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I've heard you talk before about some of the prime movers for longevity and all-risk mortality, and I'd love for you to review a little bit of that for us. I think we all know that we shouldn't smoke because it's very likely that we'll die earlier if we smoke nicotine. I'm neither a marijuana nor a nicotine smoker, so I feel on stable ground there. But anytime we say smoking nowadays, people really want to distinguish between cannabis and nicotine. So I am curious about any differences there in terms of impact on longevity. But in that context, what are the things that anyone and everyone can do, should do, to live longer, basically?
How long you got?
Well, you tell me. You tell me. I'd like to live to be, I'd like my final decade to be between 90 and 100.
Oh no, I meant how long do you, yeah, yeah.
I'm just kidding, I'm just kidding.
And will we spend from now until you're 90 talking about this?
Well, there's a risk of that.
So, let's start with a couple of the things that you've already highlighted. So smoking, how much does smoking increase your risk of all-cause mortality? And the reason we like to talk about what's called ACM, or all-cause mortality, is it's really agnostic to how you die. And that doesn't always make sense. I mean, if you're talking about a very specific intervention like an anti-cancer therapeutic, you really care about cancer-specific mortality or heart-specific mortality. But when we talk about these broad things, we like to talk about ACM. So, using smoking: smoking is approximately a 40% increase in the risk of ACM.
What does that translate to? That means I'm shortening my life by 40%?
No, it means at any point in time, there's a 40% greater risk that you're going to die relative to a non-smoker.
Got it.
And a never-smoker. Yeah, so it's important to distinguish. It doesn't mean your lifespan is going to be 40% less. It means at any point in time, standing there, your risk of death is 40% higher. And by the way, that'll catch up with you, right? At some point, that catches up.
High blood pressure is about a 20 to 25% increase in all-cause mortality. You take something really extreme like end-stage kidney disease. These are patients that are on dialysis, waiting for an organ. And again, there's a confounder there, because what's the underlying condition that leads you to that? It's profound hypertension, significant type 2 diabetes that's been uncontrolled. That's enormous. That's about a 175% increase in ACM. So the hazard ratio is 2.75.
Mm-hmm.
Type 2 diabetes is probably about a 1.25 as well, so a 25% increase. So now the question is, how do you improve? What are the things that improve those? Here we do this by comparing low to high achievers on other metrics. If you look at low muscle mass versus high muscle mass, what is the improvement? And it's pretty significant, about 3x. So if you compare low muscle mass people to high muscle mass people, as they age, the low muscle mass people have about a 3x hazard ratio, or a 200% increase in all-cause mortality. Now, if you look at the data more carefully, you realize that it's probably less the muscle mass fully doing that, and it's more the high association with strength. And when you start to tease out strength, you can realize that strength could be probably 3.5x as a hazard ratio, meaning about 250% greater risk if you have low strength compared to high strength.
And high strength is the ability to move loads at 80 to 90-
So it's all defined by given studies. The most common things that are used are actually used for the purposes of experiments that make it easy to do, and I don't even think they're the best metrics. They're usually using grip strength, leg extensions, and wall sits, squats, things like that.
Okay.
So how long can you sit in a squatted position at 90 degrees without support? That would be a great demonstration of quad strength. A leg extension: how much weight can you hold, for how long, relative to body weight? Things like that. We have a whole strength program that we do with our patients. We have something called the SMA, the Strength Metrics Assessment, and we put them through 11 tests that are really difficult. A dead hang is one of them: how long can you dead hang your body weight, stuff like that. So we're trying to be more granular in that insight but tie it back to these principles.
If you look at cardiorespiratory fitness, it's even more profound. If you look at people who are in the bottom 25% for their age and sex in terms of VO2 max, and you compare them to people at just the 50th to 75th percentile, you're talking about a 2x difference, roughly, in the risk of ACM. If you compare the bottom 25% to the top 2.5%, so you're talking about the bottom quarter to the elite for a given age, you're talking about 5x.
Wow, yeah.
A 400% difference in all-cause mortality. That's probably the single strongest association I've seen for any modifiable behavior.
Incredible. So when you say elite, these are people that are running marathons at a pretty rapid clip?
Not necessarily. It's just what the VO2 max is for that. My VO2 max would be in the elite for my age group. But then again, I'm training very deliberately to make sure that it's in that range. So I wouldn't consider myself elite at anything anymore, but I still maintain a VO2 max that is elite for my age.
I'd consider you an elite physician and podcaster, and guy, all around. But, true. But in terms of, okay, so for-
But the point is you don't have to be a world-class athlete to be elite here.
Got it.
Yeah.
Got it. So maybe we could talk a little bit about the specifics around the training to get into the top two tiers there, because it seems that those are enormous positive effects of cardiovascular exercise, far greater than the sorts of numbers that I see around, let's just say, supplement A or supplement B.
Well, this is my whole pet peeve in life. I just can't get enough of the machinating and arguing about this supplement versus that supplement. I feel like you shouldn't be having those arguments until you have your exercise house in order. You shouldn't be arguing about this nuance of your carnivore diet versus this nuance of your paleo diet versus this nuance of your vegan diet until you can deadlift your body weight for 10 reps. Then you can come and talk about those things.
Let's just come up with some-
You're right.
metrics-
Yeah.
until your VO2 max is at least at the 75th percentile, and you're able to dead hang for at least a minute, and you're able to wall sit for at least two. We could rattle off a bunch of relatively low-hanging fruit. I wish there was a rule that said you couldn't talk about anything else health-related.
We can make that rule.
No one will listen to it.
Well, I don't know about that. We can make whatever rules we want. We can call it Attia's rule. One thing I've done before on this podcast and on social media is just borrowing from the tradition in science, which is that it's inappropriate to name something after yourself unless you were a scientist before 1950. But it's totally appropriate to name things after other people. So I'm going to call it Attia's rule: until you can do the following things, don't talk about supplements.
Please refrain from talking about supplements and nutrition.
There it is. Hereafter, thought of, referred to, and referenced as Attia's rule. I coined the phrase, not him, so there's no ego involved, but it is now Attia's rule. Watch out! #attia'srule.
Oh God.
Wikipedia entry, Attia's rule. In all seriousness, and I am serious about that, a dead hang for about a minute seems like a really good goal for a lot of people. At least-
That's our goal. I think a minute and a half is the goal for a 40-year-old woman, and two minutes is the goal for a 40-year-old man. So we adjust them up and down based on age and gender.
Great, and then the wall sit? What are some numbers?
We don't use the wall sit. We do just a straight squat, air squat, at 90 degrees, and I believe two minutes is the standard for both men and women at 40.
Great. And because for some people, thinking in terms of VO2 max is a little more complicated, they might not have access to the equipment or to measure it, et cetera. What can we talk about, think about, in terms of cardiovascular? So run a mile at seven minutes or less, eight minutes or less?
That's a good question. There are really good VO2 max estimators online, and you can plug in your activity, be it a bike, run, or rowing machine, and it can give you a sense of that. I used to know all of those, but now that I actually do the testing, I don't recall them.
Oh, that's okay.
But it's exactly that line of thinking: can you run a mile in this time? If you can, your VO2 max is approximately this.
Great.
And I think somewhere in my podcast realm I've got all those charts posted, by age, by sex, showing what the VO2 max is in each of those buckets.
Terrific. We'll provide links to those, and we'll have our people find those links. And then you mentioned deadlifting body weight 10 times.
I just made that one up. We don't include that one, but-
Something like that?
We use farmer carries. So we'll say for a male you should be able to farmer carry your body weight for, I think, two minutes. That's half your body weight in each hand, and you should be able to walk with that for two minutes. For women, I think we're doing 75% of body weight, or something like that.
Great, I love it. As indirect measures of how healthy we are-
Yeah, huge.
and how long we're going to live.
Yeah, it's basically grip strength, it's mobility. Again, walking with that much weight is really hard for some people initially. We use different things like vertical jump and ground contact time if you're jumping off a box, things like that. So it's really trying to capture that. It's an evolution. I think the test is going to become more and more involved as we evolve, because it took us about a year. Beth Lewis did the majority of the work to develop this. Beth runs our strength and stability program in the practice. Basically, I just tasked her with going out to the literature and coming up with all of the best movements that we think are proxies for what you need to be the most kick-ass, what we call the Centenary Decathlete: the person living in their marginal decade at their best.