Exercise and Risk Factor Management for Lifespan and Healthspan

Key Quotes

"If you simply look at the data there's really no intervention we have including smoking cessation management of hypertension management of lipids reduction of type two diabetes all of those things have a significant impact on either disease specific or all cause mortality but when you look at cardiovascular fitness when you look at muscular strength and even muscle mass the benefits are greater and again this is just talking about it through the lens of mortality so I think the answer from a lifespan perspective is exercise but again if you expand that and ask the question through the lens of not just lifespan but also healthspan then I think it becomes even more clear because for most people the reduction in quality of life in that final decade is actually a movement problem it is a pain problem it is a fitness problem and that's what I think we should be training for."

Peter Attia argues that exercise is the single most important intervention for both lifespan and healthspan. He explains that while other interventions like smoking cessation and managing chronic diseases impact mortality, exercise provides greater benefits for cardiovascular fitness, muscular strength, and muscle mass. Attia emphasizes that the decline in quality of life in later years is often due to movement and fitness issues, which exercise directly addresses.

"We call those the centenarian decathlon goals and some of these goals are just what we would call activities of daily living but we want people to be ambitious and be thoughtful so really think about what it is you'd want to do each of those activities is deconstructed into movement patterns and physiological requirements we've gone pretty good at this now this took a couple of years to really really get down to as close as we could go from an art to a science and then for each of those activities we look at the requirements the movement requirements the strength requirements the physiological requirements and parameters all across the board then we say okay well you want to play 18 holes of golf and walk around this is what you have to be able to do you want to be able to hike for an hour averaging a pace of two miles per hour on this type of terrain down to how much ankle movement you'd have to have hip stability etc etc this is what you have to have then we project back by decades."

Peter Attia describes his "Centenarian Decathlon" framework as a tool to motivate patients to prioritize exercise. Attia explains that this method involves identifying 10 key physical activities a person wants to perform in their final decade of life. These activities are then broken down into specific movement and physiological requirements, which are projected backward by decades to illustrate the current fitness needed to achieve those future goals.

"I think it's a bit of a false dichotomy to separate them the truth of the matter is people actually want both when I hear people say I don't care about how long I live I just want to live a better quality of life I understand what they're saying and I think that's sort of shorthand for I don't want to get old in a declining state of health totally reasonable but if we're being honest I think all of us would love to live longer provided we can live better and the good news is most of the things that you do to pursue healthspan will also improve lifespan the reverse is true if you focus on it the right way."

Peter Attia contends that separating lifespan and healthspan is a false dichotomy, as individuals desire both longevity and a high quality of life. Attia suggests that interventions aimed at improving healthspan, which he defines as living without chronic disease, also contribute to a longer lifespan. He notes that focusing on healthspan through reasonable means will naturally lead to benefits for lifespan, and vice versa.

"Now apob particles are the approximate driver of the atheroma and therefore every ldl particle is a potential seed regardless of metabolic health it's also worth pointing out a zero calcium score carries with it an approximate 15 risk of being a false negative I've personally seen i don't know 10 cases of zero calcium scores that are not zero no more than that gosh if i really stopped to think about it i would be 10 over the last two years if i go back and look longer where a person has a zero calcium score but shortly thereafter a cta is done and we do indeed see soft plaque which means that there really is some advancing disease."

Peter Attia explains that apob particles are the primary drivers of atherosclerosis, meaning every LDL particle poses a risk for plaque formation, irrespective of an individual's metabolic health. Attia also cautions that a zero calcium score has a 15% chance of being a false negative, citing personal experience with cases where subsequent CTAs revealed soft plaque despite an initial zero score. This highlights the importance of considering apob levels even in seemingly healthy individuals with good cardiovascular fitness.

"The reason you treat causal risk factors is not because you are sure that this person is going to get ascvd but because you understand that by treating something that's causal you reduce the risk and again the example i've given in the past and i'll give again is nick i have a 40 year old person who's insulin sensitive super healthy everything about them looks great and they just started smoking last month and they're in my office let's just assume i did the most high fidelity lung scan in the world they don't have any evidence of lung cancer or copd for that matter should i encourage them to stop smoking or should i say look it's okay to keep smoking but the moment we start to see evidence of lung cancer we're going to stop of course the answer is obvious here nobody would disagree we would get that person to stop smoking immediately not because i know for certain that if they keep smoking they will get lung cancer many smokers do not go on to get lung cancer and by the way 15 of people who get lung cancer have never smoked but there is still causality between smoking and lung cancer and that's of course why we would tell this person to stop smoking immediately."

Peter Attia uses the analogy of smoking to illustrate why causal risk factors should be treated, even without certainty of future disease. Attia argues that if a risk factor like high apob is causally linked to cardiovascular disease, it should be addressed to reduce overall risk. He posits that just as one would advise a healthy individual to stop smoking immediately due to its causal link to lung cancer, despite not all smokers developing the disease, the same principle applies to treating causal risk factors for cardiovascular disease.