Book Review of “Outlive: The Science and Art of Longevity”

I regularly listen to “The Drive,” a podcast by Peter Attia, MD, that gives conventional medicine a much-needed integrative shot in the arm, courtesy of Attia’s commitment to evidence-based medicine. My health philosophy is more holistic than Attia’s, but I have to give him credit for elevating the conversation toward more integrative approaches even though he is a conventional, Western-trained physician.

Now Attia has distilled his wisdom into an actionable tome on the science and art of longevity. I applaud his integrity and will only offer two contrasting points I wish to make my readers aware of. The first is related to Attia’s approach to cardiovascular disease (CVD) and low-density lipoprotein (LDL) cholesterol, and the second concerns an omission in our understanding of cancer.

The Sweet Spot of Cholesterol

Attia references a 2019 Nature Reviews paper that atherosclerosis “probably would not occur in the absence of LDL-C concentrations in excess of physiological needs (on the order of 10 to 20 mg/dL).” Attia makes this the standard in his practice following the logic that “infants, who presumably require the most cholesterol, in order to meet enormous demands of their rapidly growing central nervous system, have similarly low levels of circulating cholesterol, without any developmental impairment.” He backs up this statement with 11 references on the safety and efficacy of cholesterol-lowering interventions.

First, I will question this assumption with one my own: My understanding of human physiology suggests that the body needs significantly more cholesterol from puberty through our procreative years to maintain optimal sex hormone levels. Keep in mind that the adolescent brain is still developing, and infants have lower circulating cholesterol because of how rapidly it is being utilized for neurogenesis.

Second, although lowering LDL-C is a desirable target to decrease CVD risk, rarely is the discussion balanced with the virtues of cholesterol. A massive prospective trial of CVD risk in over 15 million adults showed that the ideal range of total cholesterol is 210-240. There is no way to achieve that healthy level of cholesterol if your therapeutic target for LDL-C is 10-20 mg/dL. In the absence of cardiovascular disease, high cholesterol is documented to be associated with a decrease in mortality in the elderly.

An LDL-C that low is only possible with pharmaceutical interventions such as statin drugs and PCSK9 inhibitors. Attia provides the pros and cons of these drugs, but downplays the side effects of statins, in my humble opinion. Clinical trials assert that statin-induced muscle pain occurs in about 5% of patients, but I believe that percentage to be much higher based upon clinical experience. 

Both sides of this debate exhibit confirmation bias, but primary care physicians and cardiologists may not appreciate statin hesitancy because of the lag time between when drug therapy starts and side effects become noticeable. They may be quick to dismiss muscle pain that develops six months after starting statin therapy when the quick and easy counterfactual experiment is to recommend a period without taking the drug to see if symptoms improve. Few physicians do this, but I’ve heard countless stories of patients doing so on their own and having chronic issues resolve in weeks. They seldom report their findings back to the prescribing physician, perhaps out of concern about repercussions for their lack of compliance. 

Runaway Carcinogens

Chapter 8, titled “The Runaway Cell,” details Attia’s “medicine 3.0” approach to cancer. There were several important points made in this chapter, including an emphasis on screening for early detection and the promotion of immunotherapies. My only hesitation is Attia’s conventional designation of cancer as a stochastic disease—a random process of gene mutations that compounds as we age. He even goes so far as to state, “Plain bad luck seems to play a major role.” This is exactly what I was told by one oncologist when I was diagnosed.

I’ve done way too much research into the etiology of cancer and its relationship to environmental medicine to accept this at face value. The so-called “somatic mutation theory” of cancer is long since outdated, and although cancer is unequivocally a genetic disease, precious little attention is given to that which causes oncogenes to express themselves. As the functional medicine saying goes, “Genes load the gun, but environment pulls the trigger.”

If brilliant physicians like Attia put as much effort into studying and applying environmental medicine as they do into promoting cancer screening, we would have a completely different—and empowered—influence on cancer prevention. Environmental medicine is a discouraging topic, and that is likely what drives its slow acceptance into mainstream medicine. The amount of pollution in our food, air, and water is causing widespread health challenges, and as so many of the toxicants we are exposed to are carcinogens or endocrine disruptors, it can feel overwhelming to know where to start.

So long as we devote most of our resources to cancer treatment and screening, we will never slow down this train on a collision course to surpass CVD as the primary cause of death in the industrialized world. Preventing cancer, at its core, requires a broader and mature understanding of ecological medicine.

A Worthwhile Read

I recommend this book wholeheartedly, and the last chapter on mental health alone is worth the price of admission. Attia’s candidness releasing his own struggles to the world is no small feat of bravery. Though we may disagree on a few finer points, the overwhelming thrust of this book will be of help to many.

“Outlive: The Science and Art of Longevity” by Peter Attia, MD, with Bill Gifford