Outlive - for Mortals

Dr. Peter Attia’s longevity book Outlive is interesting and insightful, but readers should know that his muscular brand of primary care results in some very aggressive recommendations. This is a book that should be read and discussed, but not blindly followed.

Like many of my patients, I recently read Peter Attia’s Outlive, and I found the book informative and highly motivational. I appreciate his emphasis on good sleep and his rejection of nutritional dogma. And, of course, he is an expert on exercise as medicine. At least for a while, Attia’s spirit will be accompanying me to the gym, taunting me to up my game.

However, I think Attia’s approach to primary care is simply too aggressive for most, and due to our philosophical differences, I disagree with many of his recommendations.

I found myself shaking my head early in the book, when Dr. Attia launched into a rant about that famous physician’s commandment: First, do no harm.

For Attia, the admonition to do no harm is “sanctimonious bullshit,” which discourages doctors from taking the necessary actions to help our patients.

For me, “do no harm” is an important reminder that doctors have the capacity to hurt their patients. Since so much illness is self-limited, often the best intervention is “watchful waiting” — to step aside and let healing happen.

Further on, my disagreement with Dr. Attia was perfectly distilled in a short quote from former president Harry S. Truman, which opens Chapter 7:

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

This is a bold and motivational quote, but it’s also false. Yes, sometimes there is more risk with inaction. But sometimes there is more risk with action. And it is often impossible to know which course is riskier, action or inaction. Such is the beauty and bullshit of life.

Back in medical school, there was a stereotype of surgery people versus medicine people. The students going into surgery were people of action, while those going for internal medicine were people of deliberation. Surgery was for doers, medicine for debaters. Think Tom Cruise VS Woody Allen.

Within that framework, Outlive is definitely a book about primary care written by a surgeon. Dr. Attia is more prone to action than your average internist, and less likely to acknowledge uncertainty or agonize over trade-offs.

By way of example, let me offer two specific points of contention: APOE genetic testing and hyper-aggressive cancer screening.

The APOE Genetic test gives information about your propensity towards high cholesterol, and your risk of developing Alzheimer’s Dementia. People whose APOE test gives the result “e4/e4” have a relatively high risk of developing Alzheimer’s. Learning that you are at high risk for Alzheimer’s is particularly distressing because we don’t have any certain therapies to lower that risk — this is bad news without remedy.

Dr. Attia advocates his patients get this test, in part, because if you learn you have elevated risk for Alzheimer’s, you can mitigate that risk by exercising more. Perhaps, I believe this too; although, we don’t have any direct evidence, and certainly don’t know the effect size.

Also, we recommend that all people exercise anyway. I am not convinced that a heightened risk of Alzheimer’s will motivate most people to exercise more over the span of their life.

I can imagine many reasons that someone would like to know they are at high risk for developing Alzheimer’s. Perhaps this information will help them get into a clinical trial. Perhaps this information will persuade them to buy that Beemer, instead of saving for retirement. But for most, this information will only amplify their fear of aging.

I am definitely not saying that patients should never get genetic testing. However, before undergoing a genetic test that gives results which are not directly actionable, my advice to patients is: know thyself. Imagine that you get the worst possible result. Will this information help or hurt you? Would this knowledge be power, or is ignorance bliss? Is now the right time, or is this best left for tomorrow? And, more practically, do you have your life insurance squared away?

Similar to APOE testing, Dr. Attia’s approach to cancer screening does not admit the possibility that information can bring harm.

Dr. Attia is a big proponent of cancer screening — I am too. But he advocates for a uniquely aggressive screening regimen and fails to acknowledge that screening is a double edged sword.

While not fully articulated in his book, Dr. Attia’s cancer screening program seems to include yearly Pap smears for women, biennial colonoscopies beginning at age 40, and whole-body screening MRIs. These recommendations far exceed current guidelines.

Dr. Attia endorses such intensive cancer screening for the simple reason that it is better to find cancer early than late. This sounds like common sense, and yet ignores the surprising and messy history of cancer screening. Unfortunately, our mission to search and destroy early cancers has resulted in some collateral damage, so the goal is to deploy screening more judiciously.

Cancer screening has the potential to cause harm for two broad reasons: False positives and Overdiagnosis. Dr. Attia discusses only the first category.

“False positive” is a straightforward concept — the test suggests you have cancer, but you really don’t. Typically, a follow up test or procedure is necessary to confirm you are all clear. Depending on your disposition, this can range from a mild inconvenience to a panic-soaked crisis.

“Overdiagnosis” is a counterintuitive concept — the test says you have cancer, and it’s right, but the cancer should never have been found, because it was never going to harm you.

Overdiagnosis can occur for several reasons: Perhaps the cancer was less aggressive, and never destined to grow. Perhaps your immune system was going to eliminate the cancer. Or perhaps you were going to die of a heart attack before the cancer emerged.

By describing these downsides, I absolutely do not want to dissuade anyone from appropriate cancer screening. However, screening is not a situation where more is simply better.

Whole-body screening MRI in particular should be approached with caution and eyes wide open.

The allure of these scans is understandable because many people know someone who benefited greatly from an incidental finding on imaging. I certainly have patients who have had important incidental findings; however, because of the problem of overdiagnosis, I’m sometimes left wondering if they were helped or harmed.

What’s more, the risk of false positives from screening MRIs is not insignificant, and many patients fall into a seemingly endless cycle of follow-up testing. Again, depending on one’s nature, these repeated scans can range from annoying to terrifying.

The bottom line: This is a complicated, data-free zone. Advocates of scans should acknowledge the uncertainty and the potential for harm.

In summary, Outlive offers an aggressive recipe for longevity, served up by an intense individual. I can believe that Dr. Attia is on a path to a long and healthy life. But it’s a path marked by blood tests during three-hour work outs.

I do recommend you read this book – you will likely learn a lot and come out more motivated to invest in your health. But be aware that some of Attia’s recommendations are rather extreme. This might be spot-on for the rare uber-athlete who shares Dr. Attia’s disposition, but for the rest of us mortals, I recommend just a little bit less.