The 4 Horsemen of Aging – And How to Outsmart Them to Add Decades to Your Life

by | Oct 9, 2023

Are you interested in not just living longer but living better? That is the primary topic of Dr. Peter Attia’s excellent book Outlive: The Science and Art of Longevity. Dr. Attia is an interesting guy. He trained as a cancer surgeon, left medicine to be a consultant at McKinsey, and returned to medicine to help his patients live longer healthier lives. He also has a super popular podcast focused on health and longevity.

This IFOD hits on the main topics contained in the three parts of Outlive.

Medicine 2.0 vs. Medicine 3.0

In Part I of the book Dr. Attia introduces us to the concept of Medicine 3.0.

Medicine 1.0 was pre-modern medicine that “missed the mark entirely.” It was based on guesswork and didn’t employ the scientific method. Think use of leeches to bleed sick patients and drilling holes in their skulls to rid them of migraines.

Medicine 2.0 “arrived in the mid-nineteenth century with the advent of the germ theory of disease.” It is evidence-based and is focused on treating injury, sickness, and disease. The vast majority of the healthcare system is focused on Medicine 2.0 — treating you when you are sick or injured.

Dr. Attia advocates for focusing on preventing long-term chronic disease through lifestyle changes that will increase both lifespan and healthspan. He calls this Medicine 3.0 and describes it as:

The goal of this new medicine—which I call Medicine 3.0—is not to patch people up and get them out the door, removing their tumors and hoping for the best, but rather to prevent the tumors from appearing and spreading in the first place. Or to avoid that first heart attack. Or to divert someone from the path to Alzheimer’s disease. Our treatments, and our prevention and detection strategies, need to change to fit the nature of these diseases, with their long, slow prologues.

The below figure from Outlive illustrates the goal of Medicine 3.0 — to increase lifespan a bit (i.e., live longer), but more importantly, live healthier for longer.

Dr. Attia thinks it is possible to live healthily and vibrantly well into our eighties and nineties (and beyond) and then have a steep drop-off just before death. Healthspan isn’t just how long you live, but how well you live. Dr. Attia wants us to avoid the “Marginal Decade” of disease and disability that is common before most people’s deaths.

The Four Horsemen

For most people, the greatest risk to their lifespans and healthspans is what Dr. Attia calls the “Four Horsemen”: Cancer, Heart Disease, Type-2 Diabetes, and Neurogenerative Disease. Unless you engage in ultra-risky behaviors, the odds are that you will die of one of these “chronic diseases of aging.”

In Part II of the book, Dr. Attia delves into the causes and treatments for the Four Horsemen and argues that a common risk factor for all four diseases is “metabolic dysfunction” which is when something is wrong with your metabolism — the ability to turn food into energy and get rid of waste. Metabolic dysfunction can enventually manifest itself in “Metabolic Syndrome” that is diagnosed when you meet at least three of the below five criteria:

  1. high blood pressure (>130/85)
  2. high triglycerides (>150 mg/dL)
  3. low HDL cholesterol (<40 mg/dL in men or <50 mg/dL in women)
  4. central adiposity (waist circumference >40 inches in men or >35 in women)
  5. elevated fasting glucose (>110 mg/dL)

Dr. Attia believes that steps should be taken to address metabolic dysfunction WAY BEFORE a person develops Metabolic Syndrome. Waiting until Metabolic Syndrome is diagnosed makes returning to a normal metabolism incredibly challenging.

According to Dr. Attia, “the steps we take to improve metabolic health and prevent type 2 diabetes almost certainly reduce the risk of cardiovascular disease, cancer, and Alzheimer’s simultaneously.”

So, how do we prevent metabolic dysfunction? The solution addressed in Part III of Outlive discussed below.

How to Outlive

Dr. Attia says that Medicine 3.0 has five levers to pull to improve health and increase healthspan. These five are:

1. Exercise. “The data are unambiguous: exercise not only delays actual death but also prevents both cognitive and physical decline, better than any other intervention.” Plus, he says, “I now tell patients that exercise is, full stop and hands down, the best tool we have in the neurodegeneration prevention tool kit.” He recommends a combination of cardio and strength training, and a focus on building stability.

2. Diet. He actually calls this “Nutritional Biochemistry.” He is not dogmatic about which style of eating people choose. He doesn’t say everyone should be vegan, follow a Keto diet, or the Mediterranean Diet, for example. He realizes that what might work for one person might not work for another. What he does stress is limiting processed foods, refined carbs, and sugars, and focusing on consuming enough high-quality protein.

3. Sleep. Sleep is essential to long-term health and until recently has been mostly ignored by Medicine 2.0. He provides advice for improving the quality of sleep.

4. Emotional/Mental Health. The last chapter of the book is a surprisingly vulnerable look at Dr. Attia’s own emotional health and his past struggles. I was blown away (in a good way) that he shared what he did about his own mental health journey. This was my favorite chapter in the book.

5. Various Drugs and Supplements. There are some drugs that have shown promising anti-aging benefits such as rapamycin and metformin. He discusses these only briefly in the book, but hits on them in more depth on his podcast.

Note that he has entire chapters (and sometimes multiple chapters) on the first four levers — I suggest you read the book for greater insight and nuance.

My Overall Thoughts

I thought Outlive was fantastic. Even though I’ve read books and articles on this topic previously, I still learned a lot from this book. I appreciated how balanced the book was. Dr. Attia isn’t dogmatic about how each person should live their life. For example, he talks about the downsides of alcohol and how not drinking at all is the healthiest thing to do. But he realizes that some people like to drink and it may be tough socially not to drink a all. So, he suggests to drink lightly if at all (seven or less drinks a week, and no more than two a day).

I also appreciate that there is no magic bullet to having a longer healthspan. Instead, focusing on eating well, sleeping enough, exercising, and having good mental health are the keys. Makes sense. Easy in concept but not always easy to do.

Great book! My summary doesn’t really do the book justice — I recommend you read it.

A topic I’ve previously written on from Outlive is the concept of a Centenarian DecathlonTM which you can read about here: What Would You Put on Your Centenarian Decathlon List?

Another great book on longevity I’ve written about is Lifespan: Why We Age — and Why We Don’t Have To by Dr. David Sinclair. You can find that IFOD here: How to Live Longer


  1. See the article in today’s (Oct 12, 23) WSJ “The Secret to living to 100 . . . “. Genetics are a progressively greater factor the longer one lives. Those who live to 100 w/o chronic disease are the Escapers; others who practice good living habits are the Delayers.

  2. Very fascinating and pertinent information as I try to help my parents as they go through the ravages of aging

  3. This will be one of the challenges for the next decades and how government and private pension funds deal with centenarian baby boomers. #LivingLonger,WorkingLonger.


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