A diligent worker who invests for retirement will effectively lose the value of the dollars they’ve saved if they don’t also make an investment in their health.
Imagine that you spend your working years planning for a retirement that includes hiking various mountains around the world. Vacations aren’t cheap, so you save and invest to afford nights and meals at a chalet, flights and a new pair of hiking boots.
Hiking up a mountain at altitude requires a minimum level of physical ability. A hiker needs at least a VO2 max (the ability to process oxygen) of about 30 to comfortably sustain a hike, and even higher for a mountain (at 2,000 meters, our VO2 max falls by about 10%).
Every decade we age, our VO2 max falls by about 10% if we don’t invest in our health. This means that the average sedentary male who saves for a hiking vacation may be able to afford the tickets and chalet, but they won’t be physically capable of making it up a mountain.
One of the most important insights of Peter Attia’s new book, Outlive, is that health should be viewed as an investment that increases our ability to get the most out of life in old age. Just as an investment in money requires a sacrifice in the present (we must spend less today) to increase spending in the future, eating well and exercising involve making a sacrifice today to remain more capable of physical activity after we retire. Improving VO2 max means adding short bursts of high-intensity effort into a regular aerobic exercise routine.
It’s hard, but it is worth the investment.
Attia’s book is the equivalent of a research-based guide to investing in health. An individual may be committed to saving more to live better in the future, but knowledge of portfolio theory and various tax-sheltering accounts will allow investors to achieve better results (on average) from sacrifices made today. Knowing more about how to eat and exercise effectively allows us to gain greater expected benefits from sacrifices made to improve future health.
I am careful to use terms like better future investing results “on average” and greater “expected” future benefits from health. Outlive is the first book on health I’ve read that recognizes the stochastic nature of health investment. An investor following a research-based approach will select a diversified portfolio with an allocation that reflects their risk tolerance, possibly emphasizing factor exposures and minimizing fees, while locating assets in tax-efficient accounts. This doesn’t mean that this approach won’t result in a 50% loss next year or running out of retirement prematurely. It simply maximizes the likelihood of a better outcome based on available science.
Investing in health means exercising, eating well, and using what Attia referred to as “molecules” (drugs or supplements) when the evidence suggests that they improve outcomes. It doesn’t guarantee good health. A runner could keel over at age 60 from an undiagnosed heart defect and may have even lived longer if she were sedentary. You might have an uncle that lived into his 90s while eating fast food and smoking, but he’s an outlier.
The investment decisions we make in life, whether it be health, money, or relationships, involve outcomes subject to chance. Getting a colonoscopy, eating a grilled chicken sandwich instead of a burger, getting a vaccine, or going to the gym after work involve a sacrifice that we make to increase our expected quality of life in the future. Some health investments offer a higher expected return from our sacrifice than others.
Consider, for example, the overwhelming evidence supporting the benefit of an investment made to maintain muscle mass as we age. Attia notes that “strength training is a form of retirement saving. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach old age with enough of a reserve of muscle mass and bone density to continue to pursue the activities that we enjoy.” It is much better to save and invest gradually over time than to “scrape together an IRA in your late 50s and hope and pray that the stock market gods help you out.”
An average 80-year-old will have 40% less lean muscle mass than he did early in life. It’s very difficult to add lean muscle mass after you reach retirement age. Don’t imagine that you’ll be able to easily reverse years of poor decisions before retirement to resurrect your health right before the inevitable physical (and cognitive) decline we all experience in old age.
Why we need to think more about investing in health
Evolution doesn’t care about our physical and mental condition in old age. We evolved to survive long enough to reproduce. There is evolutionary evidence that the wisdom of elders was important in maintaining social success, so perhaps we evolved to maintain enough health to tell stories as our hair turns white. But nature is working against us as we try to maintain our physical and mental capabilities over time.
The good news is that we can choose behaviors that allow us to slow the inevitable physical and mental declines of old age to live longer and gain greater enjoyment from the extra time we earned by making better choices. Attia noted that the source of the single greatest improvement in longevity over recent decades has been behavioral – far fewer Americans smoke today than did 40 years ago.
Attia took aim at the medical profession for following what he called “Medicine 2.0,” which focuses primarily on finding faster and more effective ways to cure a disease. A better approach is to focus on the minor risk factors that ultimately led to the diagnosis in the first place, what Attia referred to as Medicine 3.0. Instead of spending all our time trying to fix a problem after it is often too late to provide a cure, focus instead on making modest changes that significantly reduce the probability that we’ll get sick (prevention).
Through the benefit of research and testing to assess the unique characteristics of an individual (Attia went into detail on the importance of blood testing to assess vulnerabilities), it is possible to prescribe a course of behaviors that is most likely to reduce the likelihood of future disease. If the Titanic had a radar and sonar, it could have simply made a course correction to avoid the iceberg instead of trying (and failing) to remain afloat after a collision. Likewise, if we can test, understand our bodies and make evidence-based changes in our behavior we may never have to rely on a surgeon’s knife or chemotherapy to repair us after the damage is done.
The appeal of Medicine 2.0 is that it is passive. If you experience symptoms of a disease, you see a doctor and try to fix the problem. Medicine 3.0 is more active. You have to be willing to proactively change habits. You are the captain of your own ship.
The goal of Medicine 3.0 is to take control of your own health, much as investors take control of their own portfolios. You need to do research and make behavioral changes. Instead of relying on a doctor to treat diseases as they arise, and potentially prolong life by a few months or years post-diagnosis, changing behaviors can result in a much longer period of unimpaired physical capabilities (one’s “healthspan”) and reduce the probability of succumbing to disease. Rather than the gradual decline in capabilities that comes with aging, our goal is a long, straight line of healthy living in which we gain bonus decades when we’re still thriving.
COVID highlighted the risks of health deterioration – it made us more vulnerable to the range of diseases that prey upon the defenseless. Health deterioration will happen at a predictable rate, resulting in lower mobility and increasing vulnerability to disease if we do nothing to prevent it. We will lose muscle mass, our ability to process oxygen will decline, we will become less flexible, and our ability to process information quickly and effectively will decline.
By making investments in health, we are effectively fighting against age-related deterioration. We can either surrender to the deterioration, or we can come up with a plan. The good news is that the actions we take to reduce the deterioration also increase lifespan.
Attia also noted that spending time focusing on improving physical health is useless if we’re not also taking steps to improve our emotional health. The final chapter of Outlive is a remarkably candid admission of Attia’s own struggles with his emotional health, and the steps he took to invest in mental health to maintain the quality of his relationships and peace of mind. According to Attia, “health without love and friendship is a purgatory.” In my own research on life satisfaction in retirement, I found that investment in positive relationships in retirement is even more important (provides a higher expected return if the goal is living well) than financial investments.
Investing effectively in health
Attia’s take on the science of health investments is that the single most effective way to reduce physical and cognitive deterioration is exercise – both strength training and aerobic exercise. “Exercise has been compared to a drug,” says Attia, “but that comparison may be unfair to exercise.” Compared to the reliance on pharmaceuticals in Medicine 2.0, exercise is simply more effective at improving both healthspan and lifespan. Even if it offered no benefit in terms of longevity, the improvement in quality of life through better mobility and cognition is worth the investment.
One of the most compelling examples about the benefits of nutrition also demonstrates how good studies can yield opposite results. A study found that monkeys fed a calorie-restricted diet lived significantly longer than monkeys who could eat whatever they wanted. Many believed that this study provided important evidence about the benefits of eating less. A later study found that calorie restriction among monkeys had no significant impact on longevity. The difference between the two studies turned out to be what researchers fed the monkeys. In the first study, the monkeys were fed a monkey chow with a much higher sugar content. In the latter study, the monkeys were fed a higher-quality chow with much less sugar and more protein.
In a former life, I studied the remarkable increase in obesity since the 1970s, particularly among lower-income Americans. Much of this can be attributed to changes in food technology that made extracting fructose and fat from corn much more efficient, resulting in a food system flooded with lower-cost simple carbohydrates and fat. Attia provided insight into why this macro food-system change resulted in such a dramatic reduction in health among Americans.
Overconsumption of sugars, and in particular fructose, can explain the epidemic in metabolic dysfunction – or the resistance to insulin that leads to a range of maladies that worsen health. Obesity is more likely in those who are metabolically unhealthy. As we overconsume more calories, the body (specifically the pancreas) needs to decide what to do with the excess sugar we ingest. Each extra 10 pounds of fat we gain represents 90,000 excess calories that our bodies need to store. The more weight we gain, the more potentially harmful places the body finds to store our excess fat.
Attia related a hypothesis about how humans evolved to store excess fructose. Climate changes in Europe during the Ice Age meant that humans migrating from areas where fruit grew year-round needed to find a way to store excess calories to survive through the winter. Our bodies evolved to efficiently process the excess fructose and store it as fat. As we moved into our current environment of abundant calories, our bodies were not able to adapt, resulting in excess fat storage which led to rising rates of obesity and metabolic dysfunction.
Since we can’t rely on our genetics to adapt to the new environment of abundance, we need to be “cunning” in how we adapt our own behaviors to avoid metabolic dysfunction. How? By exercising more, eating better, and getting more sleep. This involves assessing health risks and making minor adjustments to our habits. Just as wearing a seatbelt or being cautious in intersections can have a significant reduction in the likelihood of dying in a car accident, we can develop habits of daily exercise, eating less and eating better, and creating an environment conducive to sleep that is going to significantly reduce health risks over time.
Nearly all the ideas in Outlive have appeared in other books on the topic of healthy eating and longevity, most recently in David Sinclair’s best-selling book, Lifespan: Why We Age and Why We Don’t Have To. Attia has backtracked on some of his ideas in the past and seems driven by a desire to be seen as more clever than the medical establishment. But the book is worth a read and provides a solid evaluation of the science on the importance of investing in health – particularly as a reminder of the consequences of failing to be as deliberate about developing good health habits as we are about saving and investing in money.
The worst investment we can make is to sacrifice spending today to have more money in retirement if we don’t have the physical and mental resources to get enjoyment from spending it.
Michael Finke, PhD, CFP®, is a professor of wealth management, WMCP® program director, and the Frank M. Engle Distinguished Chair in Economic Security Research at The American College of Financial Services.
