The Best Exercises to Live Longer: Dr. Attia’s Outlive, Part 2

The best exercises to live longer include stability/mobility, cardiorespiratory and strength training. Dr. Peter Attia’s book, Outlive, explains why.

The best exercises to live longer is the focus of Part 2 of my review of Dr. Peter’s new book, Outlive: The Science and Art of Longevity.

Anyone who has spent even a bit of time reading about Dr. Attia or watching his interviews knows that his number one prescription for improving healthspan is exercise:

“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.”

Looming above anything else discussed in Outlive, Attia asserts that exercise has the greatest power to determine how you will live out the rest of your life. An overwhelming amount of data underscores this point, and, in fact, even a minimal amount of exercise can lengthen your life by several years.

Consistent exercise delays the onset of many chronic diseases, and is effective at extending and improving healthspan: it can reverse physical decline and slow or reverse cognitive decline as well. The bad news is that 77 percent of the US population does not exercise. The good news is that just going from zero weekly exercise to just 90 minutes per week can make a big difference in your quality of life as an old person.

Here are some facts about exercise that Attia underscores that hopefully focus your attention:

  • Going from zero weekly exercise to just 90 minutes per week can reduce your risk of dying from all causes by 14 percent.
  • Study after study has found that regular exercisers live as much as a decade longer than sedentary people.
  • VO2 max, is perhaps the single most powerful marker for longevity. (VO2 max represents the maximum rate at which a person can utilize oxygen.)
  • Whether by measures of cardiorespiratory capacity or muscular strength, the fitter you are the lower your risk of death.

Attia cites the work of Dr. John Ioannidis, Professor of Medicine at Stanford University who has run side-by-side comparisons between drug and exercise studies and found that in several randomized clinical

John Loannidis, professor of medicine at Stanford University

trials, exercise-oriented interventions performed as well or better than multiple classes of prescription drugs at reducing mortality from coronary heart disease, prediabetes/diabetes and stroke.

This is why, suggests Attia, exercise acts like a drug at the biochemical level:

  • Exercise strengthens the heart and helps maintain the circulatory system.
  • Exercise improves the health of the mitochondria, the crucial little organelles that produce energy in our cells via ATP, the energy used by cells.
  • Improved mitochondria (mitochondrial biogenesis) improves our ability to metabolize both glucose and fat.
  • More muscle mass and stronger muscles supports and protects the body, and maintains metabolic health, because muscles consume energy efficiently.
  • Exercise prompts the body to produce its own endogenous drug-like chemicals, such as cytokines that help strengthen the immune system and stimulate the growth of new muscle and stronger bones.
  • Exercise helps generate a potent molecule called brain-derived neurotrophic factor (BDNF) that improves the health and function of the hippocampus, a part of the brain that plays an essential role in memory.
  • Exercise helps keep the brain vasculature healthy, and it may also help preserve brain volume (important for reducing Alzheimer’s risk).

That begs the questions: Why and what type of exercise?

Well, as you would expect, Attia addresses those questions and more in three chapters of Outlive that primarily encompass:

  • Cardiorespiratory fitness (its association with longevity),
  • Muscular strength (its association with longevity), and
  • Stability (its association with longevity).

Stability is the last chapter about exercise in his book, but I’m going to review some of what he says about it first, because it’s the first thing that’s needed in order to do various cardiorespiratory and strength training safely and effectively.

As I mentioned in Part 1, although Dr. Attia lists hundreds of references in his book, he does not footnote most of the statistics and studies he cites; therefore, except for a few instances, I don’t either. Nonetheless, in my opinion, when he says that a certain study says a certain thing, that study exists and he’s read it.

Another thing to point out is that this review does not provide a comprehensive look at Outlive; rather, the intention is to provide enough valuable information to persuade you to get the book and benefit from its pearls of wisdom.

With that in mind, let’s dig into the longevity-extending capacity of exercise, beginning with stability.


Stability: the Foundation for The Best Exercises to Live Longer

Dr. Attia addresses stability in his last chapter on exercise, after cardiorespiratory fitness and muscular strength, but I want to address it first, because you want to build the foundation. Irrespective of where he put this chapter in Outlive, Attia agrees:

“…I think of stability as the solid foundation that enables us to do everything else that we do, without getting injured. Stability makes us bulletproof.”

Think of stability as the innate “ability to harness, decelerate, or stop force”. A person that has developed stability can respond “to internal or external stimuli to adjust position and muscular tension appropriately without a tremendous amount of conscious thought.”

Stability enables our body to summon the necessary force safely to connect different muscle groups when needed with minimal risk of injury to joints,soft tissue, and our vulnerable spine. The aim is to be “strong, fluid, flexible, and agile as you move through your world”.

So, how do you develop stability?

You get help.

You can easily learn, say, to do a bicep curl by watching others, or getting some detailed instruction, because it’s a simple movement that can be self-corrected by watching yourself do the movement in a mirror. Many stability exercises, however, are not that easy; they can be subtle and nuanced, requiring exacting compound movements (multiple muscles and positions) that are difficult to observe in the mirror, and require sufficient self-awareness about your body’s movement patterns for correct application.

In Attia’s case, he is fortunate enough to have someone in his clinic who has expertly guided him in improving what he admits was a poor foundation of stability that was leading him to various injuries as he did his cardiorespiratory and strength training.

Dr. Peter Attia’s trainer, Beth Lewis, demonstrates a stand-to-sit mobility/stability drill. This is a screenshot from a video available to buyers of the book, Outlive.

What you could do is to find someone credentialed in dynamic neuromuscular stabilization (DNS), which aims “to retrain our bodies — and our brains — in those patterns of perfect movement that we learned as little kids”.

DNS encourages you to think of the abdomen as a cylinder, surrounded by a wall of muscle, with the diaphragm on top and the pelvic floor below. You inflate the cylinder with a deep inhalation that expands your chest, ribs, abdomen and back, as if they’re one big cylindrical balloon. Once this cylinder is inflated, you feel what’s called intra-abdominal pressure (IAP). When you learn to fully pressurize this cylinder via IAP, your movement pattern becomes more safe, because the cylinder stabilizes the spine.

Of course, your options are not limited to DNS. Another option is to be coached by a yoga teacher well versed in movement precision, or to be aided by a movement modality that is proven to help you gain stable movement patterns. Make sure that whatever modality you choose to help you become more stable and mobile involves breathwork.

You also need to think about your feet, says Attia:

“If the road to stability begins with the breath, it travels through the feet—the most fundamental point of contact between our bodies and the world.”

Foundational stability begins with your feet. Before you do any exercise where you’re on your feet, you must be aware of them and how they’re contributing to the stability (or not) of the movement. Attia spends a lot of time on this topic in Outlive, as he does with breathwork; suffice to say that your feet are the beginning of a chain of inter-connected links that move up from the feet to your ankles, knees, hips and spine.

You can get some idea about the importance of your feet for stability by checking your balance. Stand on one foot — can you balance for 30 seconds? Close your eyes while standing on one foot — can you balance for 15 seconds?


Cardiorespiratory Fitness Keeps Your Ticker Ticking

Cardiorespiratory fitness encompasses both aerobic and anaerobic capacity:

  • Aerobic means ‘with air’ and refers to the body producing energy with the use of oxygen. This typically involves any exercise that lasts longer than two minutes in duration. Continuous ‘steady state’, Zone 2 exercise is performed aerobically. Think 5 kilometer jun.
  • Anaerobic means ‘without air’ and refers to the body producing energy without oxygen, which then constrains the exercise effort to just a few minutes or shorter. Think 100 meter sprint.

So, cardiorespiratory fitness requires training that encompasses long, steady state endurance work, such as jogging or cycling or swimming (Zone 2), and maximal efforts over shorter periods (typically four minutes or shorter), where VO2 max comes into play.

Good cardiorespiratory fitness is valuable in order to attain a high quality of life as you get older. A study published in 2020 by the Journal of the American College Cardiology that studied a cohort of 750,302 US male and female veterans aged 30 to 95 years came to the same conclusions as many other such studies:

  • Cardiorespiratory fitness (CRF) is inversely associated with all-cause mortality (more fitness = less death)
  • Traditional risk factors like chronic kidney disease, smoking, diabetes, atrial fibrillation, cancer, cardiovascular disease, hypertension and age all were independently linked to increased mortality risk — but none as strongly as cardiorespiratory fitness.
  • Those in the extremely fit cohort had the greatest survival. The lowest mortality risk was observed in people with exercise capacity of 14.0 METs. (METS, metabolic equivalents: One MET is defined as the energy you use when you’re resting or sitting still per minute. I wrote METs and VO2 max here.)

Click here to see an exhaustive list of METs activities -- which do you do? (Click again to close.)

This list is from Britannica

Remember: “Metabolic Equivalent of Task (MET) values are a way to estimate how many calories are burned during a specific physical activity, according to the American Council on Exercise. This table shows the MET values that researchers have assigned to various activities. A higher value correlates with more oxygen used by the body during that activity, so running has a higher MET value than sitting still.”


Let’s take a look at what Dr. Attia has to say about Zone 2 and VO2 max training.

Zone 2 Training Builds A Strong Aerobic Baseline

Zone 2 is steady-state aerobics. A good way to know if you’re in Zone 2 is when you can still have a conversation despite the effort you’re producing, but you rather not, as opposed to anaerobic training where you can only muster short exclamations.

Zone 2 can be easy to do, even for someone who has been sedentary for a while, because, as mentioned by the talk test, it’s subjective. For some people, a brisk walk might get them into Zone 2; for those in better condition, Zone 2 necessitates walking uphill. Common Zone 2 training includes riding a stationary bike, or using an elliptical machine, or jogging.

In technical terms, Zone 2 is the maximum level of effort you can maintain without accumulating lactate. You will still produce lactate, but you’ll be able to match its production with its clearance. The more efficient your mitochondrial “engine,” the more rapidly you can clear lactate, and the greater effort you can sustain while remaining in Zone 2. (More about mitochondria here.) If you are “feeling the burn” in this type of workout, then we are likely going too hard, creating more lactate than we can eliminate.

San Millán, an assistant professor at the University of Colorado School of Medicine,

In Outlive, Dr. Attia writes about San Millán, an assistant professor at the University of Colorado School of Medicine, who has conducted some valuable research about why healthy mitochondria is the key to athletic performance and metabolic health.

Mitochondria can convert both glucose and fatty acids to energy. This is special, because although glucose can be metabolized in different ways, fatty acids can only be converted to energy in the mitochondria. You want healthy mitochondria (mitochondrial biogenesis) for many reasons, one being to achieve “metabolic flexibility”.

Metabolic flexibility refers to the ability to use both fuels, fat and glucose, to produce energy for the body. Typically, someone working at a lower relative intensity (Zone 2/aerobics) will be burning more fat, while at higher intensities (VO2 max/anaerobics) they would rely more on glucose. The healthier and more efficient your mitochondria, the greater will be your ability to utilize fat — by far the body’s most efficient and abundant fuel source.

San Millán believes that metabolic flexibility is fundamental for athletes, but even more important for nonathletes, because:

  • It builds a base of endurance for your life’s activities — riding your bike for miles, or playing with your kids, grandkids, or great-grandkids.
  • It plays a crucial role in preventing chronic disease by improving the health and efficiency of your mitochondria,

Mitochondria are very plastic, meaning they can undergo morphological and functional changes in response to cellular demands. When you do aerobic exercise, many new and more efficient mitochondria are created through a process called mitochondrial biogenesis. At the same time, dysfunctional mitochondria get recycled via a process called mitophagy (which is like autophagy, but specific to mitochondria).

A person who exercises frequently in Zone 2 improves their mitochondria at each exercise session. The converse is true as well — non-exercisers lose mitochondrial health. Inevitably, Zone 2 training builds muscle, a strong mediator of metabolic health and glucose homeostasis.

Muscle is our body’s largest glycogen storage sink in the body. When you create more mitochondria, you substantially augment your capacity for using that stored fuel, rather than having it end up as fat or remaining in blood plasma. You don’t want glucose to remain in your bloodstream. Chronic blood glucose elevations damage our heart, brain, kidneys and many other organs. It also contributes to erectile dysfunction in men.

Attia asserts that while we are exercising our overall glucose uptake increases as much as one-hundred-fold over what happens while at rest. During exercise, the glucose uptake occurs via multiple pathways — the usual insulin-signaled path, as well as one called non-insulin-mediated glucose uptake (NIMGU), where glucose is transported directly across the cell membrane without the involvement of insulin. This explains why exercise, particularly in Zone 2, can be so effective in ameliorating 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”.

OK, not that you’ve laced up your sneakers for some Zone 2 training, let me convey what Attia says about the equally important part of cardiorespiratory fitness — Vo2 Max

VO2 max Training Builds Capacity

VO2 max, is a strong contender for the single most powerful marker for longevity. Typically expressed in terms of the volume of oxygen a person can use, per kilogram of body weight, per minute, VO2 max represents the maximum rate at which a person can utilize oxygen.

Whereas high intensity interval training (HIIT) intervals are very short, typically measured in seconds, or under two minutes,  VO2 max intervals are a bit longer, ranging from three to eight minutes (but usually four is the most) —  and are a bit less intense. You can do this type of training by running, on a bike, on a stationary bike, treadmill, rowing machine, or an “assault” bike (my favorite).

One effective formula for these VO2 max intervals is to go four minutes at the maximum pace you can sustain for, say, four minutes (a hard but less than exhaustive effort), and then bring the pace down for an easy four minute recovery period until the next interval.

Do not do VO2 max training until you have built a solid Zone 2 foundation!

Here’s some stats to consider showing the value of improving your VO2 max:

✔ Those below average VO2 Max (between 25th and 50th percentile) are at double the risk of all-cause mortality compared to those who are in the top quartile (75th to 97.6%). Given that a smoker has a 40% greater risk of all-cause mortality (risk of dying at any moment), poor cardiorespiratory fitness carries a greater relative risk than smoking!

✔ Someone in the bottom quartile of VO2 max (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) VO2 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.

The most accurate way to measure VO2 max test is by a maximal exercise test performed on a treadmill or bike while connected to a machine capable of analyzing your expired air. This test provides data on how much oxygen you use as you exercise and determines the maximal oxygen you can consume during exercise.

But there’s a formula that provides a useful approximation:

VO2 max = 15 x (HRmax/HRrest)

Calculate your resting heart rate by counting your heart heat (pulse at the side of your throat is often most discernible) while at rest (after you wake up or have been surfing the couch for an hour or more)

Calculate your maximum heart rate by the formula 220 – your age.

So, VO2 max for a 50 year-old with a resting pulse of 65 would be:

15 x [(220 – 50)] / 65 = 39

The downside of this formula is that your maximum heart rate may be more or less than what the formula predicts; mine is. The formula predicts that my maximum heart rate is 153 (220 – 67), but a recent treadmill test monitored by a cardiac technician put it at 168, which at a resting pulse of 50, gives me a VO2 Max of 50.

Returning to our example, is 39 a good VO2 max for a 50 year-old?

Here’s are two charts from my post, How To Reduce Obesity In Older Adults and Improve VO2 Max) Check it out if you’d like to learn more about Vo2Max and see mine.

How trainable is VO2 max, you ask?

Attia says that it’s possible to improve elderly subjects’ aerobic capacity by:

  • About 13 percent over eight to ten weeks of training, and
  • By 17 percent after twenty-four to fifty-two weeks.

He also cites a study that found that boosting elderly subjects’ VO2 max by 6 ml/kg/min, or about 25 percent, was equivalent to subtracting twelve years from their age. So, for that 50 year-old in the above example, he/she could become twelve years younger biologically by increasing his or her VO2 max from 39 to 45.

Now let’s turn to muscle, another piece of the fitness muscle you need to live long and strong.


Muscular Strength, Another Key Longevity Exercise

Build muscle as you age

(Click image to read the post)

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.

This loss of muscle (muscle wasting) is called “sarcopenia”. A recent study of older British adults found that those with sarcopenia at baseline were nearly six times likelier to report having a low quality of life a decade later than those who had maintained more muscle mass.

Although the association between cardiorespiratory fitness and longevity has long been known, the impact of muscle on longevity has been understood only recently, and it’s significant. Dr. Attia also cites 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 (presumably a similar cohort, but with average muscle mass).

What’s also been recently revealed is that even though muscle is important, more significant is the strength produced by the muscle: Those with low muscle strength were at double the risk of death, whereas those with low muscle mass, low strength AND metabolic syndrome (if you recall the discussion about this in Part 1), had a 3 to 3.33 times greater risk of all-cause mortality.

Another elevated risk for dying before your time is instigated by a loss of bone density. Dr. Attia measures bone mineral density in every patient each year, looking at both of their hips and their lumbar spine bone density using a DEXA scan, because these are three regions are what is typically used to diagnose osteopenia or osteoporosis.


Well, in addition to the undesired mobility compromises caused by osteopenia and osteoprosis, there’s this thing called “falling and breaking your hip.” Up to one-third of people over sixty-five who fracture their hip are dead within a year.

Even if a person does not die from the injury, the setback can be the functional equivalent of death, because of the ensuing loss of muscle mass and physical capacity from being bedridden.

Avoid that by exercising.

Cardiorespiratory and strength training has a greater positive impact on healthspan by managing the severity of the chronic diseases associated with aging than the drugs specifically created for those diseases. I presented this fact in some detail in my post, Exercise: Powerful Medicine for Health and Aging with Dr. Stuart Phillips, and so does Attia in Outlive, who asserts:

“Exercise is so effective against diseases of aging—the Horsemen—that it has often been compared to medicine.”


How To Be A “kick-Ass” 100 Year-Old

One insightful perspective that Attia brings to the topic of fitness is his admonition to set your fitness goals today for what you want to be able to physically do in the future in your very old age. You need to “set a trajectory”, he says.

He refers to this as the “Centenarian Decathlon”. Just like the decathlete is not the best at any of the ten events in a decathlon, he or she is good at all of them. Similarly, you need not be great at stability, or Zone 2, or VO2 max training or strength training — but you need to be decent at all of them should you want to be fit in old age.

You want to plan your trajectory, or pathway forward, recognizing the inevitable physical degradation that happens during the aging process. The more you want to be able to physically do in very old age, the fitter you need to be now!

Cleverly, Attia uses retirement savings as an analogy. Just like you (hopefully) have put aside money every month into a retirement account so you can retire with enough money saved up to sustain yourself until you part company with this world, you want to also reach older age with enough of a “reserve” of muscle (and bone density) to protect yourself from injury and chronic disease, and allow the unfettered pursuit of activities that bring you joy and fulfillment.

Just as with investments, you do not want to scramble late in life to make up for lost time, time that you could have devoted to building up your reserve of fitness.

One of several examples Attia uses to make this clear is that of a person who wants to be able to pick up his or her grandchild or great-grandchild off the floor. Let’s say the child weighs 30 pounds. To lift her off the floor is equivalent to doing a squat holding 30 pounds in front of you (like a goblet squat), suggests Attia.

Now, maybe you can do that 30 pound squat now, say at age 40 or 50, but will you be able to do it 30 or or 40 years from now, given that — without appropriate training — your muscle strength will decline by about 8 to 17 percent per decade, accelerating with time (it’s not a linear decline)?

Probably not.

Consequently, in order to be able to pick up that 30 pound kid decades from now, you need to be able to squat with more than 30 pounds today — perhaps as much as 55 pounds now.

There are many other examples to consider; here’s two:

  1. To lift a twenty-pound suitcase above your head to plop it in the overhead airplane compartment when you are older means doing so with forty or fifty pounds now.
  2. To be able to climb four flights of stairs in your eighties means you should be able to sprint up those four flights today.

In every case, you need to be doing much more now, to defend yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age.

In this regard, a useful mental exercise that Attia employs in his own life is to list what you want to be able to physically do at the tail-end of your life and evaluate what that means you need to be able to do today. (This is the trajectory). Given that just 24 percent of Americans meet the Physical Activity Guidelines for both aerobic and muscle-strengthening activity, says the CDC, the odds are you have some work to do.

If you’re thinking that the “Centurion Decathlon” is unattainable, know that thousands of elderly people are doing it, some literally.

There are several sports organizations and competitions for the elderly that allow them to remain active and competitive, pursue a sport they enjoy, and optimize their health. One such organization is the National Senior Games, also known as the Senior Olympics, which hosts senior athletes from the United States and Canada to participate in national competitions every other year. The minimum age of eligibility is 50 years old, with the oldest participants being over 100 years old.

According to the National Senior Games Association (NSGA), the 2019 National Senior Games had a record 12,100 registered participants. The 2022 National Senior Games had 11,938 athletes registered to compete, the third-highest number in National Senior Games history. The NSGA also reported that nearly 12,000 athletes aged 50 and over competed in 21 sports in five-year age divisions over 13 days of the massive multisport event in 2022.

Some examples of sport achievements by elderly athletes include 100-year-old Orville Rogers, who set a new world record in the 60-meter dash in the 100+ age group at the 2018 National Senior Games, and 103-year-old Julia Hawkins, who set a new world record in the 100-meter dash in the 100+ age group at the same event.

Here’s what Dr. Attia is focusing on for his Centenarian Decathlon:

Grip strength: how hard you can grip with your hands, which involves everything from your hands to your lats (the large muscles on your back). Almost all actions begin with the grip.

Concentric and eccentric loading: apply this for all strength training movements — contracting the muscle (concentric) and lengthening it (eccentric) under control.

Pulling motions: do this at all angles, from overhead to in front of you (pull-ups, rows, etc.), which also requires grip strength (e.g., pull-ups and rows).

Hip-hinging movements: such as the deadlift and squat, step-ups, hip-thrusters, and single-leg variants of exercises that strengthen the legs, glutes, and lower back.

If the emphasis on grip strength is surprising, know that grip strength is a proxy for all overall muscle strength. The data show that how hard you can squeeze predicts how long you’re likely to live; whereas, low grip strength in the elderly is symptomatic of sarcopenia (muscle wasting).

As with every topic I’ve covered in this review, and in Part 1, there is much more to learn that’s covered in the book. Relative to stability, Attia explains the necessity of gaining stability in our most complicated joint complex, the shoulders, as well as the spine and neck.

In my final review of Outlive (Part 3), I will cover Attia’s chapters about his least favorite topic — nutrition, as well as his insights on “the high price of ignoring emotional health”.

Stay tuned for thatHere’s Part 3


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Last Updated on July 22, 2023 by Joe Garma

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Joe Garma

I help people live with more vitality and strength. I'm a big believer in sustainability, and am a bit nutty about optimizing my diet, supplements, hormones and exercise. To get exclusive Updates, tips and be on your way to a stronger, more youthful body, join my weekly Newsletter. You can also find me on LinkedIn, Twitter and Instagram.

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