102. 为你的生命增添十年健康时光

今天我的嘉宾彼得·阿提亚再次做客本播客。

My guest today, Peter Attia, makes a return visit to the podcast.

他是一位专注于研究如何健康长寿的医生。

He's a physician who specializes in the topic of living a long, healthy life.

他花了七年时间收集整理自己的见解，最终完成了这本处女作。

It's taken him seven years to collect and organize his insights into his first book.

书名为《超越生命：长寿的科学与艺术》。

It's called Outlive, the Science and Art of Longevity.

长寿只关乎生命长度的一半。

Longevity is only half about length of life.

我们同样需要关注生活质量。

We have to be just as concerned with quality of life.

欢迎收听《我大多钦佩的人》，我是史蒂夫·列维特。

Welcome to People I Mostly Admire with Steve Levitt.

这不是一本普通的自助类书籍。

This is not your run of the mill self help book.

彼得是我认识的最聪明的人之一，这本书汇集了最前沿的科学知识，凝聚了他数十年来对如何活得更久更好的执着探索。

Peter is one of the smartest people I know, and this book represents the absolute cutting edge of scientific knowledge, the collective wisdom of Peter's decades long obsession with the question of living longer and better.

彼得从根本上解释了人体运作机制，以及这对延缓衰老的实际意义。

Peter essentially explains how the human body works and what that implies for the steps you can take to slow down the aging process.

自从拿到书稿后，我改变了许多日常习惯，包括锻炼方式和睡眠时长。

In the time since I got my hands on the manuscript, I've changed many aspects of my daily routine, the way I exercise, how much I sleep.

我甚至开始认真使用牙线了。

I've even gotten serious about flossing my teeth.

嘿，彼得。

Hey, Peter.

很高兴你能再次参加节目。

It's so great to have you back on the show.

非常感谢你再次邀请我，Steve。

Thank you so much, Steve, for having me back.

你知道，对于大多数嘉宾，即便是最优秀的，我觉得一集节目的时间刚刚好。

You know, with most of my guests, even the best ones, I feel like a single episode is the exact right amount of time.

但和你交谈时，我感觉我们只是触及了皮毛。

But with you, I feel like we barely scratched the surface.

我认识你很久了。

I've known you for a long time.

初次见面时，你热衷于各种极限——体力挑战、极端饮食、极限爱好，这些都产生了引人入胜的故事。

And when I first met you, you thrived on extremes, acts of physical exertion, extreme diet, extreme hobbies, all of which generate fascinating stories.

但在交谈中，你似乎不愿重温那些往事，直到我读完你刚出版的新书才明白原因。

But as we talked, you were hesitant to relive those old stories, and I didn't understand why until I read your new book just published.

这本书名为《超越：长寿的科学与艺术》。

It's called outlive the science and art of longevity.

读完这本书，我意识到过去十年你的改变比我认识的任何人都大，也终于理解上次节目时你为何不愿谈论过去的自己。

And reading the book, I realized that you have changed more in the last ten years than just about anyone else I know, and I now understand why the last time you came on the show, you didn't wanna talk about the old Peter.

你显然对长寿问题着迷。

You're clearly obsessed with this issue of longevity.

你以我毕生罕见的热情与执着研究着这个课题。

You've studied the question with a passion and persistence that I've rarely seen anyone devote to any topic in my entire life.

这是你一直关心的问题，还是中途发生了什么让你走上这条路？

Has it always been a question you cared about, or did something happen along the way that put you onto this path?

这绝对不是我终身的课题。

Definitely has not been a lifelong question.

大学时我是机械工程专业，主修数学，计划攻读航空航天工程博士。

In college, was a mechanical engineer student, math major, planning to do a PhD in aerospace engineering.

直到大学毕业前，我甚至觉得医学毫无吸引力。

I didn't even think medicine was remotely interesting until I had already finished college.

后来我进入医学领域，其实也是源于我对肿瘤学的兴趣。

And then even when I came to medicine, it was really through my interest in oncology.

之后我离开医学界，去了麦肯锡工作，从事信用风险评估相关的工作。

And I left medicine and then went to work for McKinsey and did credit risk stuff.

这一切随着我女儿的出生突然又回到了原点。

All of this came back quite suddenly with the birth of my daughter.

我想那可能是第一次——我猜很多父母都有同感——第一次认真思考自己的死亡问题，并开始对如何延缓死亡产生兴趣。

That was the first time, I suppose, I'm guessing this is true for many parents, but that's probably the first time I contemplated my own mortality and became interested in how to delay that.

你在书里还讲了一个故事，简直疯狂到我无法理解。

In the book, you tell a story also about it was almost so crazy I couldn't understand it.

你27岁时他们给你做错了手术还是什么？

When you're 27, they did the wrong operation or something?

那到底是怎么回事？

What was that all about?

那太荒谬了。

That was so absurd.

是啊。

Yeah.

我在医学院时背部受了重伤，得到的治疗极其糟糕，主刀医生甚至开错了部位。

When I was in medical school, I had a really bad back injury, and I received horrible care and the person who operated on me operated on the wrong side.

这是一连串重大失误，事实上他在术前甚至没面诊过我。

It was a colossal set of missteps that involved, basically he didn't even meet me or examine me prior to surgery.

我常说那是我人生中最糟糕也最宝贵的经历，因为那次手术和后续的修复手术让我失去了将近一年的光阴。

Think I've referred to that as the best worst experience of my life because it was about a year in my life that I lost with that operation and the subsequent operations that were needed to fix that operation.

但在这个过程中，我学到了极其珍贵的一课：失去健康意味着什么，无法行走意味着什么，疼痛到连刷牙都困难意味着什么。

But in the process, I learned something very valuable, which is what it means to lose your physical health, what it means to not be able to walk, what it means to be in so much pain that brushing your teeth is very difficult.

短期经历这些是一回事，但当这种状态持续一整年，就会深深刻进你的灵魂。直到现在，我每次在停车场都会特意停到最远的车位，用行走来庆祝自己重获行动能力——毕竟我曾数月无法行走。

It's one thing if you experience something like that for a couple of days or weeks, but when you experience that for a year, it gets ingrained into your psyche and there's not a day that goes by where I'm not in a parking lot where I'm so excited to be able to park as far away as possible to celebrate the fact that I can walk because I couldn't walk for months.

你基本上在二十多岁时就过完了九十岁的人生。

You essentially lived your 90 year in your twenties.

完全正确。

That's exactly right.

我在27岁时经历了生命的最后一年，不得不说，这份珍贵的礼物永远改变了我对待健康的方式。

I lived the last year of my life when I was 27 and I got to say, this is a beautiful gift that will forever change how I approach my health.

那么我们先奠定一些基础。

So let's lay some groundwork.

你在新书中提到了医学1.0和医学2.0的概念。

You talk in your new book about medicine one point zero and medicine two point zero.

能解释下这两个术语的含义吗？

Can you explain what you mean by those two terms?

有两个关键事件标志着从医学1.0到2.0相对缓慢的转型。

Well, two events define the relatively slow transition from medicine one point o to two point o.

首先是弗朗西斯·培根对科学本质及科学方法的系统阐述，这发生在十七世纪。

The first is kind of Francis Bacon's codification of what science is and perhaps what the scientific method is, and that was the seventeenth century.

必须理解的是，在此之前，人们对自然现象的解释都诉诸神明或体液失衡这类理论。

And it's important to understand that prior to that, the natural universe was really explained through things like the gods or bad humors.

虽然像希波克拉底这样的先驱者已意识到自然因素与疾病相关，但始终无法真正建立理论桥梁，自然也谈不上有效治疗。

There were some people like Hippocrates, for example, who believed that nature was somehow involved in physical ailment, but nevertheless, there was no way to bridge the gap of what that actually meant and of course, therefore no way to really offer some sort of treatment.

而推动医学从1.0迈向2.0的最大助力，是细菌理论的诞生。

But the really big boost for what allowed this transition into medicine one point zero going to two point zero was the advent of germ theory.

从技术层面说，这要归功于光学显微镜的发展。

So from a technology perspective, that would have been the development of the light microscope.

我认为正是这类技术及其带来的可能性，结合新的思维方式，让我们从对病因一无所知发展到十九世纪末期的清晰认知。

And I would say that it's the marrying of that type of technology and what it enabled coupled with this new way of thinking that allowed us to go from really having no sense of what was causing illness to having a very good sense of it in the late nineteenth century.

因此医学从1.0到2.0经历了约200年的转型，如今我们已拥有惊人技术，能完美实现两大突破——这大概就是当代医学所处的阶段。

So you had this 200 transition basically to go from medicine one point zero to medicine two point zero, which is where we, I believe we're at the end of today, where we've developed amazing tools to basically do two things very well.

第一，我们在对抗所有传染性疾病方面取得了显著成就，这得益于卫生条件改善、抗生素使用和疫苗接种。

One, remarkable success against all infectious and communicable diseases, and that's been through sanitation, antibiotics, vaccinations.

我们取得的第二个真正成功是对急性病症的治疗。

And then the second real success we've had is the treatment of acute care illness.

在重症监护、骨折治疗和创伤处理等领域，我们的能力确实令人瞩目。

So anything that has to do with critical care, broken bones, trauma, it's really remarkable what we can do.

所以你认为2.0时代的医学在生命末期干预方面做得很好，延长了寿命，但往往以牺牲那些额外月份或年份的生活质量为代价。

And so you would argue that medicine two point o has done really well at intervening near the end of life, extending life, but often at the cost of relatively low quality of life for those extra months or years that it delivers.

说到慢性疾病时——

When it comes to chronic diseases.

当你观察二型糖尿病、心血管疾病、癌症、神经退行性疾病等慢性病时，那套方法似乎效果不佳。

When you look at chronic conditions, type two diabetes, cardiovascular disease, cancer, neurodegenerative disease, that playbook doesn't seem to work very well.

它只能略微延长生命，却会降低生活质量。

All it does is slightly extend life, but with a reduction in quality of life.

鉴于《超越生存》这本书探讨的是长寿问题，而长寿只有一半关乎寿命长度，我们必须同样关注生活质量。

And given that this book outlive is about longevity, and longevity is only half about length of life, we have to be just as concerned with quality of life.

这很有趣，因为在2.0医学早期，当我们攻克传染病时，那简直是巨大的胜利。

It's interesting because early on in Medicine 02/2000, when we went after infectious diseases, that was just a huge win.

如果你看看1900年前后人们的致死病因，与现在完全不同。

If you look at what killed people at the turn of around 1900, it's a completely different set of illnesses than what kills people now.

但若从生活质量和寿命长度的整体视角来看，2.0医学的进展确实放缓了。

But if you look at it holistically with quality of life and quantity of life, the progress of medicine two point o has really slowed.

这个说法公允吗？

Is that a fair statement?

确实如此。

It is.

如果回溯1900年对比美国当时的死亡率，并剔除前八大传染病致死因素，调整后的死亡率其实毫无变化。

If you go back to 1900 and compare the mortality in The United States then to today, and you subtract out the top eight leading causes of death via infectious diseases, there has been no change in the adjusted mortality.

换句话说，除了消除了传染病之外，我们今天并不比一百二十年前的人活得更长。

In other words, we don't live any longer today than we did one hundred and twenty years ago, with the exception of the removal of infectious diseases.

这个统计数字令人震惊。

That's a staggering statistic.

不过这个说法也有点误导性。

Now, it's also a bit misleading.

当然，我相信如果当时的人们能挺过那些传染病活到现在，他们可能也无法像今天的我们这样长期抵抗某些慢性疾病。

It's of course the case, I'm sure, that if people back then had lived long enough through those infectious diseases, they likely would not have survived some of the chronic diseases to quite the extent we do today.

但我怀疑这种差异可能只有一两年左右。

But I suspect that would only be a difference of a year or two.

嗯。

Mhmm.

我们讨论的差异不会达到十年那么长。

We wouldn't be talking about a decade's worth of difference.

所以不要把责任全推给医学，我认为影响寿命增长的有很多因素，其中行为改变可能起了重要作用。

And so not to put all of the blame on medicine, though, I suspect there are many factors at work that have kept lifespan from increasing, and behavioral changes have probably been really important.

比如肥胖就是个很好的例子，这在1900年并不常见，如今却非常普遍。

Obesity, for instance, being a great example, which was not common in 1900 and is, of course, very common today.

没错。

That's right.

我认为这里的关键抵消点是：虽然现代性带来了医学2.0时代的诸多成就，但同时也带来了许多增加我们慢性病易感性的因素。

And I think that's the offsetting point there is that while modernity has brought many wonderful things in terms of the successes of Medicine two point zero, in parallel, it's brought a lot of things that have increased our susceptibility to chronic diseases.

所以我认为，我们在对抗传染病方面的成功，既让我们活得更长从而更容易患上慢性病，但更重要的因素还是现代生活的各种便利——说实在的，没人会想回到1900年生活，至少我不想——但伴随着更差的营养、更少的运动、更多的光照导致的睡眠质量下降，以及可能更多的慢性压力，所有这些因素共同导致了我们健康的恶化。

So I think our success against infectious diseases has both allowed us to be living longer and therefore be more susceptible to chronic diseases, but an even greater factor has been all of the comforts of the modern world that let's be fair, I don't think anybody is lobbying to go back and live in the year 1900, certainly I'm not, but with worse nutrition, with far less movement, with far more light and therefore less quality sleep and probably more chronic stress, All of those things have conspired against the deterioration of our health.

是啊。

Yeah.

好的。

Okay.

你所说的医学3.0，正是你所倡导的，它与医学2.0形成鲜明对比。

So what you call Medicine three point zero, that's what you espouse, it contrasts sharply with Medicine two point zero.

从宏观层面看，你会如何描述医学3.0？

At a very high level, how would you describe Medicine three point zero?

首先它更注重预防，但这个词汇在医学2.0中已沦为口号，失去了大部分实质意义。

So the first is it's much more about prevention, and that word has lost most of its meaning because it is a buzzword within Medicine two point zero.

除了心血管疾病领域我们确实采取预防措施外，其他领域我们几乎没有真正的预防策略。

And outside of cardiovascular disease where I think we do take steps to try to implement prevention, we really don't have much of a prevention strategy.

事实上，传统医学体系会辩称除了戒烟和减重外，癌症根本不存在预防措施，更没人讨论痴呆症或阿尔茨海默病的预防。

In fact, most traditional entities would argue there is no such thing as a cancer prevention besides perhaps smoking cessation and maybe the reduction of obesity, and nobody's really talking about the prevention of say dementia or Alzheimer's disease.

另一个维度是风险评估的理念。

Another dimension is the idea of risk assessment.

观察金融等行业就能明白，风险管理是成功的关键要素。

If you look at certain industries such as financial institutions, it's well understood that risk management is a very important piece of success.

我认为这对个人健康同样重要，包括不作为的风险评估。

And I would argue that's just as important if you're thinking about your own health and that includes the risk of doing nothing.

医学界常讨论干预措施的风险，却很少对比不作为的风险。

So we often talk in medicine about the risk of doing something, but that's not often contrast with the risk of doing nothing.

比如用药物降胆固醇时，人们总强调副作用和风险，但长期不干预的风险呢？

If we talk about using medications to lower cholesterol, people will often talk about, well, you know, that comes with this much of a side effect and this much of a risk, but what's the risk of not doing something over a long enough time horizon?

这就引出第三点：传统风险评估往往局限于五到十年的短期视野。

Which gets to really the third point, which is most traditional ways of thinking about risk look at a very short term time horizon, five to ten years.

用短期研究来应对终身性疾病，很难得出有效结论。

When you study things over relatively short durations that are lifelong diseases, it's very difficult to get meaningful answers.

医学3.0非常重视因果关系理解，我在书中举过这个例子：

Something that's very important to Medicine three point zero is understanding causality and in the book I use this example.

史蒂夫，如果我宣布新政策：允许人们吸烟直到肺癌风险达5%时才禁烟。

Steve, if I said to you, we're gonna institute a new policy, which is we're going to tell people that it's okay to smoke until their risk of lung cancer reaches five percent, but then we're going to tell people to stop smoking.

我觉得所有人都会看着我，说这是个愚蠢的主意。

And I think everyone would look at me and say, that's a dumb idea.

吸烟与肺癌有因果关系的事实，并不意味着每个吸烟者都会得肺癌。

The fact that smoking is causally related to lung cancer doesn't mean everybody who smokes is going to get lung cancer.

每个人都能讲出自己祖母90岁高龄每天抽两包烟却安然无恙的故事，但我们清楚地知道吸烟会极大增加患病几率，因此我们不会等到风险达到特定水平才采取行动，而是会立即劝阻停止或不要开始。

Everybody's got the story of their grandmother who's 90 smoking two packs a day and she's totally fine, but we certainly know that smoking will dramatically increase your odds of it and therefore we don't wait until your risk is a certain level before doing something about it, we say stop right away or don't start.

现在你想把同样的逻辑应用到心血管疾病上。

And now you want to apply that logic to say cardiovascular disease.

如今我们会采用那种五年或十年风险模型，认为在风险超过特定阈值前无需进行预防性治疗。

Today we would use exactly that five or ten year risk model and say, there's no need to treat people preventatively until their risk crosses a certain threshold.

而我要说，既然我们知道吸烟、高血压和载脂蛋白B与动脉粥样硬化存在因果关系，就应该从一开始就消除这些因素。

And I would say, well, we know that smoking, high blood pressure and APO B are causally related to atherosclerosis, Therefore, they should be eliminated out of the gate.

再说一遍，嗯。

And again Mhmm.

这听起来像是细微差别，但实际上存在着巨大的理念差异。

It sounds like a subtle difference, but it's actually an enormous philosophical difference.

这一点在糖尿病治疗领域表现得最为明显。

One One of the places this becomes clearest is around the treatment of diabetes.

能否请你阐述医学2.0与医学3.0模式下对糖尿病诊疗的思考？

Could you walk through medicine two point o versus medicine three point o, how you think about diabetes?

好的。

Yeah.

二型糖尿病实际上是通过糖化血红蛋白这一指标定义的，该血液检测值大致反映患者过去三个月的平均血糖水平。

Type two diabetes is a condition that is really defined by something called the hemoglobin a one which is a measurement that is taken in the blood that estimates the average blood glucose over the preceding three months, more or less.

二型糖尿病的诊断标准是糖化血红蛋白达到6.5%或更高。

So the definition of type two diabetes is a hemoglobin A1c of 6.5% or higher.

如果达到这个水平会怎样？

What happens if you reach that level?

没人会否认这就像一场四级警报的火灾。

Nobody disagrees that it's a bit of a four alarm fire.

你患各种慢性病的风险飙升，癌症风险、心血管疾病风险、阿尔茨海默病风险、肾衰竭风险，所有这些都会显著上升，因此我们想要改善这些状况。

Your risk of every chronic disease skyrockets, your risk of cancer, your risk of cardiovascular disease, your risk of Alzheimer's disease, your risk of kidney failure, all of these things just go up significantly and therefore we want to ameliorate those things.

要知道，很多人患有二型糖尿病，但很少有人直接死于二型糖尿病，理解这点很重要。

Know, it's important to understand, a lot of people have type two diabetes, very few people die from type two diabetes.

相反，二型糖尿病会提高他们死于所有其他疾病的几率。

Instead, two diabetes raises their death rate from all these other diseases.

那么如果你的糖化血红蛋白是6%会怎样？

So what happens if your hemoglobin A1c is 6%?

我们称之为糖尿病前期，可能会建议调整饮食和运动习惯。

Well, we call that prediabetes, and we might institute or suggest some changes around diet and exercise.

甚至可能使用二甲双胍这种药物，但基本不会采取更多措施，也不会过于担忧。

We might even use a drug called metformin, but we wouldn't really institute much else, and we wouldn't really raise much concern.

如果你的糖化血红蛋白是5.6，我们什么都不会说，因为这甚至低于糖尿病前期的阈值。

And if your hemoglobin A1C were 5.6, we wouldn't say anything because that's even below the threshold of prediabetes.

所以你的意思是，医学2.0就像当你跨过糖尿病界限时突然坠入灾难深渊，而实际上根据我们对人体的了解，从完全健康到严重糖尿病应该是个连续渐变的过程。

So what you're saying is the medicine two point o acts like when you cross over the line into diabetes, you've hit some huge cliff that's a disaster when probably everything we know about the human body says it's a continuous line from being totally healthy to being extremely diabetic.

但由于激励机制和经验法则的作用，我们把它当作阶梯函数来对待，而实际上并非如此。

But the way the incentives and the rules of thumb work, we treat it like it's a step function when really it isn't.

而一旦跨过那个阶梯函数门槛，采取的治疗手段就会变得非常极端且昂贵。

And the treatment that you use once you cross that step function is quite extreme and quite expensive.

如果某人平均血糖为120毫克/分升（虽未达到二型糖尿病范围），这个数值仍然是偏高的。

If somebody's average blood glucose is say 120 milligrams per deciliter, which is not in the type two diabetes range, it is still elevated.

针对这种情况的治疗手段不是药物，对吧？

The treatment for that is not medical, right?

应该通过营养调整、睡眠管理、压力调节和运动锻炼来改善。

The treatment for that is nutritional, sleep related, stress related and exercise related.

你要治疗那些患有四大疾病的人，但不会采用药物治疗。

You're going to treat those with the big four, but you're not going to treat it pharmacologically.

医学2.0的挑战之一在于，它的治疗方案几乎全部是药物性的。

And one of the challenges of Medicine two point zero is that its playbook is virtually all pharmacologic.

我想说清楚，我并不反对制药业，只是认为如果药物是你唯一的工具，那就像一个承包商只有钉子。

I want to be really clear, I'm not anti pharma, I just think that if pharma is your only tool, it's like a general contractor who only has nails.

钉子很重要，它们确实很关键，但有时你需要螺丝，有时需要锯子。

Nails matter, they're really important, but sometimes you need a screw, sometimes you need a saw.

拥有多种工具很重要。

It's important to have lots of tools.

我们所有的医学教育都基于这一种工具（虽然重要），却牺牲了我认为80%的其他工具，比如如何运用营养学？

And all of our medical education was predicated on this one, albeit important tool, but at the expense of what I would argue were 80% of the other tools out there, which is how do you use nutrition?

如何运用睡眠？

How do you use sleep?

如何运用运动？

How do you use exercise?

是的。

Yeah.

我觉得你会反感这个问题，但我还是想问。

I think you're gonna rebel at this question, but let me ask it anyway.

粗略地说，你认为一个人如果坚持遵循医学3.0而非2.0，能多获得多少年的健康寿命？

Roughly, how many extra good years do you think a person could expect to gain from faithfully adhering to medicine three point o versus medicine two point o?

这显然取决于一个人何时开始这些改变。

It clearly depends on when one institutes these changes.

可能还需要我们尚未完全掌握的关于个人基因及其后续生活中将接触到的各种影响因素的理解。

It also probably requires some understanding that we don't completely have of a person's genetics and the subsequent exposures that they're going to have in life to various elements that impact this.

但我反对某些人提出的观点，他们说：看，如果你能避免心脏病，你只能多活两三年；如果避免癌症，也只能多活两三年——这种观点假设所有这些疾病都是独立存在的。

But I reject the point of view put forth by some that says, look, if you managed to avoid heart disease, you would only live an extra two or three years and if you managed to avoid cancer, you would only live an extra two or three years because it assumes that all of these diseases exist in a silo.

但现实情况是，这些疾病相互关联，如果真如你所说，史蒂夫，我认为更像是延长了十年寿命。

But the reality of it is these diseases are so linked that if one does what you're really suggesting, Steve, I think it's more like a decade of life extension.

我很欣赏你会这么说，因为这些数字意义重大。

I love that you will say that because those are huge numbers.

如果人们相信这点，就很难不认真对待你的观点——面对可能多活十年、甚至是高质量十年的机会，谁不会停下来反思自己哪些行为在阻碍这个目标呢？

If people believe that, then it becomes incredibly difficult not to take you seriously because who faced with the possibility of having, if not ten extra years, ten extra good years, wouldn't say, I better pause for a second and think about what I'm doing that's not giving me that.

我欣赏你坚信这一点并敢于直言。

I love that you believe that and are willing to say it.

我认为这非常重要。

I think that's really important.

我告诉我的病人：即使我所有的锻炼会让我少活一年，我仍会坚持，因为生命末期的生活质量更重要。

I say to my patients that if all of the exercise I was doing shortened my life by a year, I would still do it because of that quality of life at the end.

我对此感受如此强烈，是因为过去十年我目睹了太多人在生命最后阶段被剥夺了你我视为理所当然的能力。

And I suspect that I feel so strongly about it because I've watched far too many people in the last decade of their life be so robbed of the things that you and I take for granted.

就像我回想这个周末，史蒂夫，我妻子陪女儿参加排球赛，家里只有我和五岁、八岁的两个儿子。

Like I think about what I did this weekend, Steve, my wife was at a volleyball tournament with my daughter, so it was just me and my two boys who are five and eight.

我和他们的所有互动都需要体力——蹲在地上玩耍、起身奔跑、保持充沛精力做这些事。

And everything I did with them was physical and being able to get down on the ground and play and get up and run around and have the energy to do those things.

是的，50岁做这些很容易，但我希望85岁时仍能做到，这非常困难。

Yeah, it's easy to do that when I'm 50, I but wanna be able to do that when I'm 85 and that's very hard.

但我相信这将决定我的人生质量。

But I believe that's what's going to determine the quality of my life.

不是拥有多少财富，甚至不是能享受多奢华的假期——如果我体力不支无法与同行者共度时光，这些都毫无意义。

It won't be how much money I have, it won't even be how fancy the vacations are that I might be able to take if I can't physically be robust enough to enjoy them with whoever I'm with.

稍事休息后，我们将继续与彼得·阿蒂亚的对话。

We'll be right back with more of my conversation with Peter Attia after this short break.

听你谈论3.0版医学时，虽然你不是专业经济学家，但你的观点和书中的内容与我的经济学思维产生了强烈共鸣。

Now as I listen to you talk about medicine three point o, you're not an economist by training, but almost everything that you're saying and what you write in the book, it really resonates with my economic brain's way of thinking.

如果让我用经济学术语来解读你所说的'医学3.0'，你的意思是：在不确定性中追求最长寿、最健康的生活是个动态优化问题。

If I try to translate what you're saying about Medicine three point zero into economic jargon, you're saying that living the longest, healthiest life is a dynamic optimization problem under uncertainty.

实证研究表明——就像你细致分析的数据那样——成年期持续的健康投资对晚年结果具有巨大边际影响，其效果远超大众认知和传统医学2.0的预期。

And empirically, if one studies the data, as you have so carefully, it turns out that investment in health throughout the entirety of adulthood have huge marginal impacts on later life outcomes, far bigger impacts than people generally or medicine two point o appreciates.

你觉得这个说法站得住脚吗？

Does that ring true to you?

这符合你对世界的认知方式吗？

Is that kind of the way you think about the world?

对。

Yeah.

我完全同意这个观点。

I would agree with that completely.

要实现你提到的这些收益，需要当下就付出努力。

The things that are required to capture or realize those gains you're referring to require work today.

而这种当下努力是有代价的，因为所有事情都存在机会成本。

And that work today comes at a cost because everything has an opportunity cost.

通常这个成本就是时间。

And usually that's time.

睡七个半小时或八小时而不是六个半小时，就需要更多时间。

Getting seven and a half or eight hours of sleep instead of six and a half hours of sleep takes more time.

锻炼也需要时间。

Exercising takes time.

你提到的风险概念特别引起共鸣。我一直觉得奇怪的是，希波克拉底誓言中我唯一记得的'不伤害'原则——在充满不确定性的世界里，这对经济学家来说简直是糟糕透顶的信条。

I mean, you talked about risk, and that really resonated because one thing that's I've always found strange is the only part of the Hippocratic Oath that I actually know, which is where they say, do no harm, which to an economist seems like an incredibly terrible greedo in a world of uncertainty.

我相信你会同意这点。

I'm sure you agree with that.

对吧？

Right?

是的。

Yeah.

史蒂夫，正如你肯定记得的，在书中我对希波克拉底略有微词。

And as I'm sure you recall, Steve, in the book, I go off on Hippocrates a little bit.

首先，那句引述实际上是不准确的。

First of all, that quote is actually incorrect.

真实的引文略有不同，后来被转述为'首先，不造成伤害'。

The actual quote is a little bit different and it's been paraphrased into first do no harm.

但如果你能找出一个从未造成过伤害的医生，那我就能找出一个从未做过任何事的医生。

But if you show me one physician who has never done harm, I'll show you a physician who has never done anything.

我们当然不会故意造成伤害。

We certainly don't set out to do harm.

在书中我讲了一个非常极端的案例——每个医生都能举出类似的例子——那晚我担任创伤科主任时，有个孩子被刺伤，伤口就在剑突下方。

And in the book I tell a very extreme story, which every doctor will have their example of, but I tell a story of a kid who came in, this was when I was the trauma chief one night and he had been stabbed just below his xiphoid process.

就在胸骨正下方，伤口非常小，大约只有半英寸。

So right below the sternum, he had been stabbed and it was a teeny tiny stab wound, it was probably about a half an inch.

史蒂夫，你根本无法判断刀刃的刺入方向或深度，但在那个位置，后果往往非常严重。

And you have no idea, Steve, which direction the blade went in or even how deep it was, but in that location, there were really bad outcomes.

他被送进急诊室时神志清醒状态良好，但突然情况就急转直下。

And so he's in the emergency room, and he's awake and he's fine, and all of a sudden he's not fine.

这时候你必须考虑最坏的可能性是什么？

So the thing you have to think about here is what's the worst case scenario?

最坏的情况是那把刀可能刺穿了心脏或心脏周围组织，导致血液流入心包——就是包裹心脏的纤维囊。

And the worst case scenario is that knife has somehow penetrated either his heart or something around his heart that is allowing blood to bleed into his pericardium, which is the fibrous sac around the heart.

一旦发生这种情况，心脏无法扩张，几乎会立即导致死亡。

And if that happens, the heart can't expand and that's almost an immediate death.

从发生到死亡只有一分钟左右，根本来不及送进手术室进行正规的开胸探查。

You've got about a minute until a person is dead, which is not enough time to get them up to the Operating Room and do the right thing, open them up and explore.

所以你必须进行一项极其戏剧性的操作——急诊开胸手术，在不麻醉或做任何准备的情况下，切开他的胸腔，基本上就是把心脏掏出来，切开心包膜减压，然后手动按压心脏直到送进手术室。

So you have to do something insanely dramatic called an ER thoracotomy where you, without anesthetizing him or doing anything, cut open his chest, pull his heart out basically, cut open the pericardial sac and relieve it, and then pump his heart until you get him to the OR.

但如果你判断错了，别人会觉得你疯了，对吧？

If you're wrong though, people think you're crazy, right?

你可得好好解释清楚。

You're gonna have a lot of explaining to you.

而如果你判断正确，你就救了他的命。

And if you're right, you've saved his life.

先说清楚，其实还有其他线索会指引你做出这个判断。

Now let's be clear, there are other clues you would have to point you in that direction.

你确实有时间给他做胸部超声，虽然超声分辨率不高，但能提示心脏周围可能有积液。

You do have time to do an ultrasound of his chest, and even though ultrasounds are not very high resolution, they can suggest that there might be fluid around the heart.

我当然做了超声，结果显示心脏周围有积液，果然必须进行开胸手术。打开胸腔后，在手术室里我们才清楚看到，原来那把匕首刺中了他的肺动脉，导致肺动脉向心包内出血。

And of course I did that, and there was fluid around the heart, and sure enough, had to do that thoracotomy, open him up, and once we took him to the Operating Room, we could actually see clearly what had happened which was that little knife had hit his pulmonary artery and that pulmonary artery was bleeding into the pericardium.

顺便说，这在手术室里其实很容易处理，缝了两针就好了。那人四天后就完全康复出院了。但当时你必须敢于伤害病人才能救他。

By the way, that's a very easy thing to fix in the Operating Room, it was about two stitches and that guy went home four days later totally fine, but you had to be willing to harm that patient to save his life.

幸运的是，医学上大多数案例都没这么极端，但要想有所作为，总要承担一定风险。

Fortunately, most examples in medicine are nowhere near that extreme, but there's always some element of risk if you want to make a difference.

所以我觉得希波克拉底誓言如果让经济学家来写，大概会变成'预期不造成伤害'之类的话。

So I think the Hippocratic Oath, if he had been an economist, would be something more like do no harm in expectation.

这倒是个不错的准则。

That wouldn't be a bad rule.

更好的法则是让边际收益等于边际成本，因为这本质上就是所有优化问题的答案。

A better rule would be set marginal benefit equal to marginal cost because that turns out essentially be the answer to any optimization problem.

而医学领域可能更加保守。

And medicine's probably even more conservative.

对吧？

Right?

是的。

Yeah.

医学界甚至更为保守。

Medicine's even more conservative.

即使在医学领域，也可以说设定的边际收益或边际效益要超过边际成本。

Even in medicine, could say set marginal gain or marginal benefit to be in excess of marginal cost.

但你不得不承认边际成本的存在。

But you have to acknowledge marginal cost.

你在书中提到的一种研究，我原本认为不会很有价值，但你却从中得出了真知灼见，那就是对百岁老人的研究。

One kind of study that you report on in the book that I wouldn't have thought would be very useful, but you draw real insights from, are studies of people who live to be 100.

那么通过回顾那些长寿人群，我们从这些研究中能学到什么？

So looking ex post the people who live a really long time, what is it that we learn from those studies?

如果我们提出这个问题：基因对你的寿命有多大影响？

So if we ask the question, how much do your genes play a role in your lifespan?

答案是这取决于你活多久。

The answer is it depends how long you live.

对于活到75、80岁的人来说，基因的影响微乎其微。

So for people who live up to 75, 80 years old, genes play very little effect.

直到你人生的第八个十年，你的寿命几乎与遗传基因脱钩。

Your lifespan is almost uncoupled from your genetics into your eighth decade.

但所有这些在第九、第十、第十一个十年及以后都会改变。

But all of that changes in the ninth, tenth, eleventh decade and beyond.

到那时，这几乎完全变成基因的游戏。

At that point, it becomes almost purely a genetic game.

所以神经科学领域有个玩笑：要想活到100岁，你能做的最重要的事就是选对父母。

So the joke in the neuroscience space is the single most important thing you can do to live to 100 is pick the right parents.

那么问题就变成了：究竟是哪些基因真正决定了极端长寿？

And so the question then becomes what genes are indeed responsible for extreme longevity?

令人失望的发现是，确实不存在什么特别强大的长寿基因。

The disappointing insight is there are no really great longevity genes.

虽然有几个基因表现突出，但史蒂夫，这并不意味着存在某个候选基因，等CRISPR技术完全成熟后就能直接植入所有人。

There are a handful that uniquely stand out, but it's not like there's gonna be a candidate gene, Steve, that once CRISPR is fully working, we're just gonna zap into everybody.

但我从研究这个群体中获得的最重要启示是：他们与2.0时代的医学理念完全背道而驰。

But the most important insight I took from studying that population is that they are completely at odds with medicine two point zero.

这就要回归到策略问题了。

And this gets back to strategy.

医学2.0时代的策略是：我们能帮你带病生存多久？

Medicine 2.0's strategy is how long can we help you live with disease?

所以一旦你患上糖尿病、癌症或心脏病，我们还能让你的生命延续多长时间？

So once you have diabetes, once you have cancer, once you have heart disease, how much longer can we stretch out your life?

百岁老人不是这样生活的。

Centenarians don't live that way.

观察他们的基因就会发现，基本上都是慢性病预防基因。

All of their genes, when you look at them, are basically genes that are chronic disease prevention genes.

他们只是比我们普通人晚二三十年患上同样的疾病。

They just get all the same diseases the rest of us do twenty years to thirty years later.

顺便说一句，一旦患病，他们的易感性其实和我们普通人差不多。

And once they get them, by the way, they're just about as susceptible as the rest of us to them.

仔细研究就会发现，他们的基因本质上都是慢性病预防基因。

All of their genes, when you look at them, are basically genes that are chronic disease prevention genes.

所以他们的超能力就是延迟慢性病的发作，仅此而已。

So their superpower is delaying the onset of chronic disease, full stop.

因此，这本质上就是推动整个医学3.0时代的核心理念。

And therefore, that's basically the insight that drives all of Medicine three point zero.

你必须延长无病生存期，而不是延长带病生存的时间。

You have to live longer without disease, not stretch out the time you can live with disease.

所以我觉得我的基因相当不错。

So I have pretty good genes, I think.

我的父母都还健在，都快90岁了。

Both my parents are still alive as they approach the age of 90.

这些好基因帮助我避免了糖尿病。

The good genes are helping me not get diabetes.

但确实如此。

But That's right.

如果我搞砸了得了糖尿病，那我就真的完蛋了。

If I blow it and I get diabetes, then I've really blown it.

简而言之，这就是你想表达的意思。

In a nutshell, that's kind of what you're saying.

对吧？

Right?

我不希望听到这段话的2型糖尿病患者觉得希望全无，因为关键在于我认为2型糖尿病完全可以逆转，所以永远为时不晚。

I don't want someone listening to this who has type two diabetes to think that all hope is lost, because the beauty of it is I think type two diabetes is completely reversible, so it's not too late.

但毫无疑问，一旦你经历过第一次心脏病发作，第二次发作的风险就会大幅上升。

But certainly once you've had your first heart attack, your risk of your second one goes way up.

虽然现在有很多方法可以降低这种风险，但你永远无法将风险恢复到心脏病发作前的水平。

Now, there's a lot you can do to reduce that risk, but you're never going to take it back to the risk profile that you had before you had a heart attack.

你父母年近九旬，正在步入人生罕见的第十个十年。

So your parents approaching their 90s are getting into that rarified air as they come up to abutting their tenth decade of life.

这当然也暗示你具有同样的长寿潜力。

And that would certainly suggest that you have that potential as well.

但如果你做出大量试图颠覆这种优势的糟糕选择，基因能为你做的也就只有这么多。

But if you make a whole bunch of bad choices that really try to override that, the genes will only do so much for you.

所以你认为人们可控的五大行为领域，是活得长久又健康的关键支柱。

So you think there are five areas of behavior that are under people's control, which are the pillars of living long and living well.

那么我们从锻炼开始说起。

So let's start with exercise.

你说有氧运动和力量训练都很重要。

So you say that both aerobic exercise and strength training matter.

虽然这不会让任何人感到惊讶，但我不得不说，当你展示运动有多么重要的证据时，我简直惊得从椅子上摔下来了。

And while that isn't gonna surprise anyone, I don't think, I have to say I practically fell out of my chair when you presented the evidence of just how important exercise is.

我想你的反应也是我的反应，当然知道运动很重要，但你还是无法相信其影响的规模和一致性。

I think your reaction was my reaction too, which was, of course exercise matters, but you couldn't believe the size of the impact and the consistency of it.

这种影响的幅度绝非微不足道。

The magnitude of the effect is not subtle.

VO2 max测试做起来容易...其实不容易，这是个痛苦的测试，但操作很简单。

So the VO2 max is a test that is easy to do, not easy to do, it's a miserable test to do, but it's a simple test to do.

通常是在跑步机或自行车上进行，让人运动到力竭。

It's usually done on a treadmill or a bike, and a person is exercised to exhaustion.

所以它测试的是你最大的摄氧能力。

So it is testing your maximum uptake of oxygen.

当然唯一的办法就是让你运动到无法继续运动为止。

And the only way to do that of course is to exercise you to the point where you can't exercise anymore.

这个数字越大，你的有氧引擎就越强大。

And the bigger that number, the bigger your aerobic engine.

不出所料，世界上最好的耐力运动员在这方面数值最高，即自行车手、跑步者和越野滑雪运动员。

Not surprisingly, the best endurance athletes in the world have the highest numbers there, namely cyclists, runners and cross country skiers.

在最极端的情况下，如果我拿一个年龄和性别处于后25%的人，与年龄和性别处于前2.5%的人比较，风险比大约是五倍。

So at the most extreme level, if I take a person in the bottom 25% for their age and sex and compare them to someone in the top 2.5% for their age and sex, that's a hazard ratio of about five.

这意味着全因死亡率有400%的差异。

That's a four hundred percent difference in all cause mortality.

这意味着在任何时候，VO2 max较低的人在接下来一年内的死亡可能性比前2.5%的人高出400%。

What that means is at any moment in time, the person with the lower VO two max is four hundred percent more likely to die in the upcoming year than the person in the top two point five percent.

这也太疯狂了。

That's crazy.

好吧。

Okay.

显然，前2.5%的人非常优秀，但如果你将前25%与后25%进行比较呢？

So obviously, the top two point five percent, they're awesome, But what if you compare the top 25% to the bottom 25%?

差距并没有那么大。

That's not that big a difference.

那么将后25%的人与第50到75百分位的人进行比较。

So compare the people in the bottom 25% to the people in the fiftieth to seventy fifth percentile.

我们是否认同这是一个合理的比较？

Would we agree that's a reasonable comparison?

对吧？

Right?

是的。

Yeah.

这是从表现糟糕到略高于平均水平的变化。

That's going from being bad to a little bit above average.

没错。

Yeah.

其风险比为2.75。

That has a hazard ratio of 2.75.

这意味着全因死亡率有175%的差异。

That's a 175% difference in all cause mortality.

我想指出，这比吸烟的风险比还要高。

I wanna point out that's a greater hazard ratio than smoking has.

换句话说，这比非吸烟者与吸烟者相比，带来更高的死亡概率。

In other words, that creates a greater probability of death than comparing a nonsmoker to a smoker.

好的。

Okay.

所以令人惊讶的是，这些VO2 max数值。

So it's amazing it's the v o two max numbers are.

更让我震惊的是关于肌肉质量和力量的结果，我原本以为这与长寿或健康生活毫无关系，但数据完全相反。

Even more shocking to me are the results around muscle mass and strength, which I would have suspected had nothing to do with longevity or a long healthy life, but the data are totally the opposite.

告诉我为什么这让你感到惊讶，史蒂夫。

Tell me why that's surprising to you, Steve.

为什么你会认为肌肉质量或力量不重要？

Why wouldn't you have expected muscle mass or strength to matter?

当我想到健康的人时，我猜我会想到一个轻盈年轻的人，而不会将其与力量联系在一起。

When I think of somebody healthy, I guess I think of someone who's light and youthful, and I don't associate that with strength.

我将其与瘦削联系在一起。

I associate that with leanness.

这只是我之前的想法。

That was just my own prior.

哦，这很有趣。

Oh, that's interesting.

数据并不表明一个人需要成为健美运动员，但上肢瘦体重指数前25%的人与后25%甚至第二四分位数的人相比，死亡率差异约为从75岁开始的十年内20%对50%。

The data don't suggest one needs to be a bodybuilder, but the difference between somebody in the top 25% of appendicular lean mass index versus somebody in the bottom 25% or even in the second quartile is a difference of about a twenty percent mortality over a decade starting in your mid seventies versus a fifty percent mortality over a decade starting in your seventies.

明白吗？

Okay?

这可能相当于15磅肌肉质量的差异。

That might translate to a difference of 15 pounds of muscle mass.

所以这并不是一个巨大的量。

So that's not an enormous amount.

所以你是说，对于老年人来说，15磅肌肉的差异意味着未来十年内死亡概率是50%对20%。

So you're saying 15 pounds of muscle are the difference between a fifty percent chance of dying in the next ten years for an older person versus twenty percent.

没错。

That's correct.

因此，15磅肌肉在十年间导致的死亡率增长超过一倍。

So more than a doubling of the death rate over a decade from 15 pounds of muscle.

是的。

That's right.

肌肉具有两项非常重要且截然不同的功能。

Muscle has two very important and quite distinct functions.

第一是代谢功能，随着年龄增长，我们自然会在代谢上变得更不健康，而肌肉是一个非常重要的器官，对吧？

The first is metabolic, and as we age, we naturally become more metabolically unhealthy, and muscle is a very important organ, right?

它是我们处理葡萄糖的场所，因此这是我们最重要的器官，用于储存葡萄糖以防止胰岛素抵抗和糖尿病，而这些疾病又会引发其他各种疾病。

It's where we dispose of glucose, so this is our most important organ to put glucose to prevent us from getting insulin resistant and diabetic, which then of course feeds into all those other diseases.

除此之外，它还具有所有这些结构上的益处。

And then on top of that, it has all of these structural benefits.

另一件让我感到震惊的事情是，65岁的人（顺便说这并不算老）如果遭遇严重跌倒导致髋部或股骨骨折，根据研究不同，他们在接下来12个月内的死亡率大约在10%到30%之间。

The other thing that I think I was really shocked to learn was if you take sixty five year olds, that's not that old by the way, if you take 65 year olds and subject them to a fall that is significant enough that it results in the break of their hip or femur, their mortality over the next twelve months is somewhere between ten and thirty percent, depending on the study.

那么我们如何防止人们跌倒呢？

So how do we prevent people from falling?

部分原因在于拥有足够的肌肉量和力量，以便在失去平衡时防止自己跌倒。

A part of it is just having enough muscle mass and enough strength to prevent yourself from falling when you lose your balance.

接下来我们来谈谈你的第二支柱，这让我感到惊讶和警觉，那就是睡眠。

Let's talk next about your second pillar, which was surprising and alarming to me, which was sleep.

我一直把睡眠视为必要的恶习或奢侈品。

And I've always treated sleep as either a necessary evil or a luxury.

这是应该最小化的浪费时间。

It's wasted time to be minimized.

我人生大部分时间也持这种观点。

And I shared that view for most of my life.

我曾将其视为那句老话：死后自会长眠。

I viewed it as the old adage, I'll sleep when I'm dead.

当然，后来我认识到，这句老话实际上会加速你走向死亡的时间。

Of course, what I came to learn was that adage will speed up the shortened length of time it takes for you to be dead.

看，我认为最简单的解释方式之一是从进化角度出发——我们已知的所有物种都需要睡眠，这本身就是个重要信号。

Look, I think one of the simplest ways to explain this is to go through it through an evolutionary basis, which is that it's not just that there's no species we're aware of that doesn't sleep, that's generally an important sign.

当某种特质被进化保留在所有物种中时，就值得我们关注了。

When evolution conserves something across every species, it's worth paying attention to.

但另一个问题是：既然睡眠存在明显风险，为什么进化仍将其保留在人类身上？

But the other thing is that why did it conserve it in us given the clear risk that sleep poses?

如果我们的物种平均要花费三分之一生命处于无意识状态，无法繁殖、觅食或抵御捕食者，为何我们还是保留了睡眠？

If on average our species is to spend a third of its life unconscious, you're not able to reproduce, you're not able to forage for food, you're not able to defend yourself against predators, and yet we still did it?

要知道，正是十年前这条研究线索真正引起了我的注意。

You know, to me, it was that line of inquiry over a decade ago that really got me to pay attention to this.

正如你指出的，我认为数据在这方面相当一致。

And as you point out, I think the data are quite consistent here.

伊芙和科特做了个精妙的实验：他们选取一组受试者，进行约一周的睡眠剥夺。

So Eve and Kotter did a pretty elegant experiment where they took a group of subjects and sleep deprived them for just something like on the order of, I don't know, about a week.

他们用正常受试者进行「正常血糖胰岛素钳夹」实验（这是测量胰岛素抵抗的金标准），这些受试者原本都正常，之后强迫他们每晚只睡四个半小时。

So they took a normal group of subjects, they did something called the euglycemic insulin clamp, which is the gold standard for measuring insulin resistance, and these people were normal, and then they forced them to only sleep four and a half hours a night.

仅一周内，他们的葡萄糖处理能力就下降了50%。

And within one week, their glucose disposal fell by 50%.

这实际上意味着他们几乎已处于糖尿病前期。

That's effectively meaning they're almost diabetic at that point.

我认为数据明确显示：睡眠不足（无论是时长还是质量）与健康恶化存在因果关系。

And I think the data are undeniable here that poor sleep, either in quantity or quality, is causally related to poor health.

在某些领域，这种关联比其他领域更为明显。

I think in some areas it's more clear than others.

就阿尔茨海默病、其他形式的痴呆症以及心血管疾病而言，长期睡眠紊乱是个严重问题。

When it comes to Alzheimer's disease, other forms of dementia and cardiovascular disease, chronic disruption of sleep is problematic.

好的。

Okay.

那么我们来谈谈第三个支柱——营养。

So let's talk about a third pillar, and that's nutrition.

你对营养学的了解不亚于任何人。

And you know about as much about nutrition as anyone around.

你曾创立并运营营养科学研究所（NUSI）多年。

You founded and ran the Nutrition Science Institute, NUSI, for a number of years.

但我的印象是，虽然你认为饮食在长寿中起作用，但可能相对于其实际重要性被过分强调了。

But it's my impression that while you believe diet plays a role in longevity, maybe you think it's gotten too much emphasis relative to its actual importance.

这个说法准确吗？

Is that a fair statement?

我认为是的。

I think it is.

我觉得人们往往对营养过度强调或不够重视，而真相可能介于两者之间。

I think people tend to over or underemphasize nutrition, and the truth is it's probably somewhere in the middle.

营养学面临的挑战之一是我们缺乏确定性。

And one of the challenges of nutrition is the lack of certainty we have.

与运动和睡眠不同，在营养学领域，我们很难断言有多少是绝对真理。

Unlike exercise and sleep, in nutrition there aren't that many things that we can say that are capital T true.

我们知道营养过剩和营养不良都会对健康造成灾难性影响。

We know that too much nutrition and too little nutrition are catastrophic for our health.