poorly) while shoveling snow is putting themselves at increased risk of a back injury.

- She has the patient lie on their back with legs up on a bench or chair, and asks them to inhale as quietly as possible, with the least amount of movement possible. An ideal inhalation expands the entire rib cage—front, sides, and back—while the belly expands at the same time, allowing the respiratory and pelvic diaphragm to descend. The telltale is that it is quiet. Now, exhale fully through pursed lips for maximum compression and air resistance, to strengthen the diaphragm. Blow all that air out, fully emptying yourself before your shoulders round or your face or jaw gets tense. Very soon, you will see how a full exhale prepares you for a good inhale, and vice versa. Repeat the process for five breaths and do two to three sets. Be sure to pause after each exhale for at least two counts to hold the isometric contraction—this is key, in DNS.

- In DNS, you learn to think of the abdomen as a cylinder, surrounded by a wall of muscle, with the diaphragm on top and the pelvic floor below. When the cylinder is inflated, what you’re feeling is called intra-abdominal pressure, or IAP. It’s critical to true core activation and foundational to DNS training. Learning to fully pressurize the cylinder, by creating IAP, is important to safe movement because the cylinder effectively stabilizes the spine.

- https://peterattiamd.com/outlive/videos/

- Think of your feet as having four corners, each of which needs to be rooted firmly on the ground at all times, like the legs of a chair. As you stand there, try to feel each “corner” of each foot pressing into the ground: the base of your big toe, the base of your pinky toe, the inside and outside of your heel.

- Toe Yoga: Try to lift all ten toes off the ground and spread them as wide as you can. Now try to put just your big toe back on the floor, while keeping your other toes lifted. Trickier than you’d think, right? Now do the opposite: keep four toes on the floor and lift only your big toe. Then lift all five toes, and try to drop them one by one, starting with your big toe.

- Now when I squat, or do any standing lift, my first step is to ground my feet, to be aware of all four “corners,” and distribute weight equally. (Also important: I prefer to lift barefoot or in minimal shoes, with little to no cushioning in the soles because it allows me feel the full surface of my feet at all times.)

- That’s what stability is about: safe and powerful transmission of force through muscles and bones, and not joints or spinal hinge points.

- Scapular CARs, for controlled articular rotations: Stand with your feet shoulder-width apart and place a medium to light resistance band under your feet, one handle in each hand (a very light dumbbell also works). Keeping your arms at your sides, raise your shoulder blades, and then squeeze them back and together; this is retraction, which is where we want them to be when under load. Then drop them down your back. Finally, bring them forward to the starting point. We start out moving in squares like this, but the goal is to learn enough control that we can move our scapulae in smooth circles. A large part of what we’re working on in stability training is this kind of neuromuscular control, reestablishing the connection between our brain and key muscle groups and joints.

- Adding carries to your training is a great way to train grip, but it is important always to be mindful of what your fingers are doing and how force is being transmitted through them.

- In order to go faster, you need to go slower.

- If you're not pushing ahead, you're going backwards.

- Chapter 14: Nutrition 3.0: You Say Potato, I Say “Nutritional Biochemistry”

- “Religion is a culture of faith; science is a culture of doubt.” - Richard Feynman

- Nutrition is relatively simple, actually. It boils down to a few basic rules: don’t eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens like E. coli and toxins like mercury or lead.

- If your great-grandmother would not recognize it, you’re probably better off not eating it. If you bought it on the perimeter of the grocery store, it’s probably better than if you bought it in the middle of the store. Plants are very good to eat. Animal protein is “safe” to eat. We evolved as omnivores; ergo, most of us can probably find excellent health as omnivores.

- It’s not about telling you what to eat; it’s about figuring out what works for your body and your goals—and, just as important, what you can stick to.

- The point is that humans are terrible study subjects for nutrition (or just about anything else) because we are unruly, disobedient, messy, forgetful, confounding, hungry, and complicated creatures.

- In fact, I’m convinced that compliance is the key issue in nutrition research, and with diets in general: Can you stick to it?

- Efficacy tests how well the intervention works under perfect conditions and adherence (i.e., if one does everything exactly as prescribed). Effectiveness tests how well the intervention works under real-world conditions, in real people.

- Chapter 15: Putting Nutritional Biochemistry into Practice: How to Find the Right Eating Pattern for You

- “My doctor told me to stop having intimate dinners for four. Unless there are three other people.” - Orson Welles

- Many of the problems we want to address or avoid stem from consuming calories in excess of what we can use or safely store.

- In the end, the calorically restricted monkeys lived significantly longer and proved far less likely to die of age-related diseases than the ad libitum–fed control monkeys. They were healthier by many other measures, such as insulin sensitivity. Even their brains were in better shape than those of the controls, retaining more gray matter as they aged. “These data demonstrate that caloric restriction slows aging in a primate species,” the study authors concluded.

- The quality of your diet may matter as much as the quantity.

- The key is to pick a strategy to which you can adhere but that also helps achieve your goals. This takes patience, some willpower, and a willingness to experiment.

- Any form of dietary restriction (DR) that restricts protein, for example, is probably a bad idea for most people, because it likely also impairs the maintenance or growth of muscle. Similarly, replacing carbohydrates with lots of saturated fats can backfire if it sends your apoB concentration (and thus your cardiovascular disease risk) sky-high.

- Steve Rosenberg used to say when a patient’s cancer progressed despite treatment: The patient has not failed the treatment; the treatment has failed the patient.

- The real art to dietary restriction, Nutrition 3.0–style, is not picking which evil foods we’re eliminating. Rather, it’s finding the best mix of macronutrients for our patient—coming up with an eating pattern that helps them achieve their goals, in a way that they can sustain. This is a tricky balancing act, and it requires us (once again) to forget about labels and viewpoints and drill down into nutritional biochemistry. The way we do this is by manipulating our four macronutrients: alcohol, carbohydrates, protein, and fat. How well do you tolerate carbohydrates? How much protein do you require? What sorts of fats suit you best? How many calories do you require each day? What is the optimal combination for you?

- It’s easy to overlook, but alcohol should be considered as its own category of macronutrient because it is so widely consumed, it has such potent effects on our metabolism, and it is so calorically dense at 7 kcal/g (closer to the 9 kcal/g of fat than the 4 kcal/g of both protein and carbohydrate).

- Alcohol serves no nutritional or health purpose but is a purely hedonic pleasure that needs to be managed. It’s especially disruptive for people who are overnourished, for three reasons: it’s an “empty” calorie source that offers zero nutrition value; the oxidation of ethanol delays fat oxidation, which is the exact opposite of what we want if we’re trying to lose fat mass; and drinking alcohol very often leads to mindless eating.

- I also believe that drinking alcohol is a net negative for longevity. Ethanol is a potent carcinogen, and chronic drinking has strong associations with Alzheimer’s disease, mainly via its negative effect on sleep, but possibly via additional mechanisms.

- My personal bottom line: if you drink, try to be mindful about it. You’ll enjoy it more and suffer fewer consequences. Don’t just keep drinking because they’re serving it on the plane. I strongly urge my patients to limit alcohol to fewer than seven servings per week, and ideally no more than two on any given day.

- Carbohydrates are our primary energy source. In digestion, most carbohydrates are broken down to glucose, which is consumed by all cells to create energy in the form of ATP. Excess glucose, beyond what we need immediately, can be stored in the liver or muscles as glycogen for near-term use or socked away in adipose tissue (or other places) as fat. This decision is made with the help of the hormone insulin, which surges in response to the increase in blood glucose.

- Everyone tends to be more insulin sensitive in the morning than in the evening, so it makes sense to front-load our carb consumption earlier in the day.

- Your carbohydrate tolerance is heavily influenced by other factors, especially your activity level and sleep. An ultraendurance athlete, someone who is training for long rides or swims or runs, can eat many more grams of carbs per day because they are blowing through those carbs every time they train—and they are also vastly increasing their ability to dispose of glucose via the muscles and their more-efficient mitochondria.

- Stress prompts an elevation in cortisol, which in turn stimulates the liver to drip more glucose into circulation. This tells me that we need to address her stress levels and probably also her sleep quality.

- Timing is important: If you scarf a large baked potato before working out, it will leave much less of a footprint on your daily glucose profile than if you eat it right before bedtime.

- Not all carbs are created equal. The more refined the carb (think dinner roll, potato chips), the faster and higher the glucose spike. Less processed carbohydrates and those with more fiber, on the other hand, blunt the glucose impact. I try to eat more than fifty grams of fiber per day.

- Rice and oatmeal are surprisingly glycemic (meaning they cause a sharp rise in glucose levels), despite not being particularly refined; more surprising is that brown rice is only slightly less glycemic than long-grain white rice.

- Fructose does not get measured by CGM, but because fructose is almost always consumed in combination with glucose, fructose-heavy foods will still likely cause blood-glucose spikes.

- Timing, duration, and intensity of exercise matter a lot. In general, aerobic exercise seems most efficacious at removing glucose from circulation, while high-intensity exercise and strength training tend to increase glucose transiently, because the liver is sending more glucose into the circulation to fuel the muscles. Don’t be alarmed by glucose spikes when you are exercising.

- A good versus bad night of sleep makes a world of difference in terms of glucose control. All things equal, it appears that sleeping just five to six hours (versus eight hours) accounts for about a 10 to 20 mg/dL (that’s a lot!) jump in peak glucose response, and about 5 to 10 mg/dL in overall levels.

- Stress, presumably, via cortisol and other stress hormones, has a surprising impact on blood glucose, even while one is fasting or restricting carbohydrates. It’s difficult to quantify, but the effect is most visible during sleep or periods long after meals.

- Nonstarchy veggies such as spinach or broccoli have virtually no impact on blood sugar. Have at them.

- Foods high in protein and fat (e.g., eggs, beef short ribs) have virtually no effect on blood sugar (assuming the short ribs are not coated in sweet sauce), but large amounts of lean protein (e.g., chicken breast) will elevate glucose slightly. Protein shakes, especially if low in fat, have a more pronounced effect (particularly if they contain sugar, obviously).

- Stacking the above insights—in both directions, positive or negative—is very powerful. So if you’re stressed out, sleeping poorly, and unable to make time to exercise, be as careful as possible with what you eat.

- Perhaps the most important insight of them all? Simply tracking my glucose has a positive impact on my eating behavior. I’ve come to appreciate the fact that CGM creates its own Hawthorne effect, a phenomenon where study subjects change their behavior because they are being observed. It makes me think twice when I see the bag of chocolate-covered raisins in the pantry, or anything else that might raise my blood glucose levels.”

- Protein and amino acids are the essential building blocks of life. Without them, we simply cannot build or maintain the lean muscle mass that we need.

- In my patients I typically set 1.6 g/kg/day as the minimum, which is twice the RDA. The ideal amount can vary from person to person, but the data suggest that for active people with normal kidney function, one gram per pound of body weight per day (or 2.2 g/kg/day) is a good place to start—nearly triple the minimal recommendation.

- The literature suggests that the ideal way to achieve this is by consuming four servings of protein per day, each at ~0.25 g/lb of body weight. A six-ounce serving of chicken, fish, or meat will provide about 40 to 45 grams (at about 7 grams of actual protein per ounce of meat), so our hypothetical 180-pound person should eat four such servings a day.

- Because much of the plant’s protein is tied to its roots, leaves, and other structures, only about 60 to 70 percent of what you consume is contributing to your needs, according to Don Layman, professor emeritus of food science and human nutrition at the University of Illinois Urbana-Champaign, and an expert on protein.

- Layman suggests focusing on a handful of important amino acids, such as leucine, lycine, and methionine. Focus on the absolute amount of these amino acids found in each meal, and be sure to get about three to four grams per day of leucine and lycine and at least one gram per day of methionine for maintenance of lean mass. If you are trying to increase lean mass, you’ll need even more leucine, closer to two to three grams per serving, four times per day.

- Eating protein also helps us feel satiated, inhibiting the release of the hunger-inducing hormone ghrelin, so we eat fewer calories overall.

- The default fat state of most of my patients (i.e., their baseline fat consumption when they come to me) works out to about 30–40 percent each of MUFA and SFA, and 20–30 percent PUFA—and within that PUFA group, they are generally consuming about six to ten times more omega-6 than omega-3s and usually scant amounts of EPA and DHA.

- Putting all these changes into practice typically means eating more olive oil and avocados and nuts, cutting back on (but not necessarily eliminating) things like butter and lard, and reducing the omega-6-rich corn, soybean, and sunflower oils—while also looking for ways to increase high-omega-3 marine PUFAs from sources such as salmon and anchovies.

- There is no denying that some good things happen when we are not eating. Insulin drops dramatically because there are no incoming calories to trigger an insulin response. The liver is emptied of fat in fairly short order. Over time, within three days or so, the body enters a state called “starvation ketosis,” where fat stores are mobilized to fulfill the need for energy—yet at the same time, as I often noticed when I was undergoing regular lengthy fasts, hunger virtually disappears. This paradoxical phenomenon is likely due to the ultrahigh levels of ketones that this state produces, which tamp down feelings of hunger.

- If there is one type of food that I would eliminate from everyone’s diet if I could, it would be fructose-sweetened drinks, including both sodas and fruit juices, which deliver too much fructose, too quickly, to a gut and liver that much prefer to process fructose slowly. Just eat fruit and let nature provide the right amount of fiber and water.

- In the end, the best nutrition plan is the one that we can sustain. How you manipulate the three levers of diet—calorie restriction, dietary restriction, and time restriction—is up to you. Ideally, your plan improves or maintains all the parameters we care about—not only blood glucose and insulin but also muscle mass and lipid levels, and possibly even weight—while reducing your risk of your most proximate Horseman or Horsemen.

- Stop overthinking nutrition so much. Put the book down. Go outside and exercise.

- Chapter 16: The Awakening: How to Learn to Love Sleep, the Best Medicine for Your Brain

- “Each night, when I go to sleep, I die. And the next morning, when I wake up, I am reborn.” - Mahatma Gandhi

- We now know that even one sleepless night can create a state that is the functional equivalent of being legally drunk.

- We need to sleep about seven and a half to eight and a half hours a night.

- Studies have found that people who sleep less chronically tend to have older-looking, flabbier skin than people their same age who sleep more.

- Poor sleep wreaks havoc on our metabolism. Even in the short term, sleep deprivation can cause profound insulin resistance.

- When we sleep poorly, we can be desperately, irrationally hungry the next day, and more likely to reach for high-calorie and sugary foods than their healthy alternatives. Studies show that people who are more sleep deprived tend to have a higher likelihood of indulging in a fourth meal late in the evening.

- Two large meta-analyses have found that short sleep (defined as less than six hours a night) is associated with about a 6 to 26 percent increase in cardiovascular disease.

- During a typical night, we will cycle between these sleep stages. These sleep cycles last about ninety minutes, and we may even wake up momentarily in between them—which is likely evolution’s way of protecting us from getting eaten by a lion or attacked by enemies during the night.

- Deep sleep is when the brain clears out its cache of short-term memories in the hippocampus and selects the important ones for long-term storage in the cortex, helping us to store and reinforce our most important memories of the day. Researchers have observed a direct, linear relationship between how much deep sleep we get in a given night and how well we will perform on a memory test the next day.

- When we are young, REM sleep is important in helping our brains grow and develop. Even while we are asleep, our brain is forming new connections, expanding our neural network; this is why younger people spend more time in REM. In adulthood, our REM sleep time tends to plateau, but it remains important, especially for creativity and problem solving.

- REM sleep helps us maintain our emotional awareness. When we are deprived of REM, studies have found, we have a more difficult time reading others’ facial expressions. REM-deprived study subjects interpreted even friendly or neutral expressions as menacing.

- REM sleep seems to protect our emotional equilibrium, while helping us process memories and information.

- Growth hormone is typically released in a pulse about one hour after we begin to sleep at night, or around the time at which we’re likely to enter deep sleep. On the other hand, inhibiting growth hormone reduces deep sleep, so it’s not clear which is cause or effect here. Growth hormone reaches its peak during adolescence, rapidly declines between young adulthood to middle age, and then declines more slowly after that. This pattern parallels the changes in the amount of deep sleep we get as we age.

- More research points to the forties and sixties as the decades of life when deep sleep is especially important for the prevention of Alzheimer’s disease. People who have slept less during those decades seem to be at higher risk of developing dementia later on. Thus, good sleep in middle age appears to be especially important for maintaining cognitive health.

- Sleep medications such as Ambien and Lunesta do not promote healthy, long-lasting sleep so much as they tend to promote a sleep-like state of unconsciousness that does not really accomplish much if any of the brain-healing work of either REM or deep sleep. One study found that Ambien actually decreased slow-wave sleep (deep sleep) without increasing REM, meaning people who take it are basically trading high-quality sleep for low-quality sleep. Meanwhile, Ambien has the well-publicized side effect that some users have been known to walk around and do things while “sleeping,” leading to all sorts of problems.

- The first step in this process echoes the first step in a recovery program: we must renounce our “addiction” to chronic sleep deprivation and admit that we need more sleep, in sufficient quality and quantity. We are giving ourselves permission to sleep.

- Long sleep is also often a sign not only of poor sleep quality, but other potential health problems.

- The first requirement for good sleep is darkness. Light is the enemy of sleep, full stop.

- One of the signal events as we are falling asleep is that our body temperature drops by about one degree Celsius. To help that happen, try to keep your bedroom cool—around sixty-five degrees Fahrenheit seems to be optimal. A warm bath before bed may actually help with this process, not only because the bath itself is relaxing but also because when we get out of the bath and climb into our cool bed, our core temperature drops, which signals to our brain that it is time to fall asleep.

- The first thing I tell my patients who are having difficulty sleeping is to cut back on alcohol—or better yet, give it up entirely. It’s counterintuitive, because alcohol initially acts as a sedative, so it can help us fall asleep more quickly. But as the night wears on, alcohol turns from friend of sleep to foe, as it is metabolized into chemicals that impair our ability to sleep. Depending on how much we’ve had to drink, during the second half of the night we may have a harder time entering REM sleep and be more prone to waking up and lingering in unproductive light sleep.

- Studies have found that young people who drink heavily are more likely to forget even basic tasks like locking the door or mailing a letter. Students who averaged nine drinks per week (not much, by collegiate standards) performed worse on a word-based memory test. And, in a finding that will surprise no one, students who drank more slept later and felt sleepier in the daytime, as well as performing worse on tests. More alarming is the finding that students who drank heavily two days after a bout of learning or study forgot or failed to retain most of what they had learned.

- The overarching point here is that a good night of sleep may depend in part on a good day of wakefulness: one that includes exercise, some outdoor time, sensible eating (no late-night snacking), minimal to no alcohol, proper management of stress, and knowing where to set boundaries around work and other life stressors.

- How to improve your sleep

1. Don’t drink any alcohol, period—and if you absolutely, positively must, limit yourself to one drink before about 6 p.m. Alcohol probably impairs sleep quality more than any other factor we can control. Don’t confuse the drowsiness it produces with quality sleep.

2. Don’t eat anything less than three hours before bedtime—and ideally longer. It’s best to go to bed with just a little bit of hunger (although being raven

3. Abstain from stimulating electronics, beginning two hours before bed. Try to avoid anything involving a screen if you’re having trouble falling asleep. If you must, use a setting that reduces the blue light from your screen.

4. For at least one hour before bed, if not more, avoid doing anything that is anxiety-producing or stimulating, such as reading work email or, God help you, checking social media. These get the ruminative, worry-prone areas of our brain humming, which is not what you want.

5. For folks who have access, spend time in a sauna or hot tub prior to bed. Once you get into the cool bed, your lowering body temperature will signal to your brain that it’s time to sleep. (A hot bath or shower works too.)

6. The room should be cool, ideally in the midsixties. The bed should be cool too. Use a “cool” mattress or one of the many bed-cooling devices out there. These are also great tools for couples who prefer different temperatures at night, since both sides of the mattress can be controlled individually.

7. Darken the room completely. Make it dark enough that you can’t see your hand in front of your face with your eyes open, if possible. If that is not achievable, use an eye shade. I use a silky one called Alaska Bear that costs about $8 and works better than the fancier versions I’ve tried.

8. Give yourself enough time to sleep—what sleep scientists call a sleep opportunity. This means going to bed at least eight hours before you need to wake up, preferably nine. If you don’t even give yourself a chance to get adequate sleep, then the rest of this chapter is moot.

9. Fix your wake-up time—and don’t deviate from it, even on weekends. If you need flexibility, you can vary your bedtime, but make it a priority to budget for at least eight hours in bed each night.

10. Don’t obsess over your sleep, especially if you’re having problems. If you need an alarm clock, make sure it’s turned away from you so you can’t see the numbers. Clock-watching makes it harder to fall asleep. And if you find yourself worrying about poor sleep scores, give yourself a break from your sleep tracker.

- If you find yourself lying awake in bed, unable to get back to sleep, my advice is to stop fighting it. Get up, go into another room and do something relaxing. Fix a cup of tea (noncaffeinated, obviously), and read a (preferably boring) book until you feel sleepy again. The key, says Vikas Jain, is to find something that is relaxing and enjoyable but that serves no function; you never want to give your insomnia a purpose, such as doing work or paying bills, because if you do, your brain will make sure to wake you up for it on a regular basis.

- Chapter 17: Work in Progress: The High Price of Ignoring Emotional Health

- “Every man is a bridge, spanning the legacy he inherited and the legacy he passes on.” - Terrence Real

- “Hey, it’s okay—nobody shows up here on a winning streak.”

- Ken Baldwin, who leaped off the Golden Gate Bridge in 1985, when he was twenty-eight. Unlike 99 percent of jumpers from that bridge, he survived. As he fell, he later told the author Tad Friend, “I instantly realized that everything in my life that I’d thought was unfixable, was totally fixable—except for having just jumped.”

- The CDC estimates that more than one hundred thousand Americans died from drug overdoses between April 2020 and April 2021, about as many as died from diabetes.

- These “accidental” overdoses account for almost 40 percent of all accidental deaths, a category that also includes automobile accidents and deaths from falls.

- The substance-abuse crisis has created a longevity crisis, because it is really a mental health crisis in disguise.

- Even just living alone, or feeling lonely, is linked to a much higher risk of mortality.

- “Why would you want to live longer if you’re so unhappy?” - Esther Perel

- There are many rules at the Bridge, and one of the most important ones is no minimizing. You are not allowed to minimize anything that someone else is saying, and you are especially not allowed to minimize your own experiences.

- Another rule at the Bridge is that you’re not supposed to hand anyone a Kleenex when they’re crying. They’re supposed to get up and fetch it themselves.

- Trauma generally falls into five categories: (1) abuse (physical or sexual, but also emotional or spiritual); (2) neglect; (3) abandonment; (4) enmeshment (the blurring of boundaries between adults and children); and (5) witnessing tragic events.

- Trauma, big T or little t, means having experienced moments of perceived helplessness. The situations in question may or may not have been life-or-death, he explained, “but to a child with an undeveloped brain, it may have seemed that way.”

- The most important thing about childhood trauma is not the event itself but the way the child adapts to it. Children are remarkably resilient, and wounded children become adaptive children. The problems begin when these adaptive children grow up to become maladaptive, dysfunctional adults. This dysfunction is represented by the four branches of the trauma tree: (1) addiction, not only to vices such as drugs, alcohol, and gambling, but also to socially acceptable things such as work, exercise, and perfectionism (check); (2) codependency, or excessive psychological reliance on another person; (3) habituated survival strategies, such as a propensity to anger and rage (check); (4) attachment disorders, difficulty forming and maintaining connections or meaningful relationships with others (check).

- Mental health encompasses disease-like states such as clinical depression and schizophrenia, which are complex and difficult to treat but do present with recognizable symptoms. Here, we are more interested in emotional health, which incorporates mental health but is also much broader—and less easy to codify and categorize. Emotional health has more to do with the way we regulate our emotions and manage our interpersonal relationships. I did not have a mental illness, per se, but I did have serious issues with my emotional health that impaired my ability to live a happy, well-adjusted life—and potentially did put my life in danger.

- “90% of male rage is helplessness masquerading as frustration.”

- At the Bridge, I learned that children don’t respond to a parent’s anger in a logical way. If they see me screaming at a driver who just cut me off, they internalize that rage as though it were directed to them. Second, trauma is generational, although not necessarily linear. Children of alcoholics are not inevitably destined to become alcoholics themselves, but one way or another, trauma finds its way down the line.

- Reframing is basically the ability to look at a given situation from someone else’s point of view—literally reframing it.

- When I view it through her lens, I quickly get over myself and realize that I’m the one who’s being selfish and that next time I have to do better. That’s the power of reframing. You realize that you have to step back from a situation, temper your reflexive reaction, and try to see what is actually happening.

- “When nothing seems to help, I go back and look at a stonecutter hammering away at his rock perhaps a hundred times without as much as a crack showing in it. Yet at the hundred-and-first blow it will split in two, and I know it was not the last blow that did it, but all that had gone before.” - Jacob Riis

- DBT consists of four pillars joined by one overarching theme. The overarching theme is mindfulness, which gives you the ability to work through the other four: emotional regulation (getting control over our emotions), distress tolerance (our ability to handle emotional stressors), interpersonal effectiveness (how well we make our needs and feelings known to others), and self-management (taking care of ourselves, beginning with basic tasks like getting up in time to go to work or school).

- Many behaviors expand this window: exercise, sound sleep, good nutrition, time with my family, medications such as antidepressants or mood stabilizers, deep social connections, spending time in nature, and recreational activities that do not emphasize self-judgment. These are the things I have control over. I don’t have as much control over the things that compress my window, but I still have some—for example, overcommitting to projects and saying yes to more than I should.

- It’s not complete detachment in the sense that we’re checking out, but we want to create enough of a gap between stimulus and response so that we are not simply reacting reflexively to things that happen, like a driver who cuts us off in traffic or angry or distressing thoughts that we might have. That gap, in turn, allows us to process the situation in a calmer and more rational way. Do we really need to honk and curse, and potentially make the situation worse (even if the guy deserves it)? Or is it better to simply accept what happened and move on? Mindfulness helps us reframe it: The other driver may be rushing to the hospital with a sick child, for all we know

- Another way in which mindfulness helps is by reminding us that when we are suffering, it is rarely because of some direct cause, like a rock that is crushing our leg at this very moment. Much more often, it is because we are thinking about some painful event that occurred in the past or worrying about something bad that may occur in the future.

- “Your worst enemy cannot harm you as much as your own unguarded thoughts.” - Buddha

- “We suffer more often in imagination than in reality.” - Seneca

- “There is nothing either good or bad, but thinking makes it so.” - William Shakespeare

- One obvious way this applies is in how we think about ourselves. What does our inner dialogue sound like? Is it kind and forgiving and wise, or is it harsh and judgmental, like my inner Bobby Knight? One of the most powerful exercises I learned was to simply listen to my self-talk. I would record voice memos to myself on my phone, after I did anything that could produce self-judgment, such as archery or driving my race-car simulator, or even just cooking dinner, and send each one to my therapist. My instinct in these situations was typically to scream at myself for failing somehow. My therapist at PCS told me to imagine instead that my best friend had performed exactly as I had done. How would I speak to him? Would I berate him the way I often berated myself? Of course not.

- This anger had long been an obstacle in my personal relationships, even with my family. As Terry Real had pointed out long ago, this anger was rooted in shame, but very often my anger would also create more shame. If I yell at my kids, for example, especially when I do it because I’m upset about something else, I feel shame. That shame then becomes an obstacle to my ability to reconcile with them, so I feel more shame. It’s like I’m digging myself into a hole, and it’s not only with my kids. Until I can reconcile and own my behavior, I can’t move on. This used to be a much bigger problem, but at least now I can usually spot it in real time, before the hole gets too deep.

- Changing the behavior can change the mood.

- When my family comes along, it’s important bonding time. When I’m alone, rucking serves as a mindfulness practice, a kind of walking meditation. No phone, no music, no podcasts. Just the sounds of nature, and of my heavy breathing. This is another example of how action can lead us into a better mental state.

- The most important “tactic” by far is my regular weekly therapy session (down from three or four per week when I left PCS). This is not optional. Each session begins with a physical check-in: How am I feeling? How have I slept (a big one)? Am I in physical pain? Am I in conflict? Then we dissect and discuss the events and issues of the week in minute detail. No topic is too insignificant. If, for example, I found myself getting really upset at a TV show or movie, this might be worth exploring. But we also tackle big-picture issues, the ones that propelled me into crisis in the first place. I complement my therapy sessions by writing in my journal, a place where I can practice articulating my emotions and understanding them, holding nothing back. I feel strongly that there is no substitute for this kind of work with a trained therapist.

- This is the key step. You have to believe you can change—and that you deserve better.

- As I settled into the next phase of my recovery, I began to notice something I had never experienced before: I found more joy in being than in doing. For the first time in my life, I felt that I could be a good father. I could be a good husband. I could be a good person. After all, this is the whole point of living. And the whole point of outliving.

- “Maybe the journey isn’t so much about becoming anything. Maybe it’s about unbecoming everything that isn’t really you, so you can be who you were meant to be in the first place.” - Paulo Coelho

- Longevity is meaningless if your life sucks. Or if your relationships suck. None of it matters if your wife hates you. None of it matters if you are a shitty father, or if you are consumed by anger or addiction. Your résumé doesn’t really matter, either, when it comes time for your eulogy.

- The most important ingredient in the whole longevity equation is the why. Why do we want to live longer? For what? For whom?

- “I think people get old when they stop thinking about the future. If you want to find someone’s true age, listen to them. If they talk about the past and they talk about all the things that happened that they did, they’ve gotten old. If they think about their dreams, their aspirations, what they’re still looking forward to—they’re young.” - Ric Elias

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