Goals for this document

The main goal is to significantly expand one’s healthspan, or the amount of time one feels capable. This is largely inspired by Peter Attia’s ideas on this subject - his 3 minute summary on healthspan and lifespan are here. The three hour summary of his approach is here.

According to Attia, there are four major causes of shortened healthspans for Americans:

Atherosclerotic disease, which is comprised of cardiovascular disease and cerebrovascular disease
Cancer
Neurodegenerative disease - the most common form being Alzheimer’s disease
Type 2 diabetes and related metabolic dysfunction (hyperinsulinemia, insulin resistance, fatty liver disease)

This doc is split into two sections: “How to figure out if I’m healthy” and “How to get healthy.” The tests and interventions listed here are focused on testing for / preventing the major causes listed above, and generally improving human performance - both cognitive and physical.

The 80/20 of how to get into A+ health

Workout at least five days a week (2.5 hours cardio, 2.5 hours strength training).
Get 8 hours of sleep a day
Eat 35 - 50 grams of fiber a day (the more the better)
Eat 1g of protein for every lb of bodyweight a day (or as much as you’re comfortable eating)

How to figure out if I’m healthy

These notes come from Peter Attia’s book Outlive. Here’s a spreadsheet template that I use personally to track outcomes from the tests described below.

Do a blood test

Heart health: Measure your Lp(a) (pronounced El-pee-little-a) and apoB. I think these cost about $50 together, albeit are non-standard measures for most blood labs.

ApoB

What it is. ApoB is the primary indicator of potential heart disease. Traditionally, most doctors look at a different indicator - LDL-C, which measured “bad cholesterol” levels. It turns out there are a few other items associated with cholesterol that are also useful to look at, and LDL-C and these other items are all encompassed in the ApoB reading (LDL and other heart indicators are all encased in apolipoprotein B, which is measured as “ApoB”).
Target range. Most doctors only get worried if your ApoB level is above 100 mg / dl. However, any increase in ApoB beyond the levels necessary for living (which ~ 20 / mg / dl) is increased risk of heart issues. Given ApoB levels tend to rise over time, if you want to have healthy ApoB levels when you’re 70, Attia recommends getting ApoB levels as low as possible, with 20 to 30 mg / dl when you’re in your 30s and 40s as the gold standard. This is extremely low compared to what most doctors request, and likely requires assistance with drugs called statins (which I personally haven’t explored yet) but the point is to get this number as low as possible with diet and cardio exercise. Without statins, Peter recommends trying to get to 60 mg / dl. For reference, the 20th percentile of ApoB is 78 mg / dl. 62 mg / dl is 5th percentile, so getting to 60 is darn aggressive relative modern standards.
How to lower ApoB levels: Cardio exercise, consuming less dietary fat and cholesterol, eating more fiber, taking statins, quitting smoking

Lp(a)

What it is. Having elevated Lp(a) levels puts you at greater risk of heart attacks. It can form plaque and get stuck. It’s a highly genetic thing that you only have to get measured once since it doesn’t move around a lot with behavioral changes. About 20 - 30% of Americans have elevated Lp(a) levels that put them at risk of heart issues.
Target range. Ideal Lp(a) levels are 14 mg / dl. The highest risk category is 50 mg / dl and above. If you do have a high Lp(a), the best way to lower risk is to more aggressively manage your ApoB levels.
How to lower Lp(a) levels: You can’t. But you can manage risk by keeping ApoB levels to a minimum.

Cognitive / heart health: Get an Omega Fatty Acid panel. A standard part of these panels is DHA % and EPA % (aka Omega-3 Index).

What it is. DHA and EPA are two Omega 3 Fatty Acids that have been shown to have a lot of cognitive and cardiovascular benefits, including longevity. This includes protection against neurodegeneration (e.g. Alzheimer's) and improving cardiovascular function (thereby preventing heart failures and related issues). DHA can be turned into EPA much more easily than EPA can be turned into DHA, so most supplements that provide both have more EPA than DHA.
Target Range: 8 - 12% combined for DHA % and EPA %. Average for Americans is between 4 - 5%. It takes 4 months of supplementing with fish oil or eating fish before it shows up in blood labs since that’s the lifespan of red blood cell which apparently is what’s being measured here.

Note: some folks also track Omega 6 / Omega 3 ratios. In this podcast, Attia and his guest Bil Harris recommend targeting 8 - 12% combined DHA + EPA% as opposed to Omega 6 / Omega 3 ratios, as the ratio is irrelevant if Omega 3s are up.
How to improve numbers. Eat fatty fish and supplement with fish oil.

Check your blood pressure

Attia says blood pressure is one of the most underutilized tools given many people walk around with high blood pressure and don’t know. He recommends people knowing their blood pressure and managing it aggressively if they’re not in range. Having elevated blood pressure for long periods of time can lead to including kidney damage and damage to arteries of the heart and brain. High blood pressure also seems to play a role in all chronic diseases, except for cancer.

What it is: Standard test involving a stethoscope / armband or automated cuff.
Target range: Systolic reading of 120 mm Hg or lower and a diastolic reading of 80 mm Hg or lower (also referred to as having a blood pressure of “120 over 80”). Elevated is when systolic is between 120 - 129 and diastolic is 80 or below. Having blood pressure of 130+ over 80+ is considered having hypertension. Having blood pressure of 120 over 81+ is also considered hypertension. These numbers are discussed here.

Additional notes from Attia’s podcast with Huberman: Attia says most doctor readings are inaccurate. You need to sit in a chair for 5 minutes doing nothing to get an accurate reading. He recommends his patients take blood pressure readings 2x/day for two weeks to get an accurate reading. Additionally, he says automatic cuff readings often given higher readings than manual readings, which are considered more accurate. That said, he recommends people start with automatic cuff readings. As of the podcast cited above, there is no watch or wearable device that provides accurate readings

How to improve numbers: Get adequate sleep and do cardio exercise. If still not in range, there is medication available that Attia briefly mentions here.

Get a continuous glucose monitor

What it is: A sensor that sticks via tiny needle in the back of your arm or stomach and measures blood glucose levels every few minutes. Elevated blood glucose levels over long periods of time increase the risk of all 4 major types of disease/death: atherosclerotic disease, cancer, neurodegenerative disease, and type 2 diabetes.
Cost: In my experience, bare bones CGMs such as Abbot’s Libre 3 cost $40 for 14 days with a physician prescription and coupon, or $85 without the coupon. CGM services like Levels, which provide an app with more metrics and recommendations (but with the same underlying sensor, can cost a few hundred dollars a month).
Target range:

Average glucose level of 100 mg / dl or below.
A standard deviation of 15 mg / dl or less
Avoiding spikes of over 160 mg / dl
In general, the lower the average glucose, the better, and and lower variability is better.

How to improve numbers: Eat foods with a lower glycemic index. This generally means avoiding sugar and refined carbs / processed foods. Eating fiber and exercise will also blunt glucose spikes, so eating more fiber with meals will lower your average glucose levels.

Get a DEXA scan

What it is: Measures body fat %, visceral fat, and bone mineral density. Radiation exposure is super low in these scans, so you don’t have to worry about that. Body fat % is the least important of these markers. Visceral fat, or fat that accumulates around the abdomen, is considered particularly unhealthy since it creates inflammation around vital organs, and is associated with metabolic disease. Bone mineral density measures bone strength - especially important for when we age and are at risk for breaking bones due to falling. According to Attia in this podcast, women are especially at risk for lower bone mineral density.
Cost: About $200 in urban centers
Target Ranges:

According to Attia in this podcast, we should have standards around visceral fat as a percent of total body weight, but to date we don’t. Here is a reference table of visceral fat values by gender, age, and percentiles. I imagine Attia would target the most aggressive percentile here (15%) or lower.
Bone density: have a positive t score. 0 would mean same as a healthy 30 year old. Positive (such as 1.0) means I’m 1 standard deviation ahead of someone who’s 30 years old and my gender. Don’t want to see a negative t score. This would indicate long term at risk of fractures

How to improve numbers

Visceral fat: Exercise and diet.
Bone mineral density: Strength training. Very hard to improve after bone maturation occurs in one’s early 20s. So it’s very important for young folks to do strength training (lifting weights). For older folks, the goal is to slow the rate of decline, which is also achieved through strength training. This can be supported through Vitamin D supplementation and eating sufficient protein.

Get a CT angiogram by age 40

What it is: A scan to see plaque around the heart. Previously doctors recommended calcium scans for plaque issues, but these scans only measure calcified plaque, not soft plaque that later turns into calcified plaque. Around 15% of people with a calcium score of 0 have plaque issues. It’s advised to get this scan once between ages 35 to 40.
Cost: I haven’t gotten this yet so don’t know how much it costs.
Target: Zero soft and/or hard plaque.
How to lower plaque: Everything under “How to lower ApoB levels”

Cancer scans

Worth noting that cancer is the hardest of the 4 major disease types to prevent. The major modifiable risks are smoking, insulin resistance, and obesity. Pollution in air and water may also be a factor but data here is less clear.

Out of the dozens of types of cancer, we have agreed upon and reliable screening methods for 5:

Lung cancer: MRI or CT Scans
Breast cancer: mammograms
Prostate cancer: prostate exam
Colon / colorectal cancer: colonoscopy
Cervical cancer: Pap smear

Attia did not have specific advice that strayed from normal recommendations for screenings aside from colorectal cancer.

For men

Colorectal cancer screening: Get a colonoscopy by the age of 40. A doctor puts a flexible tube in your butt with a camera at the end and looks for colorectal cancer, which is the third deadliest cancer (behind lung and breast/prostate) but easy to treat if found early. Attia recommends following up every 2 to 3 years with another colonoscopy.
Prostate cancer screening: Get a blood test for PSA (prostate-specific antigen). Normal is at or below 1 for this test. This test has had a lot of false positives and negatives, which is an issue since the next step if you think you have it is a biopsy of the colon. To be able to early detect and get higher resolution on whether prostate cancer is present, look at additional factors such as PSA velocity (change of PSA over time), PSA density (PSA value normalized to the volume of the prostate gland) and free PSA (comparing amount of PSA that is bound vs. unbound to carrier proteins). American Cancer Society recommends getting one by age 45 for men with average risk.

For women

Breast cancer screenings: Attia recommends stacking mammograms, ultrasounds, and MRIs to get the best picture of breast cancer risk and avoid unnecessary procedures. He does not go into detail about what age women should start screening - the American Cancer Society recommends starting screenings no earlier than age 40, and then start annual screenings by age 45.
Cervical cancer screening: Attia does not have non-standard advice here. Standard advice according to Mayo Clinic is to get an annual pap smear starting at age 21. A Pap smear involves collecting cells from the cervix — the lower, narrow end of your uterus that's at the top of the vagina.

For current and former smokers:

Low dose CT scan or MRI for lung cancer: Attia does not go into how early smokers should screen. Mayo Clinic recommends screening for smokers and former smokers starting at age 50, or anyone with a “20 pack year” history - which is someone who smoked a pack a day for 20 years. Smoking two packs a day for 10 years would also be a 20 pack year history.

Exercise tests

Dr. Andy Galpin, who is a fitness coach for athletes and Founder/Director of the Biochemistry and Molecular Exercise Physiology Laboratory at Cal State Fullerton, recommends doing a battery of tests 1x / year to see how well you’re doing across strength and cardiovascular indicators. His particular battery of tests, described below, covers the major areas of fitness (speed, power, force/strength, muscle hypertrophy (muscle size), muscular endurance, anaerobic capacity, maximal aerobic capacity, Whether you do well or not on these tests or not, the prescription is still to follow an exercise regime similar to the one described below, but with a bit more focus on the weaker areas. The full podcast that goes through all this stuff is here. Attia has his own version of this for his clients and tends to be more aggressive in his targets, although I haven’t found a source where he details exactly what to do and what targets to pursue.

Galpin’s targets are the ones I include in the fitness test tracker spreadsheet.

Power

Broad jump:

How: Do a standing jump (no running). Measure from tip of toes on jump to back of heel upon landing
Target:

Men: Your height.
Women: 85% of your height

Vertical jump:

How: Do a standing jump (no running). Two feet on ground. Use both hands. Measure from standing height of fingertips on both hands to lower of both sets of fingertips upon jumping.
Target:

Women: 20 inches (no age specs given)
Men under 50: 24 inches
Men over 50: 20 inches

Strength

Leg extension:

How: This is a specialized piece of gym equipment that looks like this
Target:

Through age 40: Body weight
Every decade thereafter: body weight minus an additional 10%

Deadhang:

How: Literally hang from a bar, fully extended, for as long as possible
Target: Hold for 60 seconds

Goblet squat:

How: Should look like this.
Target: Hold ½ your body weight for 45 seconds.

Muscular Endurance

Front plank

How: Should look like this
Target: Hold for 60 seconds or more

Side plank:

How: Should look like this
Target: Hold for 45 seconds or more

Pushups:

How: Chest should touch the floor when contracted and arms should be fully extended when extended.
Target:

Women: 15 (5 or less is a red flag)
Men: 25 (10 or less is a red flag).

Anaerobic Capacity

Heart rate recovery:

How: Wear some kind of heart rate monitor. Get your heart rate up as much as possible - and try to hit your max heart rate. A rule of thumb for what your target max heart rate is is 220 minus your age. So mine would be 220 - 36 = 184, although testing it at a fitness lab is the gold standard. I got mine tested and it’s actually 181, but close enough. Once you hit your max heart rate, stop working out and rest for 1 minute. After 1 minute, measure your heart rate. So if my max heart rate is 181, and one minute after stopping working out it’s 165, then my heart rate recovery is 16 beats / minute.
Target: You want your heart rate recovery to be 30 beats / minute.

Aerobic Capacity

VO2 max:

How: Go to a lab and get it tested with an aerobic test.
Target: Ideal is 55+ ml /kg / min for men and 50+ ml / kg / min for women. Minimum target is 35+ for men and 30+ for women.

How to get healthy

Exercise

The #1 longevity and health thing is exercise. Not smoking, diet, etc are important, but still not as important as exercising 3 to 6 days a week when it comes to long term health. Huberman, Galpin, and Attia all advocate exercising 5 or 6 days a week. Here’s how they recommend breaking it down:

Building Aerobic capacity

Attia thinks of aerobic capacity as a pyramid. The peak is defined by high intensity (going for max heart rate) training. The base is defined by time spent in Zone 2, or low intensity training. The higher the heart rate of the intensity trainings and the longer the time spent in Zone 2, the bigger the pyramid gets, which is a good thing.
Zone 2 cardio. Most folks define Zone 2 as cardio (biking, swimming, running etc) at a level where you can still have a conversation, but the other person would know you’re exerting yourself. Andy Galpin recommends performing all Zone 2 cardio should be performed while nasal breathing, as that’s somehow better for air quality and facial muscles. He recommends getting at least 150 minutes per week, although this can be accomplished by playing sports and other “active” activities like hiking. Peter Attia has a much more specific definition. Zone 2 for him is the highest metabolic output/work that you can sustain while keeping your lactate level below two millimole per liter. This requires using a lactate meter periodically (he recommends 1x/month) immediately after workouts to see if you’re in range. Attia recommends 180 - 210 minutes of this a week.
Max heart rate training. This is just going as hard as you can in short sprints. Andy Galpin recommends warming up for about 10 minutes, then going fast for 2 minutes then resting for 2 minutes, and repeating 3x. I like doing this with ellipticals, stationary bikes, or treadmills, although treadmills can be risky given they don’t slow down when you get tired. Galpin and Attia recommend doing this 1x/week at least, or twice if you can swing it.

Strength / physical therapy training

The key principle is progressive overload. This is where you’re slowly adding more strain to the muscles which then adapt over time by becoming larger. Every week, you want to do a bit more weight or reps than the week before. Galpin recommends adding 10% more weights or reps each week. After six weeks, he recommends down shifting by 30% to give muscles a rest, then slowly going up again. Eventually, you get strong as hell.
Tracking progress. To keep track of strength training lbs and reps, I find the “Strong” app to be affordable and simple.
Focus on full extension and compound movements. Compound exercises use multiple muscle groups, such as a bench press. This is in contrast to isolation exercises, such as a bicep curl, which focus on a particular muscle. Do each exercise full extension to ensure your muscles retain full range of motion. So if you’re doing pushups, touch the floor with your chest and then extend until your elbows are straight. If you’re doing a squat, go all the way down before extending into standup position.
Building a workout routine. Galpin recommends only focusing on 3 - 5 strength exercises in a particular day, and not changing those exercises for 2 to 3 months, to ensure you’re maxing out on each one and slowly progressing. Regarding how much to do for each exercise, Galpin’s rule of thumb based on studies is 3 sets of 3 - 5 reps if you’re optimizing for strength. If you’re optimizing for hypertrophy, 3 sets of 8 - 12 sets.

For following a particular routine, Jeff Cavaliere at Athlean-X is popular for weights. I really like his Beginner Workout, which is a 3x/week program and has three difficulty tiers for each type of foundational exercise. On each strength training day, I also add exercises from one of two sources:

Knees Over Toes Guy because he’s all about building knee/leg strength, and I have previous knee injuries. He’s incredibly earnest and nerdy about knee strength, which I find endearing. He has an app ($50 / month) that I’ve used but there are Youtube videos of people explaining his basics, which is a program he calls “Knee Ability Zero.”
Jeff Cavaliere’s Posture Restoration Exercises because my posture is crap as well.

Food and supplements

A lot of these recommendations come from Dr. Layne Norton, who has a PhD in nutritional sciences and is an International Powerlifting World Champion. He’s also a stickler for good study design.

Protein. Peter Attia and Layne Norton recommend 1g of protein for 1 lb of body weight per day. This is a lot and hard to eat honestly. Attia estimates the max per sitting is around 50g (more than that and it’ll get shit out). I aim for around 100 - 115 grams and that’s with 26g of protein isolate a day - doing more is just too much eating and diet optimization for me. If you want to read more about it I recommend looking up Layne Norton’s materials.

If you’re trying to build muscle, it’s nearly impossible to get 1g of protein / 1lb of body weight without protein powder. So if you go that route, I recommend whey protein isolate as opposed to whey protein concentrate. Whey protein concentrate has sugar alcohols which can give folks (and by folks I mean me) tremendous farts. I don’t think it matters much what brand you get as long as it’s in a GMP (good manufacturing practices certified) facility but I get is this one for the price.

Fiber. Layne Norton recommends getting at least 35 grams of fiber for a 2,500 calorie diet, although also states that the more fiber a day, the better. I aim for 50g of fiber a day. A review article came out (over 1 million subjects reviewed) showing that for every 10g increase in fiber, there was a 10% reduction in risk of mortality. Layne states it’s not well understood why fiber is so well correlated with long term health and longevity, but Attia mentions it improves glucose and ApoB levels.

I include 10g of fiber into a protein shake everyday on the recommendation of a consultation with Gillett Health, a concierge medicine practice I’ve used for personal health plans and answering questions about the protocols in this document. More than 10g and absorption can become an issue. I do a mixture of psyllium husk and inulin (two different types of fiber) since more fiber variety is better. Both have very high fiber per gram ratios. If you just get one type of fiber I was recommended to go with psyllium husk.

Fish oil. DHA and EPA are two Omega 3 Fatty Acids in fish oil that have been shown to have a lot of cognitive and cardiovascular benefits, including longevity. This includes protection against neurodegeneration (e.g. Alzheimer's) and improving cardiovascular function (thereby preventing heart failures and related issues). If you want to improve your ratios, the best way to do that is

eat fatty fish (e.g. salmon, tinned sardines or mackerel with the skin on) and
take at least 1 gram of EPA derived from fish oil each day, or 2 grams of EPA if you’re not a fish eater.

The most cost effective way of supplementing that I’ve found is Carlson’s fish oil (which actually goes down super smooth with a light lemon taste - I put it in a protein shake every morning). The most cost effective path whilst traveling I’ve found is 4 capsules of Nordic Naturals Ultimate Omega. Keep the bottle refrigerated if possible as room temp will degrade the potency of the EPA + DHA, and if the bottle gets hot it can go rancid.

The expert on fish oil I follow is Dr. Rhonda Patrick. Here’s her site with way more info on fish oil than you ever bargained for.

Creatine. This started out as a bodybuilder supplement but is now recommended for pretty much everyone, as it turns out to have lots of cognitive benefits as well. A recent study came out showing that creatine supplementation helped old ladies strengthen their hips, decreasing their probability of falling and breaking a bone (a primary cause of death for senior citizens). For creatine you want creatine monohydrate. There are other more expensive creatines out there but none have been shown to perform better and none have been tested as thoroughly as creatine monohydrate for muscle and cognitive improvements. Brand also doesn’t matter but this is the one I get. Folks under 180 lbs should shoot for 5g/day, everyday. Heavier folks often supplement up to 10g/day. The expert I follow for creatine advice is Dr. Layne Norton.

Other protocols for improving health

Early morning sunshine. Get 10 minutes of sunlight within 1 hour of waking up. This kick starts the circadian rhythm and regulates hormones, making it easier to sleep. If it’s cloudy out, or you skipped sunlight yesterday, get up to 20 minutes.

Nasal breathing. Breath through your nose as opposed to your mouth as much as possible. Research points to nasal breathing as creating healthier facial structure. Some folks go so far as to tape their mouths shut when they go to sleep to train themselves to nasal breath during sleep. I did this for a while and it helped, as I struggle with congestion / nasal breathing.

Coffee intake timing. Delay drinking coffee until 90 minutes after you wake up. It will last longer and prevent crashes.

Water intake. Hydration rule of thumb according to Andy Galpin: Throughout the day, drink half your bodyweight (in pounds) in ounces per day. So, 200 pounds → 100 ounces of water

Go to bed at the same time every night. Recent evidence suggests that in addition to getting 8 hours of sleep every night, going to bed at the same time is necessary for the body to naturally produce human growth hormone while you sleep. HGH increases metabolism and helps tissue repair, slowing aging. Even going to bed 30 minutes off every night can inhibit the release of growth hormone at night.

Contact

If you have ideas for how to improve this document, hit me up at johnnybowman@gmail.com

I also have a newsletter with hot takes on contemporary manhood and tools for emotional intelligence: check it out here.