Top Health Interventions
My best bets for adding a useful decade to life.
Some of my friends know I have a hobby of studying aging and health. Recently I was asked to compile all of my research into a list of top action items for health optimization. I thought it would be helpful to rank them and so for each item, I will indicate the required effort, cost, and degree of confidence in its effectiveness, each on a five-point scale.
Effectiveness: A 5/5 indicates strong confidence in this having a significant effect on health. I generally won’t recommend anything less than 3/5 under the precautionary principle - if you’re not sure something is helpful, generally best to avoid an unnatural intervention.
Cost: A 5/5 here indicates something that is free or nearly free. A 4/5 costs less than $5 per month. A 3/5 costs less than $10 per month. A 2/5 costs less than $50 per month. A 1/5 would have costs exceeding $100 per month.
Effort: This scale is done in reverse, with easier things rated higher and more difficult interventions rated lower. A 5/5 here indicates something that is done only occasionally. A 4/5 is something low effort that must be done at least weekly (like taking a pill). A 3/5 requires some relatively minor lifestyle change or perhaps some sort of moderate effort that must be done a few times a week - this is perhaps equivalent to moderate exercise a few times a week, or avoiding certain kinds of fast food. A 2/5 indicates something that is very hard, has to be done a few times a week, but is not a complete and total lifestyle change. A 1/5 is something that is hard and requires a total and permanent lifestyle change.
I should credit the thinkers who have most influenced my thinking on these topics: P.D. Mangan and Stephen Guyenet. Mangan is a former engineer who has become one of the leading evidence-based influencers in the fitness space, and an inspiration as a very fit man in his late 60’s who made a transition to healthy living later in life. Guyenet, the author of The Hungry Brain, puts forward the most impressive theory of nutrition and obesity while avoiding the extremes of the various diet “religions” online.
#1: Give Blood (Effectiveness: 4/5, Cost: $0 5/5, Effort: Very Easy 5/5)
I put a lot of stock in the over-mineralization theory of aging. It explains the paradox of aging, in that a nutrient critical for our development into fertile, capable adults - iron - is also a primary cause of our aging. Microevolutionary survival pressures tend much more towards us getting to an age where we can reproduce than helping us survive past the age necessary to successfully rear children. For most of us, the nest empties sometime in the 50s or 60s, and that’s when aging really accelerates.
As such, our bodies are highly optimized to absorb iron, but eventually, we absorb too much and eliminate it too slowly, and this excess causes havoc within the body. Humans for most of our history also had a greater need for iron during adulthood. Parasites extract iron from the body, for example, something almost all ancient humans dealt with that is largely absent in advanced countries today. Humans used to lose more blood, whether from low-level violence or through injuries sustained from a more physically demanding environment.
Iron deficiency can have serious, lifelong adverse effects on growing children, so industrialized countries have fortified many common foods, like rice and flour, with additional iron. Unfortunately, this speeds up iron accumulation in adults. Our bodies produce a protein, ferritin, that serves to capture iron for the body’s use while keeping it sequestered from pathogens and cancers. Over time, as ferritin levels rise, it is less able to contain iron, which when freed from ferritin can wreak havoc in the body, creating inflammation or literal rust that accumulates in age spots on the skin.
The evidence for iron playing a disproportionate role in aging, especially in men, who lack a menstrual cycle that naturally disposes of iron, is very strong. Women’s mortality accelerates more quickly than linear aging would predict after menopause, as their bodies begin to accumulate iron like men.
The solution is blood donation, which results in a 7.5% reduction in mortality for each annual donation. Based on the levels of iron accumulated in a typical diet and the iron content of blood, I recommend giving blood every four to six months. The effectiveness of these efforts can be tracked via a blood ferritin test, though this is largely unnecessary if it becomes a way of life. Anyone who donates blood at this frequency will keep their iron levels well under control. The body can easily increase its absorption of iron as needed, and the iron-rich diets we all consume due to red meat and fortification ensure we are very unlikely to become deficient.
Giving blood, of course, also helps others, which makes this an especially valuable win-win as a health practice. Blood has a shelf life of only 45 days, so blood banks need a constant influx of donors to maintain adequate supplies.
#2: Optimize Sleep (Effectiveness: 5/5, Cost: 3/5, Effort: Easy 4/5)
If not for the costs potentially involved and easy but non-trivial effort level, sleep optimization would be my top choice. Sleep sits at the foundation of our body’s amazing ability to renew itself, and poor sleep produces poor health outcomes regardless of any other mitigations. Good sleep is more important than either nutrition or exercise, though good practices in these areas tend to reinforce the others.
The most effective sleep interventions are a bit higher effort but cost nothing. Perhaps the most important is to avoid screens in the bedroom (yes, remove your television), read paper books before bed, avoid alcohol 4 hours before bed, and eliminate any amount of ambient light. Practical strategies to incorporate the above:
Watch TV or be online anywhere in the house but the bedroom. Turn on night mode on personal devices to reduce blue light. Charge devices in the kitchen, and leave devices there at night.
The latest studies on alcohol consumption are becoming more ambiguous regarding any health benefit it may provide. It probably still provides a modest benefit at low doses and it’s certainly enjoyable. My current practice is to drink the equivalent of one light beer (4% alcohol in 12 oz.) early in the evening before dinner and to avoid alcohol entirely two nights a week (on days I lift weights). On weekends, I may enjoy a stronger drink or two in the afternoon so it’s out of my system by bedtime.
Get blackout curtains and cover up any light emitted from anything in the bedroom (outlet extenders, air filters, etc) with black electrical tape. Have any outside home lighting turned off by 10 PM.
The next issue in sleep optimization is the most expensive to address, and that’s the fact that most of us are sleeping at too high of a temperature. Human civilizations have tended to thrive most when nighttime temperatures are no higher than the 60’s. Outside temperate zones, this is accomplished by people living at higher elevations or in arid environments. With central A/C, we can live comfortably in a wider range of climates, but our houses are no longer designed to cool naturally with ambient air, and many of us are not cooling our houses sufficiently to sleep well. For many in hot environments, cooling to this temperature will be impossible or cost-prohibitive.
For these situations, I recommend two options that can be used alone or in combination. First, purchase a room window or portable air conditioner to cool just the bedroom to 63-67 degrees. It will cool effectively at a fraction of the cost of running the entire system. Second, I use and highly recommend the Pod Cover from Eight Sleep. This is an amazing system (easily one of my top ten purchases) that optimizes sleep temperature throughout the night by circulating water between the sheets and mattress. It detects the phases of sleep and raises temperature gradually later in the night when that is better for sleep quality.
If you sweat at night or are constantly waking up to adjust blankets, etc, it can be a real game-changer. Tim Ferriss has noted that one of the strangest anomalies among successful people he’s interviewed was how many of them randomly owned a Chili-Pad, an earlier version (and in my experience, less effective) of the Eight Sleep technology.
#3: Strategic Sun Exposure (Effectiveness 4/5; Cost: $0 5/5; Effort: Moderate 3/5):
Much has been made in recent years of the supposed benefits of Vitamin D. Due to overzealous advice for people to avoid the sun, a substantial portion of the population is now borderline deficient in Vitamin D. There is decent evidence showing Vitamin D is at least somewhat beneficial, and the risks, costs, and effort involved make it a recommended intervention in its own right. However, studies tracking Vitamin D supplementation have failed to produce the dramatic differences in health outcomes many people expected. Since Vitamin D deficiency is associated with bad health outcomes, why is it that Vitamin D supplementation does not seem to provide a reduction in mortality?
Some have proposed that unsupplemented Vitamin D levels are simply a marker of inadequate sun exposure. While Vitamin D results from UVB rays, UVA rays induce nitric oxide in the blood. Many studies have shown that sun exposure reduces all-cause mortality, even as it increases the chance of certain types of skin cancer*. The benefit of sun exposure seems to be primarily cardiovascular.
*Interestingly, sun exposure makes you more likely to get skin cancer, but less likely to die from it.
The dermatologist-driven war on sun exposure has had undeniable health consequences. We’ve prevented some skin cancer but actually increased cancer mortality overall. There are also undeniable mental health benefits. Until very recently in man’s history when we began working in office buildings, daily sun exposure was simply a part of life. The idea that we are not designed for this is preposterous. The sun’s radiation is probably beneficial to us in the same way that exercise is - in natural doses relative to our ancestral latitudes, it stimulates repair processes and keeps us healthy.
Dermatologists will often challenge you to observe the aging differences between tissues exposed to the sun frequently (like the arms and face) to that of the back or bottom. These parts of our bodies also have thicker skin less likely to burn and also a much larger surface area. So my recommendation for sun exposure is to use sunscreen on the face, neck, and perhaps arms while exposing these larger, thicker-skinned areas to the sun.
Evidence suggests, but does not prove, that it is the UV component of sun exposure that provides health benefits. A study out of Sweden quietly documented that the use of tanning beds (UV exposure only) was associated with a drop in all-cause mortality statistically indistinguishable from sun exposure. Here’s the key table in the study:
Look at the hazard ratio under both Model 1 and Model 2. Sunbeds were statistically indistinguishable in their benefits from normal sun exposure.
Based on this, I also use a full-spectrum* tanning bed a couple of times a week, but with my face and arms covered, for about half of the recommended time for dark tanning. New users should begin gradually to avoid burning. One nice benefit of sun exposure or tanning is that it naturally produces Vitamin D. I choose to supplement with 10,000 IU once a week anyway, but this is probably unnecessary.
*Most older beds are 93%/7% or 94%/6% UVA/UVB, similar to the sun. Both are important, as UVA provides cardiovascular benefits and UVB provides Vitamin D. UVB is also what causes burning if overdone. Some new beds marketed as “ultra bronzers” skew heavily to the UVA side so people can get darker without burning but these are not ideal for those looking to strategically augment natural sun exposure.
#4: Fish Oil (Effectiveness 3/5, Cost: $10/month 3/5, Effort: Easy 4/5)
The evidence for fish oil is strong but mixed. Interventional studies have failed to show much benefit for those with cardiovascular disease, but diets including fish are associated with much lower mortality, and all-cause mortality is indeed about 13% lower for regular users of fish oil. It may also help with depression by lowering systemic inflammation.
Enough evidence exists, however, and taking it is easy enough, to recommend it as an intervention, particularly in concert with either supplemented or natural Vitamin D enhancement. Because I don’t often eat fish, I take both Swanson’s product (inexpensive) and a high-absorption formulation from Elysium Health (not inexpensive). Because fish oil is so low-risk (a food, not a supplement), I recommend taking as much of this as one can tolerate, up to 2 to 3 grams daily.
#5: Resistance & Aerobic Exercise (Effectiveness: 5/5, Cost: $0 5/5, Effort: Challenging 2/5)
You knew this was coming, yep, diet and exercise. They are ranked lower because they require a ton of effort. In deciding which to rank first, I chose exercise because I’ve observed that many more people can successfully exercise than can adjust their diet to maintain a healthy weight, so I rank diet as more difficult.
While diet will determine 80-90% of success with weight loss, and lower weight has its own independent benefits, exercise seems to exert a strong effect on long-term weight maintenance and general health. One of the scariest concepts in aging is that of sarcopenia, which is the progressive loss of muscle mass with increased age. This seems to start a downward spiral of inactivity and frailty as people approach their 60s. Thankfully, there’s a solution to this problem. Consider the following scans of the quadriceps of a 40-year-old athlete and two 74-year-olds, active and inactive:
The inactive 74-year-old’s quadriceps has degenerated into mostly fat and highly marbled*, weak muscle, whereas the active 74-year-old is almost indistinguishable from a younger fit person. These illustrations show that our own agency has a very significant effect on how we experience aging. People who take care of themselves really can enjoy at least a decade of additional productive life.
* Cattle are “finished” for market by being confined in pens where they are inactive all day and fed corn byproducts, much like the typical modern consumer.
The only way to avoid sarcopenia is through resistance training. This is best done with weight lifting but can be done without any cost through bodyweight routines. Even so, a set of weights is pretty cheap and so are many gym memberships. In my own experience, resistance exercise has major psychological and even spiritual effects that are at least as beneficial as the physical effects on the body. It seems to tap into a part of the human spirit, of high agency against the forces of decay, that Nietschze lionized but took too far in his conclusions. Mark Rippetoe describes it this way in his book Starting Strength:
Physical strength is the most important thing in life. This is true whether we want it to be or not. As humanity has developed throughout history, physical strength has become less critical to our daily existence, but no less important to our lives. Our strength, more than any other thing we possess, still determines the quality and the quantity of our time here in these bodies. Whereas previously our physical strength determined how much food we ate and how warm and dry we stayed, it now merely determines how well we function in these new surroundings we have crafted for ourselves as our culture has accumulated. But we are still animals – our physical existence is, in the final analysis, the only one that actually matters. A weak man is not as happy as that same man would be if he were strong. This reality is offensive to some people who would like the intellectual or spiritual to take precedence. It is instructive to see what happens to these very people as their squat strength goes up.
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Over and above any considerations of performance for sports, exercise is the stimulus that returns our bodies to the conditions for which they were designed. Humans are not physically normal in the absence of hard physical effort. Exercise is not a thing we do to fix a problem – it is a thing we must do anyway, a thing without which there will always be problems. Exercise is the thing we must do to replicate the conditions under which our physiology was adapted, the conditions under which we are physically normal. In other words, exercise is substitute cave-man activity − the thing we need to make our bodies, and in fact our minds, normal in the 21st century.
Rippetoe, based in Wichita Falls, Texas, and among the biggest influencers in the hardcore weightlifting space, describes himself as a Norse pagan, and his overstatement here is consistent with that worldview. Too many Christians, however, have abandoned the physical world and become functional Gnostics, idolizing weakness and spirituality above all, and people like Rippetoe overreact to this. Historic Christianity, by contrast, heavily emphasizes the dual nature of man, a creature equally spiritual and physical, and destined to have a physical body for eternity.
Considered properly, spiritual development always precedes physical development. If a person can deny their flesh and eat less than they desire, and get up on cold mornings to exercise when they would rather lay in bed, does not such behavior indicate an inner spiritual beauty, a mastery over their lower nature that would prefer to do the easy and more short-term pleasurable thing? It’s an irony that athletes are often called “meatheads” when the truth is precisely the opposite: they are those who have most trained their meat to submit to their heads.
The most important aspect of strength training is to increase weight over time, work close to the point of failure, and keep a notebook of results for accountability. If the weight isn’t going up and pushing past previous failures, you aren’t getting stronger and muscles aren’t growing. There are a plethora of programs to follow, and a great free option is Strong Lifts. I personally have had issues with back injuries in attempting to do any amount of heavy squatting or deadlifting, so for free weights, I’ve found huge benefit in a hex bar as a replacement for both (hat tip to my friend Ben for this recommendation after an early injury).
Beginners should probably heavily favor using machines to reduce injury risk, and research doesn’t support the exaggerated claims of free weight enthusiasts. Also, some people don’t seem built for it. If you’re small-boned like me, a full range of motion with heavy free weights may not be something you can do easily without injury. Lately, I have been utilizing a lower injury risk technique called Power Factor Training that features heavier weights lifted in a reduced range of motion, all with machines or safety rails. All of the programs are a bit complicated, so you have to nerd out a bit to get into them, but many find them addictive once started. Few things in our complex world allow for linear progress in something real and meaningful like resistance training.
Strength training, done properly, cannot be a complete exercise program. This is because when it is done at a proper intensity to build muscle, it can only be done 2-3 times a week, except for maybe very young men (<25) whose bodies are primed for muscle growth and thus recover more quickly. Most of us need to add in some lower-intensity aerobics on other days of the week to get adequate exercise.
“Aerobics” is somewhat misleadingly named because no exercise is as aerobic as weight lifting. Anyone who’s experienced squats or leg presses done near capacity knows the heart rarely beats faster or harder than in recovering from a set done to near failure. Even those these are anaerobic movements, the depletion of ATP by the inefficient anaerobic pathway causes the cardiovascular system to react aerobically as if under mortal threat to replenish ATP with fresh blood and oxygen. My pulse can remain over 100 for 90 minutes after a weight-lifting session. So aerobics really refers to exercise less intense than resistance training that can be undertaken more frequently to raise caloric expenditure and improve one’s personal psychology.
I hate traditional aerobic exercise for its own sake. I prefer to exercise towards some other goal than the exercise itself, whether trying to set a new PR with weights or trying to win at a sport. So my solution for this, on days when I don’t lift, is to a) play a moderate-intensity team sport for an hour or b) walk on a treadmill for 35 minutes at an 10-12% incline while watching a show or reading the news on my iPad. I find that some kind of at least moderate-intensity, 30+ minute aerobic activity is key to my maintaining a positive mood and outlook on life. Others seem to enjoy things like running or cycling for their own sake, but however you get it done, mixing in some kind of daily aerobic activity seems to have its own independent benefit to mood, cardiovascular health, and weight maintenance.
#6: Optimize Diet and Weight (Effectiveness: 5/5, Cost: $0 5/5, Effort: Difficult 1/5)
The most abused substance on Earth is junk food. This topic is so complicated that I wrote a short book under a pseudonym about my journey to formerly overweight status after struggling with weight as a child and young adult. Here I will summarize some of the frameworks that guide my thinking.
People obviously desire leaner bodies given how much is spent on diets and weight loss efforts. Since people spend their hard-earned money on something they badly want but rarely can achieve, I have come to the reluctant conclusion that losing weight permanently in our toxic food environment is among the most difficult things anyone can attempt.
Every person alive today is a walking miracle because they are the descendant of people who successfully survived and reproduced* in an unbroken chain all the way back to our first parents, in conditions of unimaginable scarcity compared to our most privileged age. The constant threat of famine and starvation strongly selected for those who could overeat as much as possible and store fat in times of plenty to survive the nearly certain deprivation to come. Our problem today is that famine never comes, and our industrial ingenuity has given us foods more varietal and palatable than our ancestors ever experienced. Given that just 50 extra calories a day result in 5 pounds of fat added annually, it’s surprising that more people aren’t morbidly obese.
* Nature is ruthless. Something like 40-60% of fertilized embryos with unique human DNA do not result in pregnancies to live birth. Once born, historically, 50% of children died before reaching reproductive age. Historical genomics data shows that on average only 80% of women and 40% of men who survived to adulthood managed to have children.
One way our society has attempted to cope with this difficulty is the emergence of the idea of “fit at any size.” The data show this is a myth, to the extent the claim is that weight doesn’t matter. Both matter. It is better to be fit than unfit, at any size. And it is independently better to be less fat than more fat, at any fitness level.
This is further borne out by the most consistently effective anti-aging intervention in species from yeast to monkeys: caloric restriction. When experimenters reduce an animal’s normal food allowance 20-30%, it will live anywhere from 10-30% longer. So what is the ideal weight? The data suggest the lowest weight possible without being underweight (adult BMI < 18). New data correcting for smoking status and maximum lifetime BMI (as opposed to counting sick people who have lost weight due to their illness) show a linear relationship between weight and mortality risk:
BMI is an imperfect but easy-to-measure proxy for body fat percentage and almost certainly underestimates the true prevalence of overfat in the modern population. One study estimated the true percentage of overweight Americans at 91% among adults and 69% among children. Since a majority are overfat, this skews our perception of health and what should be normal. An image floating around the Internet of a random beach scene from the 1970’s shows how much “normal” has changed:
Thus, the totality of our environment, from food to the behavior of others and our warped perception of normal, healthy weight, tends towards encouraging us to overeat. The only way out, I think, is to adopt a Dave Ramsey-style emotional intensity to being “weird” now for a benefit later - if you want to be healthy like no one else, you have to exercise and eat like no one else. As I often tell my children, in a sick society “you have to be weird to be normal.”
So how weird do you have to be? Very weird, especially if, like me, you have ever been overweight (especially as a child) since your body will fight you the rest of your life to restore what it perceives as homeostasis. The various diet “religions” among fitness influencers have one thing in common: an aversion to processed foods. We will likely never have the controlled experiments necessary to precisely identify the foods that are causing us to overeat, and it’s probably complex and multifactorial, as Guyenet posits. Humans are omnivores and our capitalist economy features a Darwinian competition among food scientists to find the exact flavor combinations that most overcome our relatively weak ability to inhibit overconsumption. Any effective intervention will have to seem extreme when surrounded by a society of processed food pushers and addicts. For me, this looks like:
Never consuming sugar-sweetened beverages
Eating the exact same boring breakfast every morning, as late as possible before I leave for work to extend the overnight fast and minimize hunger before lunch
Almost never buying or eating packaged desserts, crackers, chips, or cookies, including junk food with health halos like granola or “keto” candy bars
Almost never consuming restaurant food fried in seed oils
Never eating more than one small serving of bread at any meal
Almost never snacking between meals
Almost never eating a full serving of any dessert
Exercising for 30+ minutes almost every day
While I discuss strategies for dealing with hunger in my book (by allowing unregulated consumption of low-calorie-density, boring foods), we probably need to accept that hunger several times a day is a historically normal and healthy part of the human condition. At a minimum, long-term weight loss requires food to become a much smaller part of one’s portfolio of pleasure.
Next time, I’ll cover health interventions useful for those who might already be struggling with specific diagnoses related to aging.