Top Quotes: “Outlive: The Science & Art of Longevity” — Peter Attia

Introduction

“While your genome is immutable, at least for the near future, gene expression can be influenced by your environment and your behaviors. For example, 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.”

“Obesity is merely one symptom of an underlying metabolic derangement, such as hyperinsulinemia, that also happens to cause us to gain weight. But not everyone who is obese is metabolically unhealthy, and not everyone who is metabolically unhealthy is obese.”

“Studies have found that approximately one-third of those folks who are obese by BMI are actually metabolically healthy, by many of the same parameters used to define the metabolic syndrome (blood pressure, triglycerides, cholesterol, and fasting glucose, among others). At the same time, some studies have found that between 20 and 40 percent of nonobese adults may be metabolically unhealthy, by those same measures.”

“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.

If you eat a doughnut, for example, the body has to decide what to do with the calories in that doughnut. At the risk of oversimplifying a bit, the carbohydrate from our doughnut has two possible fates. First, it can be converted into glycogen, the storage form of glucose, suitable for use in the near term. About 75 percent of this glycogen ends up in skeletal muscle and the other 25 percent goes to the liver, although this ratio can vary.

An adult male can typically store a total of about 1,600 calories worth of glycogen between these two sites, or about enough energy for two hours of vigorous endurance exercise. This is why if you are running a marathon or doing a long bike ride, and do not replenish your fuel stores in some way, you are likely to “bonk,” or run out of energy, which is not a pleasant experience.

One of the liver’s many important jobs is to convert this stored glycogen back to glucose and then to release it as needed to maintain blood glucose levels at a steady state, known as glucose homeostasis. This is an incredibly delicate task: an average adult male will have about five grams of glucose circulating in his bloodstream at any given time, or about a teaspoon. That teaspoon won’t last more than a few minutes, as glucose is taken up by the muscles and especially the brain, so the liver has to continually feed in more, titrating it precisely to maintain a more or less constant level. Consider that five grams of glucose, spread out across one’s entire circulatory system, is normal, while seven grams – a teaspoon and a half – means you have diabetes. As I said, the liver is an amazing organ.

We have a far greater capacity, almost unlimited, for storing energy as fat – the second possible destination for the calories in that doughnut.”

“If you happen to be riding a stage of the Tour de France while you eat the doughnut, or are engaged in other intense exercise, those calories will be consumed almost instantly in the muscles. But in a typical sedentary person, who is not depleting muscle glycogen rapidly, the excess energy from the doughnut will largely end up in fat cells (or more specifically, as triglycerides contained within fat cells).

The twist here is that fat – that is, subcutaneous fat, the layer of fat just beneath our skin – is actually the safest place to store excess energy. Fat in and of itself is not bad. It’s where we should put surplus calories. That’s how we evolved. While fat might not be culturally or aesthetically desirable in our modern world, subcutaneous fat actually plays an important role in maintaining metabolic health.”

“Think of fat as acting like a kind of metabolic buffer zone, absorbing excess energy and storing it safely until it is needed. If we eat extra doughnuts, those calories are stored in our subcutaneous fat; when we go on, say, a long hike or swim, some of that fat is then released for use by the muscles. This fat flux goes on continually, and as long as you haven’t exceeded your own fat storage capacity, things are pretty much fine.

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. The doughnuts or whatever they might be eating are probably still getting converted into fat, but now the body has to find other places to store it.

It’s almost as if you have a bathtub, and you’re filling it up from the faucet. If you keep the faucet running even after the tub is full and the drain is closed (i.e., you’re sedentary), water begins spilling over the rim of the tub, flowing into places where it’s not wanted or needed, like onto the bathroom floor, into the heating vents or down the stairs. It’s the same with excess fat. As more calories flood into your subcutaneous fat tissue, it eventually reaches capacity and the surplus begins spilling over into other areas of your body: into your blood, as excess triglycerides; into your liver, contributing to NAFLD; into your muscle tissue, contributing directly to insulin resistance in the muscle; and even around your heart and your pancreas.”

“Fat storage capacity varies widely among individuals. Going back to our tub analogy, some people have subcutaneous fat-storage capacity equivalent to a regular bathtub, while others may be closer to a full-sized Jacuzzi or hot tub. Still others may have only the equivalent of a five-gallon bucket. It also matters, obviously, how much “water”is flowing into the tub via the faucet (as calories in food) and how much is flowing out via the drain (or being consumed via exercise or other means).

Individual fat-storage capacity seems to be influenced by genetic factors. This is a generalization, but people of Asian descent (for example), tend to have much lower capacity to store fat, on average, than Caucasians. There are other factors at play here as well, but this explains in part why some people can be obese but metabolically healthy, while others can appear “skinny” while still walking around with three or more markers of metabolic syndrome. It’s these people who are most at risk, according to research by Mitch Lazar at the University of Pennsylvania, because a “thin” person may simply have a much lower capacity to safely store fat. All other things being equal, someone who carries a bit of body fat may also have greater fat-storage capacity, and thus more metabolic leeway than someone who appears to be more lean.”

“The vast majority of the cholesterol in our circulation is actually produced by our own cells. Nevertheless, US dietary guidelines warned Americans away from consuming foods high in cholesterol for decades, and nutrition labels still inform American consumers about how much cholesterol is contained in each serving of packaged foods.”

“It took nearly two more decades before the advisory committee responsible for the US government dietary guidelines finally conceded (in 2015) that “cholesterol is not a nutrient of concern for overconsumption.””

“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.)”

“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. It is the most prevalent hereditary risk factor for heart disease, and its danger is amplified.”

“Most people have relatively small concentrations of this particle, but some individuals can have as much as one hundred times more than others. The variation is largely genetic, and an estimated 20 to 30 percent of the US population has levels high enough that they are at increased risk; also, people of African descent tend to have higher levels of Lp(a), on average, than Caucasians. This is why, if you have a history of premature heart attacks in your family, you should definitely ask for an Lp(a) test. We test every single patient for Lp(a) during their first blood draw. Because elevated Lp(a) is largely genetic, the test need only be done once (and cardiovascular disease guidelines are beginning to advise a once-a-lifetime test for it anyway).”

Cancer

“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. But many important noncancerous cells are also dividing frequently, such as those in the lining of the mouth and gut, the hair follicles, and the nails, which is why typical chemotherapy agents cause side effects like hair loss and gastrointestinal misery. Meanwhile, as cancer researcher Robert Gatenby points out, those cancer cells that do manage to survive chemotherapy often end up acquiring mutations that make them stronger.”

“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. It may seem counterintuitive to recommend fasting to cancer patients, but researchers have found that it caused no major adverse events in chemotherapy patients, and in some cases it may have improved the patients’ quality of life. A randomized trial in 131 cancer patients undergoing chemotherapy found that those who were placed on a “fasting-mimicking diet” (basically, a very low-calorie diet designed to provide essential nutrients while reducing feelings of hunger) were more likely to respond to chemotherapy and to feel better physically and emotionally.

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.” But the results of these studies suggest that maybe it’s not such a good idea to increase the level of insulin in someone who has cancer. 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.”

“Twenty years ago, someone with metastatic melanoma could expect to live about six more months, on average. Now that number is twenty-four months, with about 20 percent of such patients being completely cured. This represents measurable progress – almost entirely thanks to immunotherapy. Improved early detection of cancer will likely make our immunotherapy treatments still more effective.”

“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.”

Alzheimers

“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. The circumstantial evidence is strong.

Improved neuroimaging techniques have confirmed not only that cerebral perfusion is decreased in brains affected by Alzheimer’s disease but also that a drop in blood flow seems to predict when a person will transition from preclinical Alzheimer’s disease to MCI, and on to full-fledged dementia.”

“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. 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. The authors found that this association held up even after adjusting for the usual confounders such as age, sex, socioeconomic status, diseases such as diabetes and cancer, smoking, and lifestyle factors such as sleep patterns, walking pace, and time spent watching TV. And there appeared to be no upper limit or “plateau” to this relationship; the greater someone’s grip strength, the lower their risk of dementia.”

“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).”

Tips

“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.

The good news is that at intersections we have choices. We have agency. We can decide whether and when to drive into the crossroads. This gives us an opportunity to develop specific tactics to try to avoid getting hit in an intersection. 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. A high school friend who is now a long-haul truck driver agrees: before entering any intersection, even if he has the right of way (i.e., a green light), he always looks left first, then right, specifically to avoid this type of crash.”

“I used to recommend long periods of water-only fasting for some of my patients-and practiced it myself. But I no longer do so, because I’ve become convinced that the drawbacks (mostly having to do with muscle loss and undernourishment) outweigh its metabolic benefits in all but my most overnourished patients.”

Exercise

“Study after study has found that regular exercisers live as much as a decade longer than sedentary people.”

“Someone in the bottom quartile of VO, max for their age group (i.e., the least fit 25 percent) is nearly four times likelier to die than someone in the top quartile – and five times likelier to die than a person with elite-level (top 2.3 percent) VO max. That’s stunning. These benefits are not limited to the very fittest people either; even just climbing from the bottom 25 percent into the 25th to 50th percentile (e.g., least fit to below average) means you have cut your risk of death nearly in half, according to this study.

These results were confirmed by a much larger and more recent study, published in 2022 in the Journal of the American College of Cardiology, looking at data from 750,000 US veterans ages thirty to ninety-five. This was a completely different population that encompassed both sexes and all races, yet the researchers found a nearly identical result: someone in the least fit 20 percent has a 4.09 times greater risk of dying than a person in the top 2 percent of their age and sex category. Even someone of moderate fitness (40th to 60th percentile) is still at more than double the risk of all-cause mortality than the fittest group, this study found. “Being unfit carried a greater risk than any of the cardiac risk factors examined,” the authors concluded.”

“Millions of people are suffering from a little-known and underdiagnosed liver condition that is á potential precursor to type 2 diabetes. Yet people at the early stages of this metabolic derangement will often return blood test results in the “normal” range. Unfortu-nately, in today’s unhealthy society, “normal” or “aver-age” is not the same as “optimal.”

• “The metabolic derangement that leads to type 2 diabetes also helps foster and promote heart disease, cancer, and Alzheimer’s disease. Addressing our metabolic health can lower the risk of each of the Horsemen.
• Almost all “diets” are similar: they may help some people but prove useless for most. Instead of arguing about diets, we will focus on nutritional biochemistry – how the combinations of nutrients that you eat affect your own metabolism and physiology, and how to use data and technology to come up with the best eating pattern for you.
• One macronutrient, in particular, demands more of our attentión than most people realize: not carbs, not fat, but protein becomes critically important as we age.”

Exercise

“The strong association between cardiorespiratory fitness and longevity has long been known. It might surprise you, as it did me, to learn that muscle may be almost as powerfully correlated with living longer. 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. Further analysis revealed that it’s not the mere muscle mass that matters but the strength of those muscles, their ability to generate force. It’s not enough to build up big pecs or biceps in the gym — those muscles also have to be strong. They have to be capable of creating force. 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.

Strength may even trump cardiorespiratory fitness, at least one study suggests. 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.”

“He found that 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.

Even better: You don’t need a doctor to prescribe exercise for you.

Much of this effect, I think, likely has to do with improved mechanics: 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.”

“At a deeper biochemical level, exercise really does act like a drug. To be more precise, it prompts the body to produce its own, endogenous drug-like chemicals. 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.”

“Longitudinal and cross-sectional studies find that fat-free mass (meaning mostly muscle mass) and activity levels remain relatively consistent as people age from their twenties and thirties into middle age. But both physical activity levels and muscle mass decline steeply after about age sixty-five, and then even more steeply after about seventy-five. It’s as if people just fall off a cliff sometime in their mid-seventies.

By age eighty, the average person will have lost eight kilograms of muscle, or about eighteen pounds, from their peak. But people who maintain higher activity levels lose much less muscle, more like three to four kilograms on average. While it’s.not clear which direction the causation flows here, I suspect it’s probably both ways: people are less active because they are weaker, and they are weaker because they are less active.

Continued muscle loss and inactivity literally puts our lives at risk. Seniors with the least muscle mass (also known as lean mass) are at the greatest risk of dying from all causes. One Chilean study looked at about one thousand men and four hundred women, with an average age of seventy-four at enrollment. The researchers divided the subjects into quartiles, based on their appendicular lean mass index (technically, the muscle mass of their extremities, arms and legs, normalized to height), and followed them over time. After twelve years, approximately 50 percent of those in the lowest quartile were dead, compared to only 20 percent of those in the highest quartile for lean mass.”

“Someone with more muscle mass is less likely to fall and injure themselves, while those who are less likely to fall for other reasons (better balance, more body awareness) will also have an easier time maintaining muscle mass. Conversely, muscle atrophy and sarcopenia (age-related muscle loss) increase our risk of falling and possibly requiring surgery — while at the same time worsening our odds of surviving said surgery without complications.”

“Let’s say the kid weighs twenty-five or thirty pounds. That’s basically the same as doing a squat while holding a thirty-pound dumbbell in front of you (i.e., a goblet squat). Can you do that now, at age forty? Most likely. But now let’s look into the future. Over the next thirty or forty years, your muscle strength will decline by about 8 to 17 percent per decade — accelerating as time goes on.

So if you want to pick up that thirty-pound grandkid or great-grandkid when you’re eighty, you’re going to have to be able to lift about fifty to fifty-five pounds now. Without hurting yourself. Can you do that? I press the issue. You also want to be able to hike on a hilly trail? To do that comfortably requires a VO2 max of roughly 30 ml/kg/min. Let’s take a look at the results of your latest VO2 max test — and guess what, you only scored a 30. You’re average for your age, but I’m afraid that’s not good enough, because your VO2 max is also going to decline. So we’re going to have to go ahead and cross that hike off your list. You can pull it off now, but you likely won’t be able to do it when you’re older.

On it goes. To lift that twenty-pound suitcase overhead when you are older means doing so with forty or fifty pounds now. To be able to climb four flights of stairs in your eighties means you should be able to pretty much sprint up those same stairs today. 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.”

“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.”

“Muscle is the largest glycogen storage sink in the body, and as we create more mitochondria, we greatly increase our capacity for disposing of that stored fuel, rather than having it end up as fat or remaining in our plasma. Chronic blood glucose elevations damage organs from our heart to our brain to our kidneys and nearly everything in between — even contributing to erectile dysfunction in men. Studies have found that while we are exercising, our overall glucose uptake increases as much as one-hundred-fold compared to when we are at rest. What’s interesting is that this glucose uptake occurs via multiple pathways. There is the usual, insulin-signaled way that we’re familiar with, but exercise also activates other pathways, including one called non-insulin-medicated glucose uptake, or NIMGU, where glucose is transported directly across the cell membrane without insulin being involved at all.

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.”

“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.”

“Even if you are not competing in high-level endurance sports, your VO2 max is an important number that you can and should know.

Testing is widely available, even from some of the larger fitness chains. The bad news is that the VO2 max test is an unpleasant affair that entails riding an exercise bike or running on a treadmill at ever greater intensity, while wearing a mask designed to measure oxygen consumption and CO2 production. The peak amount of oxygen you consume, typically close to the point at which you “fail,” meaning the point where you just can’t keep going, yields your VO2 max. We have all our patients do the test at least annually, and they almost all hate it. We then compare their results, normalized by weight, to the population of their age and sex.

Why is this important? Because our VO2 max is a pretty good proxy measure of our physical capability. It tells us what we can do — and what we cannot do.”

“I push my patients to train for as high a VO2 max as possible, so that they can maintain a high level of physical function as they age. Ideally, I want them to target the “elite” range for their age and sex (roughly the top 2 percent). If they achieve that level, I say good job — now let’s reach for the elite level for your sex, but two decades younger.”

“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.”

“I do these workouts on my road bike, mounted to a stationary trainer, or on a rowing machine, but running on a treadmill (or a track) could also work. 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.”

“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.

Where HIIT intervals are very short, typically measured in seconds, VO2 max intervals are a bit longer.”

“The sad fact is that our muscle mass begins to decline as early as our thirties. An eighty-year-old man will have about 40 percent less muscle tissue (as measured bỳ cross section of the vastus lateralis, aka the “quad” muscle of the thigh) than he did at twenty-five.”

“It takes much less time to lose muscle mass and strength than to gain it, particularly if we are sedentary. Even if someone has been training diligently, a short period of inactivity can erase many of those gains. If that inactivity stems from a fall or a broken bone, and lasts longer than a few days, it can often kick off a steep decline from which we may never fully recover. 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). That’s substantial, and it shows just how dangerous inactivity can be. If someone is sedentary and consuming excess calories, muscle loss accelerates, because one of the primary destinations of fat spillover is into muscle.”

“One study looked at sixty-two frail seniors (average age seventy-eight) who engaged in a program of strength training and found that even after six months of pure strength training, half of the subjects did not gain any muscle mass. They also didn’t lose any muscle mass, likely thanks to the weight training, but the upshot is, it is very difficult to put on muscle mass later in life.”

“The takeaway for readers here is that your BMD is important, demanding at least as much attention as muscle mass, so you should at least check your BMD every few years. (Particularly if your primary sports are nonweight-bearing, like cycling or swimming.)”

“Many studies suggest that grip strength — 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. In these studies, grip strength is likely acting as a proxy for overall muscle strength, but it is also a broader indicator of general robustness and the ability to protect yourself if you slip or lose balance. If you have the strength to grab a railing, or a branch, and hold on, you might avoid a fall.”

“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. (Bonus points: Hold the kettlebell up vertically, keeping your wrist perfectly straight and elbow cocked at ninety degrees, as though you were carrying it through a crowded room.) 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. This is, obviously, a lofty goal — please don’t try to do it on your next visit to the gym. Some of our patients need as much as a year of training before they can even attempt this test.”

“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.”

Breathing

“Breathing is also important to stability and movement, and even to strength. Poor or disordered breathing can affect our motor control and make us susceptible to injury, studies have found. In one experiment, 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.”

“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 Put,” the “Sad Guy,” and the “Yogini” — each corresponding to a different set of stability strategies:

Mr. Stay Put

HYPERINFLATED. This person is an upper-chest breather who tends to pull up into spinal extension for both respiration and stability. Their lumbar spine is in hyperextension, while their pelvis lives in anterior (forward) tilt, meaning their butt sticks out. They are always pulling up into themselves, trying to look like they are in charge. They have a limited sense of grounding in the feet, and limited ability to pronate to absorb shock (the feet turn outward, or supinate). All of the above makes them quite susceptible to lower back pain, as well as tightness in their calves and hips.

Sad Guy

COMPRESSED. Everything about them is sort of scrunched down and tight. Their head juts forward, and so do their shoulders, which kind of roll to the front because they are always pulling forward to try and take in more air. Their midback rolls in an overly flexed or hyperkyphotic posture, and they have limited neck and upper limb motion. Sometimes their lower legs externally rotate, and the feet overpronate. Gravity is weighing them down.

Yogini

UNCONTROLLED. These folks have extreme passive range of motion (i.e., flexibility) — and extremely limited ability to control it. They can often do a toe touch and put their palms flat on the floor, but because of their lack of control, these people are quite prone to joint injuries. They are always trying to find themselves in space, fidgeting and twitching; they compensate for their excessive flexibility by trying to stabilize primarily with their neck and jaw. It is very hard for them to put on lean mass (muscle).”

“I was a hyperinflated Mr. Stay Puft, according to Beth: When I inhaled, my ribs would flare out and up, like a rooster thrusting out his chest. This got air into my lungs, but it also pulled my center of mass forward. To balance, my spine would curve into kyphosis, and my butt would stick out (Beth called it “duck butt”). This hyperextended my hamstrings, effectively disconnecting them from the rest of my body, so I was unable to access these muscles. For all those years, before I realized this, I was deadlifting using only my back and glutes, with virtually no help from my powerful hamstrings. In terms of breath training, I needed to think about getting air out, the exhale — while someone who tends more toward the Sad Guy type should work on getting air in, inhaling via the nose rather than the mouth.

The idea behind breath training is that proper breathing affects so many other physical parameters: rib position, neck extension, the shape of the spine, even the position of our feet on the ground. The way in which we breathe reflects how we interact with the world.”

“Beth likes to start with an exercise that builds awareness of the breath and strengthens the diaphragm, which not only is important to breathing but is an important stabilizer in the body. 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. A noisy inhale looks and feels more dramatic, as the neck, chest, or belly will move first, and the diaphragm cannot descend freely, making it more difficult to get air in.

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.”

“Here’s another quick exercise to help you understand how to create IAP: breathe all the way in, so you feel as if you are inflating the cylinder on all sides and pulling air all the way down into your pelvic floor, the bottom of the cylinder. You’re not actually “breathing” there, in the sense that air is actually entering your pelvis; you’re seeking maximal lung expansion, which in turn sort of pushes your diaphragm down. With every inhale, focus on expanding the cylinder around its whole diameter and not merely raising the belly. If you do this correctly, you will feel the entire circumference of your shorts expand evenly around your waist, even in the back, not just in the front. When you exhale, the diaphragm comes back up, and the ribs should rotate inward again as your waistband contracts.

This inhale develops tension, and as you exhale, pushing out air, you keep that muscular tension all around your cylinder wall. This intra-abdominal pressure is the basic foundation for everything that we do in stability training — a deadlift, squats, anything. It’s as if you have a plastic bottle: with the cap off, you can crush the bottle in one hand; with the cap on, there is too much pressure (i.e., stability) and the bottle can’t be crushed. I practice this 360-degree abdominal breathing every day, not only in the gym but also while I am at my desk.

Your “type” also indicates how you should work out, to some extent. The Stay Puft people tend to need more grounding through the feet and more work with weight in front of them so as to pull their shoulders and hips into a more neutral position. Beth typically has someone like me hold a weight in front of my body, a few inches in front of the sternum. This forces my center of mass back, more over my hips. Try it with a light dumbbell or even a milk carton, and you’ll see what I mean. It’s a subtle but noticeable change of position.

With the Sad Guys and Gals, Beth tends to work more on cross-body rotation, having them swing the arms across the body to open up the chest and shoulders. She is cautious about loading the back and shoulders, preferring to begin with body weight exercises and split-leg work, such as a walking lunge with a reach, either across the body or to the ceiling, on each step.

For the Yoginis, Beth recommends doing “closed-chain’” exercises such as push-ups, using the floor or wall for support, as well as using exercise machines with a well-defined and limited range of motion, given their lack of joint control.”

Balance

“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.”

“Balance is the real challenge with swimming, because our center of mass is way off from our center of volume, causing our hips to sink. Good swimmers learn to overcome this imbalance with training.”

“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.”

Conclusion

“The people who are still drinking in older age tend to do so because they are healthy, and not the other way around. Similarly, people who drink zero alcohol often have some health-related reason, or addiction-related reason, for avoiding it. And such studies also obviously exclude those who have already died of the consequences of alcoholism.

Epidemiology sees only a bunch of seemingly healthy older people who all drink alcohol and concludes that alcohol is the cause of their good health. But a recent study in JAMA suggests that this might not be true. This study found that once you remove the effects of other factors that may accompany moderate drinking — such as lower BMI, affluence, and not smoking — any observed benefit of alcohol consumption completely disappears. The authors concluded that there is no dose of alcohol that is “healthy.””

“The large Spanish study known as PREDIMED (Prevención con Dieta MEDiterránea) was elegant in its design: rather than telling the nearly 7,500 subjects exactly what they were supposed to eat, the researchers simply gave one group a weekly “gift” of a liter of olive oil, which was meant to nudge them toward other desired dietary changes (i.e., to eat the sorts of things that one typically prepares with olive oil). A second group was given a quantity of nuts each week and told to eat an ounce per day, while the control group was simply instructed to eat a lower-fat diet, with no nuts, no excess fat on the meat they did eat, no sofrito (a garlicky Spanish tomato sauce with onions and peppers that sounds delicious, and weirdly, no fish.

The study was meant to last six years, but in 2013 the investigators announced that they had halted it prematurely, after just four and a half years, because the results were so dramatic. The group receiving the olive oil had about a one-third lower incidence (31 percent) of stroke, heart attack, and death than the low-fat group, and the mixed-nuts group showed a similar reduced risk (28 percent). It was therefore deemed unethical to continue the low-fat arm of the trial.”

“Cheese is a processed food, invented as a way to preserve milk, which would otherwise spoil quickly without refrigeration.”

“CGM is available only by prescription and is most commonly worn by patients diagnosed with type 1 or type 2 diabetes, who need to monitor their glucose levels from moment to moment. For these people, CGM is an essential tool that can protect them from life-threatening swings in blood glucose. But I think nearly every adult could benefit from it, at least for a few weeks, and it will likely be available to consumers without a prescription in the not-too-distant future. It’s currently fairly easy for a nondiabetic to obtain a CGM from one of several online metabolic health start-ups.”

“Insulin treatment alone can cost hundreds of dollars a month. Also, as CGM becomes more common, and more readily available without a prescription, the cost is sure to come down. Typically, my healthy patients need to use CGM only for a month or two before they begin to understand what foods are spiking their glucose (and insulin) and how to adjust their eating pattern to obtain a more stable glucose curve.”

“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, 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.

So if someone weighs 180 pounds, they need to consume a minimum of 130 grams of protein per day, and ideally closer to 180 grams, especially if they are trying to add muscle mass.”

“Another very important function 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. This is why, if we go to bed upset about something, it almost always seems better in the morning. We remember the event but (eventually) forget the pain that accompanied it. Without this break for emotional healing, we would live in a state of constant anxiety, every memory triggering a renewed surge of the emotions around that event.

If this sounds like PTSD, you are correct: studies of combat veterans found that they are less able to separate memories from emotions, precisely due to their lack of REM sleep. It turned out that the veterans put out high levels of noradrenaline, the fight-or-flight hormone that effectively prevented their brains from relaxing enough to enter REM.”

“If all members of a clan or a tribe adhered to the exact same sleep schedule, the entire group would be vulnerable to predators and enemies for several hours every night. Obviously not ideal. But if their sleep schedules were staggered, with some individuals going to bed early while others were more inclined to stay up late and tend the fire, the group as a whole would be much less vulnerable.”

“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.”

“Everyone differs in their caffeine tolerance, based on genes and other factors (23andMe tests for one common caffeine-related gene). I’m a very fast metabolizer, so I can handle that afternoon espresso without it affecting my sleep too much; I can even drink coffee after dinner, and it seems to have no impact (unlike alcohol). Someone who metabolizes caffeine slowly should probably stop at one or two cups, before noon.”

“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.”

“If my wife comes home and snips at me because I didn’t help put away the groceries, my tendency might be to think, Hey, I’m working really hard and I can’t always pitch in. And that sense of entitlement would sneak up inside me because, well, I am working very hard, and someone else can put away the groceries.

But then I ask myself, Wait, what has Jill’s day been like today?

She had to pick up our boys from school and take them to the grocery store, where they probably fought like wild animals and made everyone in the store think Jill is the worst mother on the planet because she can’t control her spoiled little brats, while she stood in line at the deli counter just to get me the perfectly sliced deli meat that can’t be found with the prepackaged deli meat, and then on the way home she hit every single red light while the boys threw Lego bricks at each other.

And you know what? 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.”

“One simple tactic that I use to cope with mounting emotional distress is inducing an abrupt sensory change — typically, by throwing ice water on my face or, if I’m really struggling, taking a cold shower or stepping into an ice bath. This simple intervention stimulates an important cranial nerve, the vagus nerve, which causes our heart rate and respiratory rate to slow and switches us into a calm, parasympathetic mode (and out of our fight-or-flight sympathetic mode). Interventions like these are often enough to help refocus and think about a situation more calmly and constructively. Another technique I have grown very fond of is slow, deep breathing: four seconds to inhale, six seconds to exhale. Repeat. As the breath goes, the nervous system follows.

It is also important to note that DBT is not a passive modality. It requires conscious thought and action on a daily basis. One tactic that I’ve found especially helpful is called opposite action — that is, if I feel like doing one thing (generally, not a helpful or positive thing), I’ll force myself instead to do the exact opposite. By doing so, I also change the underlying emotions.”