Rating: 5/5 Ein fantastisches Buch, welches eben nicht nur auf langes Leben, sondern v.a. auf langes GUTES Leben eingeht und was es dafür bedarf. Das ist ein super Ansatz, den ich voll und ganz teile. Attia schafft es dann auch, weder zu viele Anekdoten, noch zu viele Studien aneinanderzureihen, wie das oft in solchen Büchern ist, sondern immer eine gute Mischung beizubehalten. Das ist absolut nicht selbstverständlich und eine große Leistung. Ich persönlich habe auch enorm viel mitgenommen und werde in der Folge meinen Trainingsplan nach diesem Buch anpassen. Absolute Empfehlung. ## Highlights ==Part I als Hörbuch gehört, daher hier keine Highlights== ### Part II > [!quote] Quote (Page 126) Since then, 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 Cardiology15 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. > [!quote] Quote (Page 129) This is not an atypical scenario: when a patient comes to me and says their father or grandfather or aunt, or all three, died of “premature” heart disease, elevated Lp( a) is the first thing I look for. > [!quote] Quote (Page 130) How to Reduce Cardiovascular Risk > [!note] Note .h3 > [!quote] Quote (Page 130) Together, our stories illustrate three blind spots of Medicine 2.0 when it comes to dealing with atherosclerotic disease: first, an overly simplistic view of lipids that fails to understand the importance of total lipoprotein burden (apoB) and how much one needs to reduce it in order to truly reduce risk; second, a general lack of knowledge about other bad actors such as Lp( a); and third, a failure to fully grasp the lengthy time course of atherosclerotic disease, and the implications this carries if we seek true prevention. > [!quote] Quote (Page 131) The various treatment guidelines specify target ranges for LDL-C, typically 100 mg/ dL for patients at normal risk, or 70 mg/ dL for high-risk individuals. In my view, this is still far too high. Simply put, I think you can’t lower apoB and LDL-C too much, provided there are no side effects from treatment. You want it as low as possible. > [!quote] Quote (Page 133) Lipoproteins aren’t the only significant risk factors for cardiovascular disease; as noted earlier, smoking and high blood pressure both damage the endothelium directly. Smoking cessation and blood pressure control are thus non-negotiable first steps in reducing cardiovascular risk. > [!quote] Quote (Page 133) 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. > [!quote] Quote (Page 133) we need to use nutritional interventions in tandem with drugs. > [!quote] Quote (Page 145) Cancer cells are different from normal cells in two important ways. 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. > [!quote] Quote (Page 146) The second property that defines cancer cells is their ability to travel from one part of the body to a distant site where they should not be. > [!quote] Quote (Page 146) One of the biggest obstacles to a “cure” is the fact that cancer is not one single, simple, straightforward disease, but a condition with mind-boggling complexity. > [!quote] Quote (Page 146) In fact, there didn’t seem to be any individual genes that “caused” cancer at all; instead, it seemed to be random somatic mutations that combined to cause cancers. So not only is breast cancer genetically distinct from colon cancer (as the researchers expected), but no two breast cancer tumors are very much alike. If two women have breast cancer, at the same stage, their tumor genomes are likely to be very different from each other. Therefore, it would be difficult if not impossible to devise one treatment for both women based on the genetic profile of their tumors. > [!quote] Quote (Page 147) deaths. If we want to reduce cancer mortality by a significant amount, we must do a better job of preventing, detecting, and treating metastatic cancers. > [!quote] Quote (Page 147) But what causes cancer to spread? We don’t really know, > [!quote] Quote (Page 148) Traditional chemotherapy occupies a fuzzy region between poison and medicine; > [!quote] Quote (Page 148) These drugs attack the replicative cycle of cells, and because cancer cells are rapidly dividing, the chemo agents harm them more severely than normal cells. > [!quote] Quote (Page 148) Hitchens was experiencing the primary flaw of modern chemotherapy: It is systemic, but still not specific enough to target only cancerous cells and not normal healthy cells. > [!quote] Quote (Page 148) Ultimately, successful treatments will need to be both systemic and specific to a particular cancer type. > [!quote] Quote (Page 149) cause. Clearly, cancer cells are genetically distinct from normal human cells. But for the last century or so, a handful of researchers have been investigating another unique property of cancer cells, and that is their metabolism. > [!quote] Quote (Page 149) But these cancer cells weren’t “respiring” the way normal cells do, consuming oxygen and producing lots of ATP, the energy currency of the cell, via the mitochondria. Rather, they appeared to be using a different pathway that cells normally use to produce energy under anaerobic conditions, meaning without sufficient oxygen, such as when we are sprinting. The strange thing was that these cancer cells were resorting to this inefficient metabolic pathway despite having plenty of oxygen available to them. > [!quote] Quote (Page 151) unfashionable. One of the more puzzling questions he has tackled was why cancer cells needed to produce energy in this highly inefficient way. Because the inefficiency of the Warburg effect may be the point, as Cantley, Matthew Vander Heiden, and Craig Thompson argued14 in a 2009 paper. While it may not yield much in the way of energy, they found, the Warburg effect generates lots of by-products, such as lactate, a substance that is also produced during intense exercise. In fact, turning glucose into lactate creates so many extra molecules that the authors argued that the relatively small amount of energy it produces may actually be the “by-product.” There’s a logic to this seeming madness: when a cell divides, it doesn’t simply split into two smaller cells. The process requires not only the division of the nucleus, and all that stuff we learned in high school biology, but the actual physical materials required to construct a whole new cell. Those don’t just appear out of nowhere. Normal aerobic cellular respiration produces only energy, in the form of ATP, plus water and carbon dioxide, which aren’t much use as building materials > [!quote] Quote (Page 151) The Warburg effect, also known as anaerobic glycolysis, turns the same amount of glucose into a little bit of energy and a whole lot of chemical building blocks—which are then used to build new cells rapidly. Thus, the Warburg effect is how cancer cells fuel their own proliferation. But it also represents a potential vulnerability in cancer’s armor.fn1 > [!quote] Quote (Page 152) I suspect that the association between obesity, diabetes, and cancer is primarily driven by inflammation and growth factors such as insulin. Obesity, especially when accompanied by accumulation of visceral fat (and other fat outside of subcutaneous storage depots), helps promote inflammation, as dying fat cells secrete an array of inflammatory cytokines into the circulation > [!quote] Quote (Page 152) This chronic inflammation helps create an environment that could induce cells to become cancerous. > [!quote] Quote (Page 153) This in turn suggests that metabolic therapies, including dietary manipulations that lower insulin levels, could potentially help slow the growth of some cancers and reduce cancer risk. > [!quote] Quote (Page 154) need. What I am saying is that we don’t want to be anywhere on that spectrum of insulin resistance to type 2 diabetes, where our cancer risk is clearly elevated. To me, this is the low-hanging fruit of cancer prevention, right up there with quitting smoking. Getting our metabolic health in order is essential to our anticancer strategy. > [!quote] Quote (Page 156) Other types of dietary interventions have been found to help improve the effectiveness of chemotherapy, while limiting its collateral damage to healthy tissues. Work by Valter Longo of the University of Southern California and others has found that fasting, or a fasting-like diet, increases the ability of normal cells to resist chemotherapy, while rendering cancer cells more vulnerable to the treatment. > [!quote] Quote (Page 157) More studies need to be done, but the working hypothesis is that because cancer cells are so metabolically greedy, they are therefore more vulnerable than normal cells to a reduction in nutrients—or more likely, a reduction in insulin, which activates the PI3K pathway essential to the Warburg effect. > [!quote] Quote (Page 164) One striking feature of immune-based cancer treatment is that when it works, it really works. It is not uncommon for a patient with metastatic cancer to enter remission after chemotherapy. The problem is that it virtually never lasts. The cancer almost always comes back in some form. But when patients do respond to immunotherapy, and go into complete remission, they often stay in remission. Between 80 and 90 percent28 of so-called complete responders to immunotherapy remain disease-free fifteen years out. This is extraordinary—far better than the short-term, five-year time horizon at which we typically declare victory in conventional cancer treatment. One hesitates to use the word cured, but in patients who do respond to immunotherapy, it’s safe to assume that the cancer is pretty much gone. > [!quote] Quote (Page 200) Because metabolism plays such an outsize role with at-risk e4 patients like Stephanie, our first step is to address any metabolic issues they may have. 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. > [!quote] Quote (Page 201) 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. > [!quote] Quote (Page 201) magnitude that my own skepticism of the power of exercise, circa 2012, has slowly melted away. I now tell patients that exercise is, full stop and hands down, the best tool we have in the neurodegeneration prevention tool kit. > [!quote] Quote (Page 202) Sleep is also a very powerful tool against Alzheimer’s disease, as we’ll see in chapter 16. > [!quote] Quote (Page 202) Sleep disruptions and poor sleep are potential drivers43 of increased risk of dementia. > [!quote] Quote (Page 203) Another somewhat surprising risk factor that has emerged is hearing loss. Studies have found that hearing loss44 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. > [!quote] Quote (Page 203) While depression is also associated with Alzheimer’s disease, it appears to be more of a symptom than a risk factor or driver of the disease. Nevertheless, treating depression in patients with MCI or early Alzheimer’s disease does appear to help reduce some other symptoms of cognitive decline. 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.) > [!quote] Quote (Page 204) I’m not quite as confident that regular sauna use will reduce your risk of Alzheimer’s disease as I am that exercise will do so, but I am much more confident than I was at the outset of my journey. 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 percent46 (and the risk of ASCVD by 50 percent). 47 Other potential interventions that have shown some promise in studies include lowering homocysteine with B vitamins, 48 while optimizing omega-3 fatty acids. > [!quote] Quote (Page 205) Broadly, our strategy should be based on the following principles: 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. WHAT’S GOOD FOR THE LIVER (AND PANCREAS) IS GOOD FOR THE BRAIN. Metabolic health is crucial to brain health. 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. OUR MOST POWERFUL TOOL FOR PREVENTING COGNITIVE DECLINE IS EXERCISE. ### Part III > [!quote] Quote (Page 215) I’m constantly tinkering, experimenting, switching things up in my own regimen and in that of my patients. And my patients themselves are constantly changing. We are not bound by any specific ideology or school of thought, or labels of any kind. We are not “keto” or “low-fat,” and we do not emphasize aerobic training at the expense of strength, or vice versa. We range widely and pick and choose and test tactics that will hopefully work for us. We are open to changing our minds. > [!quote] Quote (Page 215) We adapt our tactics on the basis of our changing needs and our changing understanding of the best science out there. > [!quote] Quote (Page 220) It turns out that peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, is perhaps the single most powerful marker7 for longevity. > [!quote] Quote (Page 222) relationship. First, the magnitude of the effect size is very large. Second, the data are consistent and reproducible across many studies of disparate populations. Third, there is a dose-dependent response (the fitter you are, the longer you live). Fourth, there is great biologic plausibility to this effect, via the known mechanisms of action of exercise on lifespan and healthspan. And fifth, virtually all experimental data on exercise in humans suggest that it supports improved health. > [!quote] Quote (Page 223) I can’t tell you, from these data, that simply having a high VO2 max will offset your high blood pressure or your smoking habit, as much as these hazard ratios suggest it might. Without a randomized controlled trial, we can’t know for sure, but I kind of doubt it. But I can say with a very high degree of certainty that having a higher VO2 max is better for your overall health and longevity than having a lower VO2 max. Period. > [!quote] Quote (Page 223) It might surprise you, as it did me, to learn that muscle may be almost as powerfully correlated with living longer. > [!quote] Quote (Page 223) Further analysis revealed that it’s not the mere muscle mass that matters but the strength of those muscles, their ability to generate force. > [!quote] Quote (Page 224) Strength may even trump cardiorespiratory fitness, at least one study suggests. 14 Researchers following a group of approximately 1,500 men over forty with hypertension, for an average of about eighteen years, found that even if a man was in the bottom half of cardiorespiratory fitness, his risk of all-cause mortality was still almost 48 percent lower if he was in the top third of the group in terms of strength versus the bottom third.fn4 > [!quote] Quote (Page 225) The data demonstrating the effectiveness of exercise on lifespan are as close to irrefutable as one can find in all human biology. > [!quote] Quote (Page 226) Your exoskeleton (muscle) is what keeps your actual skeleton (bones) upright and intact. Having more muscle mass on your exoskeleton20 appears to protect you from all kinds of trouble, even adverse outcomes following surgery—but most important, it is highly correlated with a lower risk of falling, 21 a leading but oft-ignored cause of death and disability in the elderly. As figure 10 reveals, falls are by far the leading cause of accidental deaths in those ages sixty-five and older—and this is without even counting the people who die three or six or twelve months after their nonfatal but still serious fall pushed them into a long and painful decline. > [!quote] Quote (Page 231) Think of the Centenarian Decathlon as the ten most important physical tasks you will want to be able to do for the rest of your life. > [!quote] Quote (Page 231) I find it useful because it helps us visualize, with great precision, exactly what kind of fitness we need to build and maintain as we get older. It creates a template for our training. > [!quote] Quote (Page 235) The three dimensions in which we want to optimize our fitness are aerobic endurance and efficiency (aka cardio), strength, and stability. All three of these are key to maintaining your health and strength as you age. > [!quote] Quote (Page 239) A professional cyclist might spend thirty to thirty-five hours a week training on his or her bike, and 80 percent of that time in zone 2. For an athlete, this builds a foundation for all their other, more intense training. > [!quote] Quote (Page 240) Because I am a numbers guy and I love biomarkers and feedback, I often test my own lactate while I am working out this way, using a small handheld lactate monitor, to make sure my pacing is correct. The goal is to keep lactate levels constant, ideally between 1.7 and 2.0 millimoles. This is the zone 2 threshold for most people. > [!quote] Quote (Page 242) 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. > [!quote] Quote (Page 243) This in turn explains why exercise, especially in zone 2, can be so effective in managing both type 1 and type 2 diabetes: It enables the body to essentially bypass insulin resistance in the muscles to draw down blood glucose levels. I have one patient with type 1 diabetes, meaning he produces zero insulin, who keeps his glucose in check almost entirely by walking briskly for six to ten miles every day, and sometimes more. As he walks, his muscle cells are vacuuming glucose out of his bloodstream via NIMGU. He still needs to inject himself with insulin, but only a tiny fraction of the amount that he would otherwise require. > [!quote] Quote (Page 243) 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. How much zone 2 training you need depends on who you are. > [!quote] Quote (Page 243) Based on multiple discussions with San Millán and other exercise physiologists, it seems that 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. > [!quote] Quote (Page 243) I am so persuaded of the benefits of zone 2 that it has become a cornerstone of my training plan. Four times a week, I will spend about an hour riding my stationary bike at my zone 2 threshold. One way to track your progression in zone 2 is to measure your output in watts at this level of intensity. (Many stationary bikes can measure your wattage as you ride.) You take your average wattage output for a zone 2 session and divide it by your weight to get your watts per kilogram, which is the number we care about. So if you weigh 60 kilos (about 132 pounds) and can generate 125 watts in zone 2, that works out to a bit more than 2 watts/ kg, which is about what one would expect from a reasonably fit person. These are rough benchmarks, but someone who is very fit will be able to produce 3 watts/ kg, while professional cyclists put out 4 watts/ kg and up. It’s not the number that matters, but how much you are improving over time. > [!quote] Quote (Page 244) Besides improving mitochondrial health and glucose uptake and metabolic flexibility, and all those other good things, zone 2 training also increases your VO2 max somewhat. But if you really want to raise your VO2 max, you need to train this zone more specifically. > [!quote] Quote (Page 248) How trainable is VO2 max? The conventional wisdom, reflecting the bulk of the literature, suggests that it’s possible to improve elderly subjects’ aerobic capacity by about 13 percent over eight to ten weeks of training, and by 17 percent after twenty-four to fifty-two weeks, according to one review. > [!quote] Quote (Page 248) The payoff is that increasing your VO2 max12 makes you functionally younger. One study found that13 boosting elderly subjects’ VO2 max by 6 ml/ kg/ min, or about 25 percent, was equivalent to subtracting twelve years from their age. If > [!quote] Quote (Page 249) Even if we are not out to set world records, the way we train VO2 max is pretty similar to the way elite athletes do it: by supplementing our zone 2 work with one or two VO2 max workouts per week. > [!quote] Quote (Page 249) 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.fn4 Group comparisons for VO2 max are Low (bottom 25%), Below Average (26th to 50th percentile), Above Average (51st to 75th percentile), High (75th to 97.6th percentile), and Elite (top 2.3%). Source: Mandsager et al. (2018). > [!quote] Quote (Page 251) The good news, I suppose, is that you don’t need to spend very much time in the pain cave. Unless you are training to be competitive in elite endurance sports like cycling, swimming, running, triathlon, or cross-country skiing, a single workout per week in this zone will generally suffice. > [!quote] Quote (Page 254) Another metric that we track closely in our patients is their bone density > [!quote] Quote (Page 254) Why do we care so much? Just as with muscle, it comes down to protection. We want to slow this decline, armoring ourselves against injury and physical frailty. The mortality from a hip or femur fracture is staggering once you hit about the age of sixty-five. It varies by study, but ranges from 15 to 36 percent in one year—meaning that up to one-third of people over sixty-five who fracture their hip are dead within a year. Even if a person does not die from the injury, the setback can be the functional equivalent of death in terms of how much muscle mass and, hence, physical capacity is lost during the period of bed rest > [!quote] Quote (Page 256) A far more important measure of strength, I’ve concluded, is how much heavy stuff you can carry. > [!quote] Quote (Page 257) I structure my training around exercises that improve the following: 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. 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.” Pulling motions, at all angles from overhead to in front of you, which also requires grip strength (e.g., pull-ups and rows). 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. > [!quote] Quote (Page 258) Even I was surprised to discover that there is an enormous body of literature linking better grip strength in midlife and beyond to decreased risk of overall mortality.fn5,23 The data are as robust as for VO2 max and muscle mass, in fact. Many studies suggest that grip strength22—literally, how hard you can squeeze something with one hand—predicts how long you are likely to live, while low grip strength in the elderly is considered to be a symptom of sarcopenia, the age-related muscle atrophy we just discussed. > [!quote] Quote (Page 259) Training grip strength is not overly complicated. One of my favorite ways to do it is the classic farmer’s carry, where you walk for a minute or so with a loaded hex bar or a dumbbell or kettlebell in each hand. > [!quote] Quote (Page 259) That said, a farmer’s carry is pretty straightforward (weight in each hand, arms at sides, walk). The most important tip is to keep your shoulder blades down and back, not pulled up or hunched forward. > [!quote] Quote (Page 259) Another way to test your grip is by dead-hanging from a pull-up bar for as long as you can. (This is not an everyday exercise; rather, it’s a once-in-a-while test set.) You grab the bar and just hang there, supporting your body weight. This is a simple but sneakily difficult exercise that also helps strengthen the critically important scapular (shoulder) stabilizer muscles, which we will talk about in the next chapter. Here we like to see men hang for at least two minutes and women for at least ninety seconds at the age of forty. (We reduce the goal slightly for each decade past 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. > [!quote] Quote (Page 260) In life, especially as we age, eccentric strength is where many people falter. Eccentric strength in the quads is what gives us the control we need when we are moving down an incline or walking down a set of stairs. It’s really important to keep us safe from falls and from orthopedic injuries. > [!quote] Quote (Page 266) Stability is tricky to define precisely, but we intuitively know what it is. 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. > [!quote] Quote (Page 271) I will try to explain at least some of the basic principles that underlie stability training. > [!quote] Quote (Page 272) about. If you’d like to know more after you’ve read this chapter, I suggest visiting the websites for DNS (www.rehabps.com) and the Postural Restoration Institute (PRI) (www.posturalrestoration.com), the two leading exponents of what I’m talking about here. > [!quote] Quote (Page 272) Stability training begins at the most basic level, with the breath. > [!quote] Quote (Page 272) 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. > [!quote] Quote (Page 273) One simple test that we ask of everyone, early on, looks like this: lie on your back, with one hand on your belly and the other on your chest, and just breathe normally, without putting any effort or thought into it. Notice which hand is rising and falling—is it the one on your chest, or your belly, or both (or neither)? Some people tend to flare their ribs and expand the chest on the inhale, while the belly is flat or even goes down. This creates tightness in the upper body and midline, and if the ribs stay flared, it’s difficult to achieve a full exhalation. Others breathe primarily “into” the belly, which tilts the pelvis forward. Still others are compressed, meaning they have difficulty moving air in and out altogether, because they cannot expand the rib cage with each inhalation. Beth identifies three types of breathing styles and associated phenotypes, which she jokingly calls “Mr. Stay Puft,” the “Sad Guy,” and the “Yogini”—each corresponding to a different set of stability strategies: > [!quote] Quote (Page 275) 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. > [!quote] Quote (Page 278) To help reacquaint us with our feet, Beth Lewis likes to put me, and our patients, through a routine she calls “toe yoga.” > [!quote] Quote (Page 278) Toe yoga is a lot harder than it sounds, which is why I’ve posted a video demonstration of this and other exercises at www.peterattiamd.com/ outlive /videos. First, Beth tells her students to think of their 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. This is easy, and revelatory; when was the last time you felt that grounded? 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. > [!quote] Quote (Page 279) point. One of the goals of stability training is to regain mental control, conscious or not, over key muscles and body parts. > [!quote] Quote (Page 279) efficiently. 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.) > [!quote] Quote (Page 284) I would urge you to film yourself working out from time to time, to compare what you think you are doing to what you are actually doing with your body. I do this daily—my phone on the tripod is one of my most valuable pieces of equipment in the gym. I film my ten most important sets each day and watch the video between sets, to compare what I see to what I think I was doing. Over time, that gap has been narrowing. > [!quote] Quote (Page 309) Once you strip away the labels and the ideology, almost all diets rely on at least one of the following three strategies to accomplish this: CALORIC RESTRICTION, or CR: eating less in total, but without attention to what is being eaten or when it’s being eaten DIETARY RESTRICTION, or DR: eating less of some particular element( s) within the diet (e.g., meat, sugar, fats) TIME RESTRICTION, or TR: restricting eating to certain times, up to and including multiday fasting > [!quote] Quote (Page 310) From the standpoint of pure efficacy, CR or caloric restriction is the winner, hands down. > [!quote] Quote (Page 310) it also allows the most flexibility with food choices. The catch is that you have to do it perfectly—tracking every single thing you eat, and not succumbing to the urge to cheat or snack—or it doesn’t work. > [!quote] Quote (Page 310) DR or dietary restriction is probably the most common strategy employed for reducing energy intake. It is conceptually simple: pick a type of food, and then don’t eat that food. It only works, obviously, if that food is both plentiful and significant enough that eliminating it will create a caloric deficit. > [!quote] Quote (Page 310) TR or time restriction—also known as intermittent fasting—is the latest trend in ways to cut calories. In some ways I think it’s the easiest. > [!quote] Quote (Page 311) But the more significant downside of this approach is that most people who try it end up very protein deficient > [!quote] Quote (Page 311) CR: Calories Matter > [!quote] Quote (Page 311) book. If you’re ingesting one thousand extra calories a day, of anything, you’re going to have problems sooner or later. In prior chapters, we’ve seen how excess calories contribute to many chronic diseases, not only metabolic disorders but also heart disease, cancer, and Alzheimer’s disease. We also know from decades of experimental data (chapter 5) that eating fewer calories tends > [!quote] Quote (Page 312) There is plenty of research showing that people who count their calories and limit them can and do lose weight, the primary end point of such studies. > [!quote] Quote (Page 312) One slight advantage is that calorie counting is agnostic to food choices; you can eat whatever you want so long as you stay within your daily allowance. > [!quote] Quote (Page 315) Taken together, then, what do these two monkey studies have to tell us about nutritional biochemistry? Avoiding diabetes and related metabolic dysfunction—especially by eliminating or reducing junk food—is very important to longevity. There appears to be a strong link between calories and cancer, the leading cause of death in the control monkeys in both studies. The CR monkeys had a 50 percent lower incidence of cancer. The quality of the food you eat could be as important as the quantity. If you’re eating the SAD, then you should eat much less of it. Conversely, if your diet is high quality to begin with, and you are metabolically healthy, then only a slight degree of caloric restriction—or simply not eating to excess—can still be beneficial. > [!quote] Quote (Page 316) The monkeys teach us that if you are metabolically healthy and not over-nourished, like the NIH animals, then avoiding a crap diet may be all you need. Some of the NIH CR monkeys ended up with some of the longest lifespans ever recorded in rhesus monkeys. It seems quite clear, then, that even for monkeys, limiting caloric intake and improving diet quality “works”—it’s how you pull it off that is tricky. > [!quote] Quote (Page 317) DR: The Nutritional Biochemistry “Diet” > [!quote] Quote (Page 317) We have too many choices and too many delicious ways to take calories into our body. Hence the need for dietary restriction. We need to erect walls around what we can and cannot (or should not) eat. The advantage of DR is that it is highly individualized; you can impose varying degrees of restriction, depending on your needs. > [!quote] Quote (Page 320) Alcohol 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). > [!quote] Quote (Page 321) I also believe that drinking alcohol is a net negative for longevity. Ethanol is a potent carcinogen, and chronic drinking has strong associations9 with Alzheimer’s disease, mainly via its negative effect on sleep, 10 but possibly via additional mechanisms. > [!quote] Quote (Page 321) My personal bottom line: if you drink, try to be mindful about it. > [!quote] Quote (Page 321) 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, and I manage to do a pretty good job adhering to this rule myself. Carbohydrates > [!quote] Quote (Page 322) Carbs probably create more confusion than any other macro. They are neither “good” nor “bad”—although some types are better than others. > [!quote] Quote (Page 322) We already know that it’s not good to consume excessive calories. In the form of carbohydrates, those extra calories can cause a multitude of problems, from NAFLD to insulin resistance to type 2 diabetes, > [!quote] Quote (Page 323) Now we have a tool to help us understand our own individual carbohydrate tolerance and how we respond to specific foods. This is called continuous glucose monitoring, or CGM, and it has become a very important part of my armamentarium in recent years.fn2 > [!quote] Quote (Page 327) One thing CGM pretty quickly teaches you is that 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.fn6 Also, sleep disruption or reduction dramatically impairs glucose homeostasis over time. > [!quote] Quote (Page 328) Lessons from Continuous Glucose Monitoring > [!quote] Quote (Page 328) 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. > [!quote] Quote (Page 329) 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. > [!quote] Quote (Page 329) Nonstarchy veggies such as spinach or broccoli have virtually no impact on blood sugar. Have at them. Foods high in protein and fat16 (e.g., eggs, beef short ribs) have virtually no effect on blood sugar > [!quote] Quote (Page 329) 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 > [!quote] Quote (Page 330) Protein > [!quote] Quote (Page 331) The first thing you need to know about protein is that the standard recommendations for daily consumption are a joke. Right now the US recommended dietary allowance (RDA) for protein is 0.8 g/ kg of body weight. This may reflect how much protein we need to stay alive, but it is a far cry from what we need to thrive. > [!quote] Quote (Page 331) How much protein do we actually need? It varies from person to person. In my patients I typically set 1.6 g/ kg/ day as the minimum, > [!quote] Quote (Page 332) 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 day19 (or 2.2 g/ kg/ day) is a good place to start— > [!quote] Quote (Page 332) The literature suggests that the ideal way to achieve this20 is by consuming four servings of protein per day, each at ~ 0.25 g/ lb of body weight. > [!quote] Quote (Page 335) Fat > [!quote] Quote (Page 339) Medicine 2.0 has to offer is broad contours: MUFA seems to be the “best” fat of the bunch (based on PREDIMED and the Lyon Heart study), and after that the meta-analyses suggest PUFA has a slight advantage over SFA. But beyond that, we are on our own. > [!quote] Quote (Page 340) In the final analysis, I tell my patients that on the basis of the least bad, least ambiguous data available, MUFAs are probably the fat that should make up most of our dietary fat mix, which means extra virgin olive oil and high-MUFA vegetable oils. After that, it’s kind of a toss-up, and the actual ratio of SFA and PUFA probably comes down to individual factors such as lipid response and measured inflammation. Finally, unless they are eating a lot of fatty fish, filling their coffers with marine omega-3 PUFA, they almost always need to take EPA and DHA supplements in capsule or oil form. TR: The Case for (and Against) Fasting > [!quote] Quote (Page 340) 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— > [!quote] Quote (Page 341) Fasting over long periods32 also turns down mTOR, the pro-growth and pro-aging pathway we discussed in chapter 5. This would also be desirable, one might think, at least for some tissues. At the same time, lack of nutrients accelerates autophagy, 33 the cellular “recycling” process that helps our cells become more resilient, and it activates FOXO, 34 the cellular repair genes that may help centenarians live so long. In short, fasting triggers many of the physiological and cellular mechanisms that we want to see. > [!quote] Quote (Page 341) in order. First, we have the short-term eating windows that we’ve mentioned previously, where someone will limit their consumption of food to a specific time frame, > [!quote] Quote (Page 342) But I am not convinced that short-term time-restricted feeding has much of a benefit beyond this. > [!quote] Quote (Page 351) Many studies have found powerful associations between insufficient sleep (less than seven hours a night, on average) and adverse health outcomes ranging from increased susceptibility to the common cold to dying of a heart attack. Poor sleep dramatically increases one’s propensity3 for metabolic dysfunction, up to and including type 2 diabetes, 4 and it can wreak havoc with the body’s hormonal balance. 5 > [!quote] Quote (Page 351) As important as sleep is for the body, it may even be more so for the brain. Good sleep, in terms of not only quantity6 but quality, is critical to our cognitive function, our memory, and even our emotional equilibrium. We feel better, in every way, after a night of good sleep. Even while we are unconscious, our brain is still working, processing thoughts and memories and emotions (hence, dreams). It even cleans itself, 7 in a manner similar to a city sweeping the streets. Relatedly, there is a growing body of evidence that sleeping well is essential to preserving our cognition8 as we age and staving off Alzheimer’s disease. > [!quote] Quote (Page 354) How long do we need to sleep? > [!quote] Quote (Page 354) But many, many studies have confirmed what your mother told you: We need to sleep about seven and a half to eight and a half hours a night. > [!quote] Quote (Page 356) This may come as a surprise to you, as it did to me, but poor sleep wreaks havoc on our metabolism. Even in the short term, sleep deprivation can cause profound insulin resistance. > [!quote] Quote (Page 357) But it cuts both ways: long sleep is also a sign of problems. People who sleep eleven hours or more nightly have a nearly 50 percent higher risk of all-cause mortality, likely because long sleep = poor quality sleep, but it may also reflect an underlying illness. > [!quote] Quote (Page 358) that limiting subjects’ sleep to four or five hours a night suppresses their levels of leptin, the hormone that signals to us that we are fed, while increasing levels of ghrelin, the “hunger” hormone. > [!quote] Quote (Page 358) Sleep and Cardiovascular Disease > [!quote] Quote (Page 358) Unfortunately, poor sleep has much the same effect, putting the sympathetic nervous system on permanent alert; we get stuck in fight-or-flight mode, and our blood pressure and heart rate remain elevated. This, in turn, multiplies the stress placed on our vasculature. > [!quote] Quote (Page 359) duration. The MR data confirmed the observational findings, 30 that sleeping less than six hours a night was associated with about a 20 percent higher risk of a heart attack. Even more noteworthy, the researchers found that sleeping six to nine hours a night (i.e., adequately, by the researchers’ definition) was associated with a reduction in heart attack risk—even among individuals with a high genetic predisposition for coronary artery disease. > [!quote] Quote (Page 359) Sleep and the Brain > [!quote] Quote (Page 361) Both REM and deep NREM sleep (which we’ll call “deep sleep” for convenience) are crucial to learning and memory, but in different ways. Deep sleep is when the brain clears out its cache33 of short-term memories in the hippo-campus 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 observed34 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. > [!quote] Quote (Page 361) In adulthood, our REM sleep time tends to plateau, but it remains important, especially for creativity and problem solving. By generating seemingly random associations between facts and memories, and by sorting out the promising connections from the meaningless ones, the brain can often come up with solutions to problems that stumped us the previous day. Research has also found that REM sleep is especially helpful36 with what is called procedural memory, learning new ways of moving the body, for athletes and for musicians. Another very important function37 of REM sleep is to help us process our emotional memories, helping separate our emotions from the memory of the negative (or positive) experience that triggered those emotions. > [!quote] Quote (Page 362) Deep sleep, on the other hand, seems to be essential to the very health of our brain as an organ. > [!quote] Quote (Page 362) while we are in deep sleep, the brain activates a kind of internal waste disposal system that allows cerebrospinal fluid to flood in between the neurons and sweep away intercellular junk; while this happens, the neurons themselves pull back to allow this to happen, the way city residents are sometimes required to move their cars to allow street sweepers to pass through. > [!quote] Quote (Page 363) But sleep disturbances, in turn, may help create conditions that allow Alzheimer’s to progress. Insomnia affects 30 to 50 percent47 of older adults, and there is ample research showing that sleep disturbances often precede the diagnosis of dementia by several years; they may even appear before cognitive decline. > [!quote] Quote (Page 364) More research points51 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. > [!quote] Quote (Page 364) Assessing Your Sleep > [!quote] Quote (Page 366) there are some fairly effective things you can do to improve your ability to fall asleep and stay asleep— > [!quote] Quote (Page 367) 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. > [!quote] Quote (Page 367) The next step is to assess your own sleep habits. > [!quote] Quote (Page 367) In parallel, you should make a longer-term assessment of your sleep quality over the last month. Probably the best-validated sleep questionnaire is the Pittsburgh Sleep Quality Index, > [!quote] Quote (Page 369) Sleeping Better > [!quote] Quote (Page 370) The first requirement for good sleep is darkness. > [!quote] Quote (Page 370) ability to sleep. One large-scale survey62 found that the more interactive devices subjects used during the hour before bedtime, the more difficulties they had falling asleep and staying asleep—whereas passive devices such as TV, electronic music players, and, best of all, books were less likely to be associated with poor sleep. > [!quote] Quote (Page 371) to). Turn off the computer and put away your phone at least an hour before bedtime. Do NOT bring your laptop or phone into bed with you. Another very important environmental factor is temperature. Many people associate sleep with warmth, but in fact the opposite is true: One of the signal events64 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. > [!quote] Quote (Page 371) Our internal “environment” is just as important to good sleep. 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. > [!quote] Quote (Page 371) 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. > [!quote] Quote (Page 373) Another way to help cultivate70 sleep pressure is via exercise, particularly sustained endurance exercise (e.g., zone 2), ideally not within two or three hours of bedtime. My patients often find that a thirty-minute zone 2 session can do wonders for their ability to fall asleep. > [!quote] Quote (Page 373) Another way to turn down71 the sympathetic nervous system and prepare the brain for sleep is through meditation. > [!quote] Quote (Page 374) 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. > [!quote] Quote (Page 386) 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. Most of the things that wound children fit into these five categories. Trauma is a pretty loaded word, and the therapists at the Bridge were careful to explain that there can be “big-T” trauma or “little-t” traumas. Being a victim of rape would qualify as a big-T trauma, while having an alcoholic parent might subject a child to a host of little-t traumas. But in large enough doses over a long enough time, little-t traumas can shape a person’s life just as much as one major terrible event. Both types can do tremendous damage, but little-t trauma is more challenging to address—in part, I suspect, because we are more inclined to dismiss it. Jeff English, one of the therapists I was working with, offered a useful blanket definition: 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.” > [!quote] Quote (Page 390) Terrence Real’s book10 I Don’t Want to Talk About It, a groundbreaking treatise on the roots of male depression. Once