Category: science

I am a fan of Dr. Peter Attia who is a physician focused on the science of longevity.  He strives to help his patients simultaneously improving lifespan (delay the onset of chronic disease) and healthspan (quality of life). In 2023 he released the book Outlive where he systematically explains his approach to healthcare which is focused on prevention (sneak peak… exercise is the most powerful tool) and personalization. He has a podcast call The Drive where he interviews people whose work can inform anyone interested in long term health and fitness.

Attia is science oriented and he is willing to re-think his positions when data contradicts his beliefs. He isn’t overly certain, saying he has “strong opinions which are loosely held.” He has written a nice series on studying studies which discusses how to read and evaluation the quality of published research which often has flaws.

I have been inspired by his idea of training for the centenarian decathlon (additional details in AMA 39 and Drive #261, videos of some of the exercises). Identify what you want to be able to do when you are in your 90s such as lifting a child to decorate a tree. Backcast what fitness needs to be achieved earlier in life in view of the typical loss of strength due to aging and drop of VO2max. Your training program should strive to improve your fitness so that your fitness level bisect the backcast projection. Once you are at the level (and maybe a bit more as a buffer), it’s ok to ride the enviable decline. Make sure you don’t injure yourself while training.

Some of my fondness likely comes from confirmation bias. Attia’s material is very close to many of the conclusions I reached when I was trying to understand what leads to a healthy life. I captured my conclusions in Health and Fitness in One Post.

Attia notes that the biggest threat to longevity are chronic diseases (CDC). He groups these into four catagories of chronic diseases which he sometimes refers to as the four horseman:

• Metabolic Disease (a spectrum of everything from hyperinsulinemia to insulin resistance to fatty liver disease to type 2 diabetes). These are arguably the most preventable diseases through diet and exercise. Metabolic disease also contributes to atherosclerotic and possibility neurodegenerative diseases and some forms of cancer.
• Atherosclerotic Disease (comprised of cardiovascular disease and cerebrovascular disease). I haven’t personally studied this group of diseases. It’s the next thing I want to study. Number one on all cause mortality.
• Cancer: until there are major breakthroughs early detection is key. Survival once the cancer has metastasized is poor and hasn’t significant improved in 70 years, though there are some promising approaches that might finally result in breakthrough treatments
• Neurodegenerative Disease (Alzheimer’s disease being the most common). As far as I can tell, there are no effective treatments. While there are some theories and ideas of how to prevent, there are not strong causal links. 

Attia has identified what he believes are the  Five Tactics for Longevity which are:

• Exercise physiology: the most “powerful drug” in our arsenal
• Nutritional Biochemistry: Diet, fasting
• Sleep: 7-8.5 hours. Not too little. Not too much.
• Increase distress tolerance: Constance, chronic stress has negative consequences to health and wellness. Controlled, acute stress is helpful.
• Exogenous Molecules: medications, supplements, hormones

Exercise

Attia has a framework of exercise includes four areas which provide unique benefits:

• Stability: Balance, efficient movement. This is particularly important as people age because it reduces the likelihood of injuries due to  falling. Some forms of yoga, Pilates, and Dynamic Neuromuscular Stabilization (DNS)  are examples. Having good stability is key to training without injuring yourself.
• Strength: Developing muscle strength. The more strength you have the easier it is for you to engage in heavy work. It is easier to build strength when we are young, and we have a tendency to lose strength as we age. BUT there are a numbers of studies that show people who are in their 60s (and older) can gain strength with training.
• Aerobic Efficiency which focuses on metabolic “base” (zone 2): improving mitochondrial function which is key to your ability to burn fat, reduce the risk of diabetes, and be able to sustain endurance. Cycling, running. and rowing are some of the best options for zone 2 workouts.
• Anaerobic peak: High Intensity (zone 5): Builds your metabolic systems ability to handle peak exertion and grows VO2max. Often part of an high intensity interval (HIIT) protocol.

Nutritional Biochemistry

The area of diet and fasting is one of the areas that Attia demonstrates his strong opinions held loosely. His position has shifted since I started to follow him. First, the things which have been consistent

• Except for people who are food insecure, one of the biggest health threats is eating too many calories. Excess calories is a huge driver of metabolic diseases, and contributes to the other horseman
• Sugar is a lot like a poison to our metabolic system. Minimize it.
• Get enough protein to maintain and build muscles. The amount of protein we need goes up as we age

When I first starting to reading material by Attia he had a strong beliefs which including the following (which he has backed away from)

• Adopting good nutritional practices (the right diet) can significantly improve overall health / longevity
• Fasting is a useful technique for almost everyone to optimize health
• While not advocating it for everyone, Peter lived a strict keto diet for several years and wrote about the benefits.

With the publishing of Outlive his position is slightly different

• Bad nutrition can really hurt health, good nutrition doesn’t significantly improve health
• Extended fasts are useful when people have severe metabolic issues, but the typical lost of muscle is not worth the benefits for most people.
• Intermittent fasting can be useful if it helps someone avoid eating too much food, but has little or no additional value over eating the same number of calories spread out over a longer period of time.

TL;DR

• Effective contact tracing combined with quarantining individuals at risk is highly effective with the least impact to most people’s lives.
• COVID vaccines are highly effective. If you over 30 you should get one. For healthy people under 30, COVID has had very low mortality rate which has lead some people to recommend skipping it. Most medical professionals recommend getting a vaccine for the under 30, and I think it’s wise because it significantly lowers the likelihood of long COVID which can be devastating.
• Masking slows the spread of COVID, but there are social costs to masking. Mask, or don’t mask to achieve desired impact, not as a way to signal political identity (for or against).
• There are bad actors who are spreading misinformation, unless there is a peer reviewed paper from experts, don’t believe it.
• Just because people are sharing  misinformation doesn’t mean those people are bad actors. They could have been taken in. Take the time to understand and assume good intent.

The best COVID response I have see is in Taiwan, an island nation of 21 million people (about the same as the state of Florida). Early in the pandemic Taiwan required people entering the country quarantine for 14 days and then everyone was free to continue on with life. Any break out cases were contact traced with people possibly impacted quarantined. When the number of infections started to climb Taiwan instituted a 2-week lock down and mask wearing. Other than those 2-weeks people have been completely free to move around, large public gatherings have continued, masks not required. There was excellent government support. Taiwan has a national health care system which is accessible to all. Financial support was provided to people who were quarantined. Quarantines were “enforced” with Geo-Fencing of people’s phones and large fine if people violated their 14 day quarantine. The results? Taiwan had 2 deaths and 40 infections in the same period that Florida had 150 deaths and 12,000 infections even though the vaccination rate is similar.

I have growing increasingly frustrated by the politicalization in the USA when it comes to COVID. Vaccines and masking have become tools to signal political identity rather than tools whose use is driven by good science. Worse yet, it seems like conversations about this topic is dripping with contempt. Can we move this back to a discussion of public health like when we were battling polio?

There is strong evidence of the following:

• Vaccines are an effective means of limit the spread and lessen the impact of infections.  Before vaccines, many children did not live into their teen years. The history of vaccines in western culture dates back to 1700s (Asia the 1500s?). Famous successes include the elimination of smallpox (Catherine the Great an early advocate); diphtheria, cholera and typhoid control; and the near elimination of polio.
• The COVID vaccine is a vaccine developed by scientists, just as the previous vaccines that most of us have trusted in the past. People are not being injected with poison or micro chips. The development process was accelerated and the testing was streamlined compared to the past, but at this point we have far more data about safety and efficacy in the field after a year than that traditional testing would have produced.  In other words, the COVID vaccine is as safe and as effective as other vaccines. BTW: A Brief History of mRNA vaccines is fascinating.  Katalin Karik is a real hero in the story!
• In very rare cases vaccines cause severe reactions which can impact people’s health. First of all, there are allergic reactions which can lead to shock.  This is why you are asked to sit for 20 minutes after your shot.  If you have a reaction like that a shot of adrenalin will stop the reaction and with a dose of Benadryl no damage is done.  Other reactions are myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining outside the heart) which is usually mild and goes away on its own.  Finally, there are blood clots, a condition called thrombosis with thrombocytopenia syndrome which happens to women younger than 50 on the J&J vaccine.   (Just avoid this vaccine!) Since 100’s of million people have had the vaccines, these serious side effects are very rare.  Statistically, the “average” person will have better health outcomes by taking a vaccine, but these with the serious side effects still have a benefit from the vaccines.  If they do not have the vaccine, Covid19 tends to cause these same serious effects in these people and can lead to hospitalization.
• All of “evidence” that vaccines are responsible for diseases like autism has been discredited.  The sample size of the original study was 8 with no controls or determination when the autism symptoms started!  There is a big difference between causation and coincidence. There was a good paper that evaluates the original study link between vaccines and autism. There is the attempt explain the increase in autism over the past decades by blaming factors like vaccines, but in fact autism is a genetic disorder which seems to be caused by the increasing age of fathers like down syndrone is related to the age of mothers.
• Physical distancing and wearing masks slow the transmission of viruses in general, and COVID in particular. Masks preventing the spread of respiratory infections have been common doctrine for more than 100 years. Masks have been demonstrated to be effective with COVID in a randomly assigned trial. [Full paper].  Paper about mask impacting upper bound on one-to-one exposure to infectious human respiratory particles. N95 are the best, surgical masks are more effective than double layer cloth masks. Single layer cloth masks are more a fashion statement than an effective tool. A common issue with most masks is that they don’t seal very well. Aaron Collins, aka mask nerd, a mechanical engineer who specializes in nano materials has produced a number of documents and videos reviewing and ranking masks. Projectn95 is a clearing house for informational about PPE and COVID tests.

Against this are some observations that I don’t have randomized controlled experiments but I believe to be true:

• Wearing mask is causing significant stress for all people, but especially children because it makes it much harder to connect with others.
• In several Asian country wearing masks in public has been somewhat common in public since SARS and has not disrupted society and connections. That said, when with family, eating in restaurants, attending classes, etc masks come off.
• Lockdowns and other restrictions disproportionally impact the most vulnerable people because they have not been able to work remotely, often lost jobs, and when working are at elevated risk due to their regular contact with others.
• Schools being closed has been very hard on the children, and extremely difficult for parents, especially single parents, and have been extremely difficult for teachers to teach.  Germany has been able to keep their schools open by using better ventilation and masks, unlike many US school districts.
• There is growing evidence that unmasked children in school tend not to be a large vector of COVID being spread. Closing schools or place extreme distancing protocols seems to harm the children far more than it has stopped the spread of COVID.

Was Covid a lab leak?

• An number of reputable journalists reported that there were saftey issues at the Wuhan lab just weeks before the first cases of Co
• The scientists I know believe the evidence we have today favors a natural process bring COVID to humans.  There are several scientists who have questions this conclusion.  Several of the papers by these scientists have been built on faulty data or assumption. Most have not been written by people who specialize in this field. Likewise, they have not gone through the peer review process, rather have been released as positional papers, editorials, or letters to the editor. Examples of some questionable reasoning:
  • We should have found it animals.  It took 15 years after SARS to find these links. There are some close  relatives of Covid19 have been already been found in nature.
  • There should be multiple animal to human transmissions (preliminary evidence of at least two jumps). With SARS it took many years to discover this.
  • the Wuhan lab has very poor protocols and controls. The lab in question was built by the French at BioHazard Level 4, is reported by visiting researchers to use excellent safety protocols. The director is well regarded by all of the leaders in the field. Counter-point is that there are entrenched interests which are inclined to cover-up mistakes and we should continue to be open minded about the origin.

Mis-Information

• Covid has killed more people who have received the vaccine than who haven’t received the vaccine is simply not true. Since less than 50% of the world’s population has been vaccinated this is preposterous at a world level, since the vaccines are widely known to reduce the death rate from COVID.  In Israel where 85% of the population (9.3 million) has been vaccinated, there are more vaccinated people than unvaccinated.  But of course more people unvaccinated are dying than vaccinated even in absolute numbers.  On October 1, 2021 the number of serious Covid cases in Israel was 644, with 472 unvaccinated, 123 with two shots and 49 boosted.  In the week previous to October 1, 129 people died of Covid, 65% unvaccinated (84), 26%  one or two shots (34) and 8% with booster (1).  So even in Israel with 85% vaccinated, more unvaccinated die than vaccinated. This shows that the hypothesis that more vaccinated people die of Covid than unvaccinated is wrong, even in a population where 85% of the people are vaccinated.  (Israeli data is more reliable than US data because they have universal healthcare and good record keeping.)

Questionable Position

• Great Barrington Declaration signed by folks who are bucking against the common narrative of the larger medical community. I find myself sympathetic to their position, but have some concerns about their reasoning. First, we have evidence of re-infection which suggest herd immunity will never be achieved.

Things I want to followup on

• Historical analysis of past attempts of containment. One classic comparison was Saint Louis vs Philly during the Spanish flu.
• Some of the countries which did early masking / lockdowns has worse outcomes than countries that were looser. Of course there are many factors which impacted both infection rates and mortality rates. Any way to understand which factors have what prepositional impact?
• At the end of 2020 models suggested risk of death from COVID vs flu was lower under 14, higher above 14, growing significantly the higher the age. How has another year of data plus better treatment changed these numbers?

To Deepen understanding of science method (and frequent failures) in the medical space

• Studying Studies by Dr. Peter Attia
• Bad Science by Ben Goldacre

Miscellaneous Information

• Dry Heat Sterilization of N95 Masks: 30minutes in dry 100C deactivates covid while preserving the structure of the mask