Peter Attia’s Outlive starts with the medicine: biology, physiology, chemistry and so on. There’s an excellent explanation on arterial plaque. I did not know that cardiovascular diseases were caused by the body trying to heal itself from within, dealing with LDL cholesterol as best it can. There’s also good explanations about our synapses and cancers.
But what’s the point?
Information does not change action.
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Attia’s book is about the four modern horsemen of human mortality: cancer, heart disease, type two diabetes, and neurodegenerative diseases.
Like other areas of discovery, medicine follows the pattern: identification, react, ‘proact’. The Ghost Map tells the story of choleras identification in 1854. Covid-19’s cadence meanwhile was within a year: sequence, treatment, and bundled with the flu shot.
According to Attia, there is a lot more room to proactively address the four horsemen.
Channeling Michael Pollan, switching from hundreds of pages to a few words that address the action, the advice might be:
Get stronger. Eat your best foods. Sleep well.
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The book is thick. Parts are dense. Even now, days later, I can’t explain parts.
But that’s okay.
The main point of the book is to be intentional. Like the vegetarian experiment and as good bayesians we should tinker. Attia is rarely absolute: Do this but not that! Instead it’s about you getting to this point of heart rate or insulin sensitivity or sleep.
One takeaway from Covid-19 was our heterogeneity (see: The End of Average). Outlive fits in this line of thinking. It’s your healthspan, it’s your lifespan, it’s your choice.
So get stronger, eat your best foods, and sleep well.
Dr. Henri J. Breault of Tecumseh, Ontario is a hero. Working as a pediatrician in a hospital, Brenault’s widow recalls him coming home from work one day and exclaiming I’m sick and tired pumping kids’ stomachs!
So he invented the childproof medicine cap.
At the time, Canada had about 100,000 cases and 100 deaths.
Breault came up with the palm-and-twist bottle. As an aside, how great is YouTube? This short video shows four different child-proof caps. I did not know how the pinch one worked! Breault’s creation is fourth.
Prior to Breault’s 1967 invention was a public education campaign.
We know that education affects behavior much less than systems affect behavior.
Easy Money looked at how expense accounts affect behavior.
“If someone says financial literacy at a party I basically give them a thirty-minute lecture. The idea is that in a perfect world if someone is taught about FICO and its impact on their life, they would take action to improve their FICO score. This is just not what researchers have found – and it’s really robust…the punchline is that environment matters.” – Kristen Berman, All the Hacks, October 2021
So, don’t bring an educational solution to a design fight.
When not listening to podcasts, I can often hold a conversation while running, and conversing is a proxy for Zone 2 cardio. It’s a Goldilocks exercise. Is this a better way to run?
Between Instagram stories, Andrew Huberman emails, and runner scuttlebutt, Zone 2 is in the zeitgeist. Without getting into physiology, can we figure out if it’s a fad or worth our focus?
Metrics. We count what’s easy. Miles and minutes are easier to count than training zone sessions. Hurricanes are graded by their wind speed but it’s the water volume that does the damage. Speed is easier to measure and report. Daily users were standard but it was people who used the product that gave Pinterest engineers a better signal. Easy to count, collect, and combine metrics are overrated.
+1 for Zone 2.
Incentives. ‘Why am I seeing this?’ is a good question. Who is selling me something? Vegetarianism is underrated because the people who sell it don’t have that much to gain. Status points, sure, but if something’s not being sold it’s more believable.
+1 for Zone 2.
Barbell approach. Sometimes average measures are worse. Exercise may be like that. Every workout at 145 beats per minute is not as good as some workouts at 170 bpm and others at 125bpm, though the average is the same. Zone 2 is easier than the 145 average which goes against the ‘more is better’ mindset.
+1 for Zone 2.
Swept up. It’s easier to get swept up in something. Housing bubbles. Crypto. Or just the feeling of a local sports team playing deep into the playoffs. The internet feed makes it even easier. Instagram knows my age, interests, and engagements. Oh, a forty-year-old running dude, the magic math concludes, here’s a bunch of running videos promoting zone two cardio. Is this an echo chamber?
-1 for Zone 2.
Conclusion: I’ll do more Zone 2 training. Happy New Year.
The most powerful decision hack is ease. Make something easy to choose (ex. social proof), make it easy to execute (ex. now), make it easy to justify (ex. let the person tell a good story) and so on. Economist John List joined Tim Ferriss (Overcast) and talked about how we do that with childhood vaccinations.
“You’re going to be in the delivery room. Your kid is going to come out. Everyone is going to be happy. The doctors and nurses will make sure you wife is happy and the baby is healthy. Then the doctor is going to give you a playbook that says: We are going to give these vaccinations today and when you bring your baby back in six months it’s going to get a checkup and some new vaccinations. In twelve months, same thing. In eighteen months, same thing. The polio vaccination occurs in that time period. Any parent is going to do well by their kid and bring them to the doctor checkups, so it’s not an extra cost and you automatically get it.”
John List
Ease, make it easy. Inverted it’s the same plan: make undesirable behaviors more difficult. A few others:
Weight Watchers makes it easy to follow because it’s easy to understand. Like eating bananas.
It is surprising there are not more anti-science beliefs.
1. Science isn’t static, there’s not much canon.
2. Science is mostly not a putting-a-man-on-the-moon problem.
3. Science communication persuasion is difficult, especially relative to cultures, norms, and habits.
4. Science belief doesn’t follow formal logic, it is contextual. There are plenty of people who don’t trust a medical engineering but trust engineered medicine, or vice versa.
One way to think about all the non-science beliefs is as three states of the world: -1, 0, and 1. Put another way: anti-science, ignorant, pro-science.
Sometimes science denial is an information problem. If people only knew…. But that’s not quite it. Yes, sometimes scientific knowledge is zero, ‘they just don’t know the facts’.
“The other thing I think is wrong about how the media portrays it (science denial) is as misinformation. Science denial is about disinformation. Someone has intentionally created the theory that rebreathing into a mask will give you CO2 poisoning. Someone has made that up and filtered it out through the internet where it hits someone’s cognitive bias and they start to believe it.” – Lee McIntyre, Behavioral Grooves, November 2021
Most of life is not a ‘they just know the facts’ situation. C’mon, how many things do you dear reader not hold an opinion on. More often, it’s not non-consumption, but belief in something else. Weight Watchers and financial education are also examples of this state. Plus, our views on science and medicine, finances, and diet-health-lifestyle all have a strong identity component. If someone said, “Look, I hear what you are saying but I don’t trust the experts and this online community are my people,” you would have no idea if they were a Boglehead, a CrossFit participant, or anit-vax father of two.
The case at hand is like an errant Sudoku puzzle, there’s something else in that spot and it’s attached to a person’s identity.
Around here we try to skip the ‘they just don’t know the facts’ stage and go right to designing change. Personal finance is about shifting what we buy, often time rather than stuff. Heath is about shifting what we eat and what we do, replacing one thing with a healthier option. Anti-science persuasion then must replace the anti-science beliefs with something else. The trick here, says McIntyre is to plant a seed. Rather than ‘the facts’, be empathetic and offer suggestions. Reframe your aim from conversion to combustion, be the spark but let them do the work.
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It is wild how many things we do become part of our identity.
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Update February 15, 2022. Even ‘hard’ sciences are hard. Only forty percent of cancer biology studies replicated and eighty percent of pharmaceutical studies in academic labs cannot be replicated in industrial ones. Also, plastic recycling has (always?) been a sham: NPR Planet Money.
The best analogy to understand Loretta Breuning’s book Status Games is calories.
For many years survival was difficult. One problem was calories. So ‘evolution selected’ creatures with a mutation where certain foods (fat, sweet, salt, etc.) released good brain chemicals. Those creatures did better than others and became dominant. In a world with plentiful food those same adaptations aren’t as helpful.
For many years survival was difficult. One problem was predators. So ‘evolution selected’ creatures with a mutation where certain social group circumstances released good brain chemicals. Those creatures did better than others and became dominant. In a world with fewer predators those same adaptations aren’t as helpful.
Evolutionary life was hard so species adapted. Tigers and orangutans have no predator and tigers and orangutans are the only mammals to live alone. Like five fingers on a hand, something about social was splendid for survival. These groups included a pecking order and status games – which have at least two advantages.
Status games as alchemy. In a nod to Rory Sutherland, status games are a form of marketing where there’s a large reward for a not very large cost. Actual fights among mammals are rare. This makes sense. Fights reduce survival chances. Having a way to find out who is right/strong/better/whatever without the fight is quite nice.
Status games protect the group. Status games trim the tails of an individual’s outcome but make reproduction more likely. Any individual mammal is more likely to survive somewhere in the middle of the pack rather than in a non-stop quest to be ‘top dog’. And, Loretta writes, “It enables weaker individuals to enjoy the protection of stronger individuals in the face of common enemies.”
Groups are good for survival and status games are good for groups. So status became part of our human operating system.
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One analogy for the human brain is the elephant and the rider. The rider is our conscious brain and it is giving directions, narrating the story, and feeling in charge but really the elephant is going to go where it wants to go – and per Breuning the elephant wants to travel on well trodded paths. “Your animal brain just strives to repeat behaviors that trigger happy chemicals and avoid behaviors that trigger unhappy chemicals.” Thanks to the evolutionary advantage of being in groups, our brains have a simple set of chemical instructions.
Good: being in a group, ideally higher up.
Bad: being separate from a group, demoted in a group.
Groups are important so we seek groups. Everywhere are groups and everything is a status game. Fancy cars are status games. But so is ethics, morals, politics, house size, neighborhood, intelligence, partner, ability to drink, family heritage, even hardships. Find the chemical rewards and you will find the game. “Each brain sees the world through the lens of the neural pathways it has,” Breuning writes.
So, status games are normal but maybe not as helpful as they were. If we have to play, then we can play wisely. Remember, explains Loretta, it’s the dopamine that makes something feel good, not the thing. “The simple way to do this,” Breuning concludes, “is to put yourself up without putting others down.”
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I have no idea how much of this book is true but I liked it for a two reasons. First, it acknowledges the world as it is. Animals compete and form cliques, just like us, because we are animals. Two, the book’s perspective is action oriented. This is how things are and this is what you can do, I imagine Breuning advising. Most of all this book reminded me of Spent, we are all signaling and we are all playing status games.
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Comments: it is ironic that ‘pecking order’ is from domesticated chickens. Also, ‘evolution selected’ is just how we assign action and our brains like effects from actions. Examples include Headspace, poker, and international espionage and it is the source of the expression ‘don’t shoot the messenger’.
May 2022 Update. Scott Alexander’s review of The Gervais Principle offers an example of status games, and why they are helpful, in the context of Seinfeld.
Health is a good proxy, like with finance and fitness, for understanding systems because it involves personal choice, design, social factors, marketing, culture, and so on.
Part of the reasons diets, like the diet formerly known as Weight Watchers, work is design. One design is zero point foods, like bananas. Zero points isn’t zero calories but it is zero thought. The primal diets do the same thing. Carbs bad, meat good. Fasting also succeeds due to good design. Vegetarian too. The best diets combine easy rules and identity.
Here’s the pitch: the birthday cake diet or BCD.
The first product would be a book. Or, better, a self-help book! It would outline all the advantages of better eating, all the research of behavioral scientists, and all the philosophy around intentionality and purpose. Tolle meets Tversky to defeat Tollhouse. The pitch is: the only junk food you would ever eat would be birthday cakes.
People could just decide to only eat birthday cakes. But then again there’s a fasting app that’s essentially just a timer — and it’s a great idea! The BCD frames inaction (not eating) as action (waiting for a birthday cake). Annie Duke I know would approve.
‘Okay’ you’re thinking, ‘it’s not just birthday cake that’s bad for you.’ True. So after the first book about the why, comes the second book with the how. Taking a page from WW, the second book used slices of cake as the metric. One cookie? One slice of cake. Chips? One slice. A granola bar? Half a slice. Pizza? Half a slice. Bananas? Free! It’s not as clean as the points system, but framing things as a slice of cake definitely will change some consumption patterns.
The books will kickstart the funding needed for recurring revenue. Birthday cake as a service anyone? BCAAS! The BCD wouldn’t even need to create products. This business white labels ones from the big bakers or leverages the identity and design ease to create Keto ones or whatever. Plus birthdays are regular events. The Total Addressable Market is everyone every year.
The BCD is super social media friendly. Like cheat day posts on Instagram, the BCD sells the experience of blowing out the birthday. You haven’t had cake all year, how about one that’s five feet across? The BCD is shareable. Imagine the local, regional, and national news. This is so influencer friendly. Is a low CAC tastier than birthday cake? We will find out.
So email me to sign up and join the next great eating revolution: the birthday cake diet.
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This posts are too much fun. Somehow this is the second Birthday themed post, here is the birthday bet. In college a friend framed regular beer as having a ham sandwich and light beer as not. I still think of that when I see a can of Budweiser.
If this blog has a core, at the moment, it’s about decision making. One way to change decision making is to change the initial conditions. One way to do that is to dial ease up or down.
Losing weight is about introducing new habits and breaking old habits. WW, formerly Weight Watchers, uses ease a lot. Make the good things relatively easy and make the less good things relatively difficult. For example, part of what makes keeping a food journal a successful dietary change is that it introduces a friction, writing down the food forces our focus: do I really want to eat this? There’s no noting bananas though.
“To introduce new habits you want to pick foods you can eat on autopilot. If you’re with WW there are zero point foods that you don’t need to pay attention to. Bananas are pretty healthy and you’re probably not going to overeat bananas.” – Julie O’Brien, The Science of Change, November 2021
The episode is full of behavioral hacks, for instance having slack in the system for an occasional treat (or lapse). Another is the idea of rules of thumb. WW has points, intermittent fasting has times, Whole30 has no carbs. Each also restricts booze.
As a teen I worked retail with a woman who did the points system. She ate popcorn all the time. I didn’t get it. Popcorn has calories. But it worked for her.
As a teen I thought the world was more black and white. Now I get there’s more shades of grey. Now I appreciate the aspects of designing ease.
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Here’s a few more posts about the different ways ease works.
In Average is Over Tyler Cowen predicts that future jobs will reward people who work well with machines and humans. There will be good careers for people who understand people and data.
For instance, a doctor spends years of her life in medical school and residency and attends continuing medical education courses to ‘know a thing’. But she also must convince her patients. The way we do each of these will change with time but these are the two parts any job. Put another way, it doesn’t matter how good the model is if people don’t follow it.
“The (diabetes treatment) model we created beats 95% of primary care physicians, not because they aren’t smart, but they don’t go through the six million (treatment) combinations in their head. For endocrinologists there’s a top quintile who get results as good as the best output of our algorithm. They don’t do it by choosing the best algorithm, they use their humanity to talk to their patients about adhering to the drug regime. They are getting results a different way.” – Len Testa, Causal Inference, October 2021
Good convincing outperforms better medicine! This is why financial education does not work. Action does not follow information like a tail follows a dog.
Testa doesn’t elaborate how the doctors describe the diabetes deterrents, but it’s probably in the listener’s language. “Excise the statistical jargon,” said David Spiegelhalter and communicate better.
We highlight design because humans are conditional creatures. Certain circumstances make certain actions more or less likely. Living near a huge retirement community in Florida shows this contrast clearly. The involvement in new sports like pickleball, water volleyball, and sand tennis exemplify the design principle: If you build it, they will come.
In talking about his book,Drink?, David Nutt notes how much alcohol is a cultural act. Per Nutt, alcohol’s health impacts are terrible, the societal costs are large, and meaningful outcome changes wouldn’t require that much tweaking to the current system. But we don’t change.
Culture is design too. So to not drink a person needs to counter culture.
“In my book I suggest if people say to you, ‘Why aren’t you drinking?’ quite a good repost is to say, ‘Because I’ve got quite a busy day tomorrow.'” – David Nutt, London Real, February 2020
The second design is around fasting, an area design helps.
“Right around the five hour mark of a fast you’ll probably get hungry (this being our ‘normal’ time between meals), and that’s the most difficult time. Sleeping through that is the best idea then. If you can start a fast at three p.m., then in the evening you have to stay away from the snacks, but when you wake up you’re in that cruise state of twelve plus hours.” – Matt Tullman, No Meat Athlete Radio, October 2021
In my experience this is true. Fasting pangs are non-linear. Depending on the time, circumstances, and maybe even hydration, a fast can be more or less difficult. Sleeping through those time-based hunger troughs can help.
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Nutt sounded quite certain in the podcast about the health effects, but a query for “cancer alcohol meta analysis” showed less convincing results. In an attempt to be more Bayesian I’ll update from ‘quite bad for you’ to ‘pretty bad for you’.
The Waiter's Pad 