In "How Not to Age," Dr. Michael Greger explores evidence-based strategies for combating aging through simple lifestyle changes and dietary adjustments. Drawing from over 13,000 citations of peer-reviewed anti-aging research, Greger dismantles the traditional approach to aging, presenting eleven pathways in our cells that can be disrupted to promote longevity. Inspired by the practices of centenarians and those in 'blue zone' regions, the book offers practical, cost-effective methods to enhance bodily functions, such as boosting autophagy with spermidine-rich foods and addressing senescent cells with quercetin. Greger's guide provides accessible insights into achieving both physical and mental youthfulness, making ultimate longevity attainable for everyone.

How Not to Age Book Review

You shouldn’t judge a book by it’s cover and it’s very true for How Not To Age. On the face of it, it’s a healthy eating guide, but it’s more than that. There is so much information in the book that it’s more of a reference manual. And don’t think it’s one of those books where half of it is footnote references, no, there are so many of those Greger decided to put the 995 pages of citations online! 

Not that it’s written like a text book, the English is at just the right level for a popular science reader, but that it would be impossible for a mere mortal to remember a fraction of it. I found myself skipping paragraph after paragraph of details – once I had the high-level picture I didn’t think I needed the specifics. For example, he explains about DNA damage, then different types of DNA damage, then foods that target a single type of DNA damage – unless you are prone to that exact type of damage you’re unlikely to tweak your diet to that extent. But that’s what I mean by it being a reference manual – IF you have a specific metabolic disorder or out-of-range biomarker then look up in here, it will probably tell you exactly what foods to consider. Or hopefully, one day, he’ll feed it all into an AI doctor that can coach us individually on what to eat.

Having said that, I came out with a long list of ways to improve my health through diet, and I consider myself to already be well above average on my nutritional intake. Though, as Michael Greger points out a couple of times, average in today’s society is not a good benchmark given the prevalence of multimorbidity in the older population.

As usual I’ve picked 101 key points from the book below, but maybe the biggest takeaway is just how much health improvement can be achieved with the right nutrition – resulting in perhaps 18 years of additional life.

If there's one thing this monster of a book will tell you about your diet (as it repeats it over and over again) is that meat is bad for you. Oh, and eat your greens!

Highlights

Here are 101 key points from How Not to Age:

• I remain agnostic as to whether such a breakthrough [“longevity escape velocity”] is possible.
• Lifespans of spouses sometimes correlate as much as — or even more than — those of genetic relatives.
• AMPK activators can effectively fool the body into thinking it is starving, switching it into protective housecleaning mode.
• Age-impaired mitochondria don’t just become less efficient — they may become actively harmful.
• Barberries have been shown to successfully lower LDL cholesterol levels an average of fourteen points (mg/dL).
• Daily black cumin consumption has been found in systematic reviews and meta-analyses of randomized controlled trials to significantly improve weight loss, cholesterol, triglycerides, blood pressure, and blood sugar control.
• “low acid” coffee is a reference to low chlorogenic acid — which is exactly what we don’t want.
• By the time most people reached their sixties and seventies, their spermidine levels (a potent activator of autophagy) has already fallen to about a third.
• When we are younger, senescent cells are cleared by our immune system.
• Quercetin doses as low as the human equivalent of one small apple a week reduced cellular senescence and improved the healthspan of aging mice.
• Fisetin has been shown to have anti-inflammatory effects in clinical trials.
• A 105-year-old may have a DNA methylation age of a 60-year-old.
• Long-term meditators appear to have the same aging rates as nonmeditating controls.
• The food most consistently linked to accelerating aging is meat.
• Those who get more folate in their diet tend to live longer and are protected against cardiovascular disease, several cancers, and a wide range of other chronic diseases.
• Advanced glycation end products (AGEs) have been found to adversely affect virtually all tissues and organs.
• Modern industrial methods used to manufacture breakfast cereals, like explosion puffing and extrusion cooking, accelerate starch digestion and absorption, which cause exaggerated blood sugar responses.
• Blood sugar control may be improved by adding two teaspoons of vinegar to a meal.
• There is a single IGF-1-lowering gene variant that adds as much as ten years or so to life expectancy if you inherit it from both parents.
• Height may help explain the gender differential in life expectancy.
• Vegans have been found to have lower rates of all cancers combined.
• The positive association between decreased protein intake and decreased mortality in middle age appeared to flip at around age sixty-five into a negative relationship.
• Those born genetically predisposed to higher IL-6 levels are less likely to survive to old age.
• If cholesterol were introduced as a new food additive, the conclusion would almost certainly be that it could not be considered safe at any level.
• The food components that rate as most pro-inflammatory are saturated fat and trans fat.
• Turmeric is the single most anti-inflammatory food.
• Perhaps the benefits of the omega-3s are offset by the industrial toxins that now contaminate much of the aquatic food chain.
• Ginger powder has been used to successfully treat rheumatoid arthritis and osteoarthritis.
• Taking an aspirin a day is generally not recommended for those without a known history of heart disease or stroke.
• Inhibiting mTOR is considered to be the best validated aging regulator [but] rapamycin is not ready for prime time as an anti-aging drug.
• Caloric restriction has been heralded by some as a fountain of youth, but negative side effects may include dangerously low blood pressure, infertility, slower healing of wounds, menstrual irregularities, sensitivity to cold, and loss of strength, bone, and libido.
• When we drink the milk of a faster-growing species, especially later in our life, there is concern we may “over-stimulate” mTOR signaling.
• Those taking antioxidant supplements don’t appear to live any longer.
• Most of the rare genetic syndromes of premature aging are caused by mutations of DNA repair genes.
• Ounce for ounce, dried herbs and spices pack the greatest antioxidant punch.
• Consumption of cocoa has been found to decrease markers of oxidative stress as well as lower blood pressure.
• Drinking a mug (300 mL) of green tea every day improves DNA resistance to free radical damage.
• Cruciferous vegetable intake is associated with decreased risk of cardiovascular disease, cancer, and mortality from all causes put together.
• Supplemental beta-carotene, vitamin E, and higher doses of vitamin A may even cut people’s lives short.
• No impact on inflammation, cancer, cardiovascular disease, long-term frailty, or death has been found epidemiologically for dietary resveratrol exposure.
• Looking “old for your age” is actually an indicator of poor health and a strong predictor of mortality.
• Women tend to have longer telomeres than men.
• Longer telomeres were associated with the intake of vegetables, fruits, legumes, nuts, and other foods high in fiber and antioxidants.
• Nearly every supplement study to date has failed to find benefits for our telomeres.
• Four of the top five dietary risk factors for death were foods of which we’re not eating enough = vegetables, nuts and seeds, fruits and whole grains.
• Increasing intake of the fish oil fats has little or no effect on cardiovascular health.
• Exercising for twenty minutes may add an hour (two microlives) to your life giving a three-to-one return.
• In terms of lifespan, one burger appears to equal two cigarettes.
• Eating just that single daily serving of processed meat is expected to take off around two years of life.
• Excess sodium appears to be humanity’s number one dietary risk factor for death.
• Increasing tea consumption by three cups a day may decrease the risk of premature death from all causes put together by 24 percent (the equivalent of adding about two years onto your lifespan).
• Artificial sweeteners may mess with our microbiomes and metabolism.
• The Global Burden of Disease Study was clear and unambiguous: “The safest level of drinking [alcohol] is none.”
• Fruit juice can carry a similar load of sugar to soft drinks but, unlike soda, is not associated with a shortened lifespan.
• Every ten-beats-per-minute increase in resting heart rate above about sixty-five beats per minute is associated with a 10 to 20 percent increase in the risk of premature death.
• A single daily serving of beans, chickpeas, or lentils may be associated with a 10 percent decrease in all-cause mortality risk.
• Canola oil lowers LDL cholesterol better than olive oil does, and, unlike olive oil, canola has been shown not to acutely impair artery function.
• Sweet potatoes have formed the bulk of the traditional Okinawan diet since the 1600s.
• Sea veggies have been associated with significantly lower all-cause mortality.
• A quarter teaspoon of garlic powder can dramatically improve artery function and slow the progression of atherosclerosis.
• Recommend 1,000 mcg of cyanocobalamin a day for everyone after age sixty-five, ideally as a chewable, sublingual, or liquid supplement.
• Population studies have found a correlation between regular aerobic exercise and decreased risk of at least thirty-five different diseases.
• Manual labor is associated with a shorter, not longer, life, again suggesting the primacy of confounders like socioeconomic factors.
• The same mortality rates were found in identical twins whether they exercised vigorously or not.
• For runners, the recommended upper limit for potential longevity benefits is thirty miles a week.
• The magnitude of artery function impairment from a week of five-hour nights is similar to that reported in people who smoke, have diabetes, or have coronary artery disease.
• Once you control for these secondary mediators, the significant link between stress and mortality does appear to disappear.
• Social isolation — an objective measure of social disconnectedness — and the subjective feeling of loneliness are both associated with an increased risk of premature death.
• Calcium supplements appear to raise the risk of heart attacks and strokes.
• Having a normal cholesterol level in a society where it’s normal to drop dead of a heart attack isn’t necessarily something to celebrate.
• No atherosclerotic plaques were found only when LDL was down around 50 or 60.
• Dietary cholesterol has long been known to be a significant contributor to atherosclerosis.
• Low-carb diets have been found to worsen heart disease and significantly higher risk of dying from cancer.
• In women, hair loss is associated with a ninefold increased risk of having metabolic syndrome.
• A high glycemic diet of refined carbohydrates is associated with developing age-related hearing loss.
• Dehydroepiandrosterone (DHEA) replacement has repeatedly failed to beat out placebo.
• Our ancient ancestors got an estimated seven times more fiber than we’re getting now.
• In 2004, an authoritative report from the National Academy of Medicine concluded that testosterone therapy offered no clear evidence of benefit for any health outcome.
• Garlic appears to offer the best of both worlds, dampening the overreactive face of the immune system by suppressing inflammation, while boosting protective immunity.
• Those who get regular flu shots live longer lives on average.
• Nothing beats nuts for reducing the associated risk of dying before one’s time.
• The immune boost we get from consuming broccoli and other cruciferous vegetables not only protects us against pathogens found in food but also against pollutants in the environment.
• Eating greens at least nearly every day may be one of the most powerful steps we can take to extend our lifespan.
• Berries appear to reduce all-cause mortality risk as much as green leafy vegetables.
• Various grape products can cause a small (five-point) drop in LDL cholesterol, but raisins did not seem to work.
• The stress response molecules in plants may activate the same protective responses in us.
• Aging is accompanied by dysbiosis, an unhealthy imbalance of gut flora characterized by a loss of fiber-fed species.
• Having high levels of trimethylamine oxide (TMAO) is associated with a significantly higher risk of having a heart attack or stroke, or dying prematurely in general.
• A recent systematic review of randomized controlled trials of probiotic supplements for healthy older adults found that there was insufficient evidence for the improvement of health outcomes.
• Our microbiome can’t make SCFAs (short-chain fatty acids) unless we eat fiber.
• Caloric restriction has been said to extend the lifespan of “every species studied,” but this isn’t even true of all strains within a single species.
• Those who are very obese (BMI ≥ 35) throughout their adult lives lose at least seven years of life and nineteen years of healthy life.
• The CALERIE trial does suggest that even “normal weight” individuals should eat less to improve their health and longevity.
• The largest and longest trial of alternate-day fasting disturbingly found a significant increase in LDL cholesterol.
• Exercise boosts FGF21 levels, which may in fact be one of the reasons it’s so good for us.
• The optimum ratio of protein to carbohydrates across species for lifespan appears to be about one to ten.
• The higher the animal protein intake, the higher the mortality rates, whereas the higher the plant protein intake, the lower the mortality rates. 
• Four NAD+ precursors were tested in older adults: tryptophan, NA, NAM, and NR. They all failed to improve muscle strength or function, affect mitochondrial function, and even nudge NAD+ levels in their muscles.
• The lack of demonstrable clinical benefit would seem to preclude NR supplementation.
• Canadian study found that nearly eighteen years of lifespan were up for grabs based on simple, commonsense health behaviors.
• A midlife switch between the ages of forty-five and sixty-four to even just the barest of minimums of healthy habits resulted in a 40 percent lower risk of dying in the subsequent four years.