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I’ve been reading Dr. Peter Attia’s book Outlive: The Science & Art of Longevity and I plan on writing a full review of the book once I’ve finished it but I just got through the most important section of the book and I’ve realized that these three chapters deserve more attention than I can give them in a review of the full book and everyone needs a reminder and encouragement to exercise along with the knowledge necessary to do it wisely. So here is my review of chapters 11 thru 13 of Attia’s Outlive.
Near the beginning of his 75 page dive into the topic of exercise Attia writes:
More than any other tactical domain we discuss in this book, exercise has the greatest power to determine how you will live out the rest of your life. There are reams of data supporting the notion that even a fairly minimal amount of exercise can lengthen your life by several years. It delays the onset of chronic diseases, pretty much across the board, but it is also amazingly effective at extending and improving healthspan. Not only does it reverse physical decline, which I suppose is somewhat obvious, but it can slow or reverse cognitive decline as well. (It also has benefits in terms of emotional health, although those are harder to quantify.)
So if you adopt only one new set of habits based on reading this book, it must be in the realm of exercise. (pages 217-218)
At an earlier point in the book Attia suggested that when you are trying to improve your lifespan and healthspan (which is what this book aims to help you with) exercise is more important than your diet, and more important than any drugs you may or may not be taking. He even suggested to people reading the book who wanted to get healthier sooner rather than later that they should skip 200 pages and start reading these chapters. Exercise is essential.
Of course you already knew this, or you at least knew that exercise is good for you. Doctors will often advise their patients to exercise but, as Attia observes, “the advice rarely goes beyond generic recommendations to move more and sit less.” (page 219). People, especially those who have never exercised regularly, need more than just generic recommendations. They need to have a good understanding of the benefits of exercise are so that they can muster the drive necessary to do it, and they need to know what they should actually be doing in their work-outs, generic phrases like, “moderate-intensity aerobic activity” (which the government recommends we get 150 minutes of every week) are meaningless because they lack context and specificity.
Attia explains both the benefits of exercise and tells us what we should focus on with all the context and specificity we need to start our fitness journeys. The benefits of exercise were pretty well summarized in the quote I opened this review with so I won’t spend any more time explaining that right now, but Attia digs into various pieces of scientific research to show you that there is no drug in existence that could possibly give you the benefits a good exercise routine will give you.
The more important question than if exercise is good for us is what should we do when we exercise. Attia breaks down the three types of exercise we should be doing and how much we should be doing it: Zone 2 exercise, VO2 max training, and strength training. We’ll take a look at what he has to say for each of these.
Zone 2 Exercise
Most fitness nerds break down the levels of exercise intensity into five levels, or zones, with zone 1 being a calm walk and zone 5 being your maximum output. Zone 2 exercise could be something like a run, bike ride, swim, or light ruck where one is, “going at a speed slow enough that one can still maintain a conversation but fst enough that the conversation might be a little strained.” (page 237) If you can string multiple sentences together you aren’t working hard enough to be in zone 2, if you can only get a few words out at a time you are in zone 3. Zone 2 exercise is in the range where you speak one sentence at a time.
Zone 2 workouts shouldn’t feel painful. Proper zone 2 exercise should not be enough for us to accumulate lactic acid (the chemical that causes muscle pain during workouts) for us to feel the burn. You’ll have to spend some time experimenting with different types of workouts to see what a zone 2 workout looks like for you. At my current level of fitness a good zone 2 workout for me is a 25 pound ruck at a 2.5-3 mph pace, in the coming months I hope to be able to increase both that weight and speed while staying in zone 2.
After speaking with multiple exercise physiologists Attia says, “it seems that about three hours per week of zone 2, … is the minimal required for most people to derive a benefit and make improvements.” (page 243) That could be four 45 minute sessions, six half hour sessions, three hour long sessions, or some mixture of timing that can fit into your schedule. But there seems to be nothing wrong with going longer, three hours per week is the minimum, Attia tells us he does at least four. Even five or six hours a week shouldn’t hurt you assuming you have the time for it.
If you are following the sort of plan that Attia lays out here the majority of your time exercising will be at a zone 2 level of intensity, and if you are just starting out on your fitness journey zone 2 exercise should be your primary focus, so figure out what zone 2 activities you enjoy doing and find some good podcasts or something. For most of his patients Attia won’t introduce VO2 max or strength training until they’ve spent five or six months working in zone 2 and improving their stability (another topic we’ll get to later). I do think most of Attia’s patients are in their 40s, 50s, and 60s so if you are younger than that and in decent shape you could probably move on faster, but I’m not a doctor or exercise physiologist so don’t trust me completely on that assumption.
VO2 Max Training
VO2 max is as far from zone 2 exercise as we could possibly be. It is essentially our maximum output. “At VO2 max, we are using a combination or aerobic and anaerobic pathways to produce energy, but we are at our maximum rate of oxygen consumption.” (page 244) From what I understand our rate of oxygen consumption is what limits us from pushing harder, or that is at least the variable that we can actually measure and Attia thinks we should test our VO2 max output once a year.
The test isn’t pleasant, it involves being put on a treadmill or stationary bike with a mask strapped to your face hooked up to a machine that measures your oxygen consumption as you are told to sprint as fast as you can. I’d imagine you’d either want to throw up or pass out at the end of the test but the number it gives us is probably the best quantifiable way to measure fitness. The higher your VO2 max the fitter you are. Someone with a VO2 max of 25 is able to walk up a steep hill while someone with a VO2 max of 50 could run up that same hill.
The main focus of Attia’s medical practice (and this book) is improving patient’s lifespan and healthspan. Unless we are actively trying to improve it our VO2 max naturally drops as we age. Attia tells his patients to get their VO2 max up as high as possible so their decline starts off at a higher point and when they hit their 80s they won’t dread every time they have to walk up a flight of stairs. The lofty goal he initially sets for his patients is to achieve a VO2 max score within the top 2% of people their age, and if they hit that aim for a score at the top 2% of people twenty years younger.
But how do we improve our VO2 max score? Zone 2 exercise will help but what you really need to get things going is some high intensity interval training usually taking place on a stationary bike, rowing machine, treadmill or around a track. What Attia tells us, “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. … Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down.” (pages 249-250) Four to six sets of that with a proper warm up and cool down is a great workout to do once a week.
If you have never done a workout like this before I can assure you it is quite difficult but it is rewarding. It has been nearly ten years since I have done something like it and I’m probably not in a good enough shape to do it now. Remember Attia has his patients wait at least five or six months before letting them attempt something like this; you’re not going to be able to get right off the couch and do something like this without a high risk of hurting yourself. Don’t hurt yourself.
Strength Training and Stability
Of the three types of exercise Attia tells us we should be doing, strength training is the one where he gives us the least amount of specific guidance on what exactly we should be doing, for how long, and how often. In fact I don’t think he gives us any of that at all.
Instead he tries to get us to think about strength differently than how most people do. For example instead of measuring strength like one would in a powerlifting competition Attia suggests, “A far more important measure of strength, I’ve concluded, is how much heavy stuff you can carry.” (page 256) He mentions that Michael Easter’s book The Comfort Crisis was an inspiration for that mindset and the thing that got him into rucking. (The Comfort Crisis was the main inspiration behind my 2023 rucking article and a book I think everyone should read.) Attia tells us that he goes on a heavy ruck (50 or 60 pounds) up and down hills multiple times a week.
One goal related to carrying things he suggests are being able to ruck a third of your body weight. Another is for men to be able to take a dumbbell half of your body weight in each hand and walk around for at least a minute, for women he suggests carrying two dumbbells whose weight adds up to 75% of their body weight. It is unlikely that you can do these things right now but you should be working towards being able to do them in the future.
Other things Attia focuses on during strength training are grip strength, concentric and eccentric loading (providing resistance both when shortening and lengthening muscles), pulling motions, and hip-hinging movements. Whatever strength training you do make sure you are improving yourself in all of these categories.
Weight lifting has its benefits but Attia tells us not to do it until we have mastered our stability, especially with heavy loads. Lifting with bad form and bad stability will only lead to injury so Attia spends an entire chapter talking about stability and has his patients spend six months working with stability trainers before they start lifting weights.
Attia spends a good bit of time in his stability chapter explaining its importance. To make a long story short I’ll say that virtually nobody is able to do simple movements (like a squat) optimally. Sub-optimal form in our movements will lead us to hurt ourselves so we need to train ourselves to move optimally before we start putting too much stress onto our bodies.
Attia then talks about multiple things we need to get under control, he talks the most about breathing and our feet suggesting those are the two things most important to focus on but he also spends a bit of time talking about our spine, shoulders and hands. I’m not going to go into detail on these topics because I don’t feel like I can give them the attention they deserve in the time I have, you should go read the book to get a proper understanding of these things rather than whatever confusion I’d give you if I tried to explain these things.
Is it feasible for you to spend six months with a trainer working on stability like Attia will tell his patients to do? Maybe, maybe not. Trainers with that sort of specialization may not be available where you live or something you can afford. Luckily Attia provided a series of videos here that you can watch to learn some of the more essential stability exercises. How long should you really wait before lifting heavy things? I’m not sure, six months might be a bit too conservative for some of you, just make sure you don’t hurt yourself.
Conclusion
I think you should read Outlive especially these three chapters. I’ve seen people around the internet claim this is the best health book there is, this will be the first one I finish so I’m not in a good position to verify that claim but Attia definitely sets a high bar here, he explains everything well, his suggestions and takes are rather conservative compared to a lot of stuff you’ll see floating around in the health world so you won’t feel like he is trying to get you to join a cult throughout the book, and he manages to make things relatable and entertaining. I had to force myself to finish writing this article before I finish the last two chapters because I struggled to put the book down otherwise. I plan on writing a review of the full book once I’m done but don’t let me failing to get around to doing that stop you from picking up a copy of this book.
The exercise guidance Attia gives here is guidance that should be followed. At some point in the beginning of the book Attia mentioned that he believed exercise was more important than diet for your general health and longevity. That is probably the most controversial claim in the whole book, but considering the fact that no diet or drug can give you the benefits that proper exercise can I’m inclined to believe it so stand up and start moving.