Every move against mortality, ranked by how much it moves the number and by the quality of the evidence behind it.
You bought the sauna before you measured your blood pressure.
Longevity spending lands at the bottom of this page. The returns sit at the top. This is the order in which the work gets done.
Measure
Tier 0. Establish the numbers once, completely, if the budget allows. If it does not, Tier 1 is unchanged for almost everyone.
Locate the highest open gap
Start at Tier 1. Find the first lever your numbers say is unpulled.
Pull one lever for 90 days
One. Executed to the standard written beside it.
Reassess, then descend
Retest the marker. Move to the next lever only when the one above it is closed.
Never buy a Tier 4 solution to a Tier 1 problem.
ARandomised trials, or meta-analyses of themBLarge prospective cohorts, consistent across populations, with a dose-responseCOne cohort, one population, or cross-sectional dataDMechanism or animal data only. No human mortality data
Tier 0
Measure first
Precision medicine. The starting point if it can be afforded. Its job is to decide which of the levers below are yours and which you can skip. The numbers move later, at the lever.
00
The full measurement
23%of people who went on to an event were moved to high risk when coronary calcium was added to the standard score
ApoB. Lipoprotein(a). Coronary artery calcium. HbA1c and fasting insulin. VO2 max, grip strength, and lean mass. Seven days of home blood pressure. A genomic panel where it changes management. Lp(a) is elevated in roughly one in five people, is almost entirely inherited, and is invisible on every standard lipid panel.
Measure once, completely. Then buy only the levers your numbers name.
Each of these moves all-cause mortality by 20 percent or more, on evidence that survives scrutiny. Close these before anything below them.
01
Cardiorespiratory fitness (VO2 max)
4 to 5×the mortality in the least fit fifth of the population versus the fittest
In 122,007 patients followed for a median of 8 years, the least fit group carried roughly five times the mortality of the elite group. In 750,302 veterans the gradient held at every age and in every subgroup. Moving from below average to above average is associated with approximately 30 percent lower risk. In these data, low fitness costs more than smoking or diabetes.
150 to 180 minutes a week of zone 2 work, plus one interval session at or near maximal effort once your physician has cleared you for it. Test VO2 max directly and retest every 6 months.
10+ yearsof life lost to smoking. Stopping before 40 removes approximately 90 percent of the excess risk
Smokers lose a decade. Stopping before 40 removes roughly 90 percent of the excess risk, and stopping at any age recovers years. Nothing else on this page compensates while it continues.
Stop. Varenicline and nicotine replacement roughly double quit rates, and your physician can prescribe them. If you have never smoked, go to 03.
27%lower all-cause mortality at a systolic target under 120 versus under 140, in adults over 50 at raised cardiovascular risk
SPRINT randomised 9,361 adults over 50 at raised cardiovascular risk, and was stopped early because the intensive arm was dying less. It excluded diabetes and prior stroke, and the intensive arm had more syncope and kidney events. Across 613,815 patients in trial data, every 10 mmHg removed from systolic pressure removes 13 percent of all-cause mortality and 20 percent of major cardiovascular events. Approximately half of adults with hypertension do not know they have it, which makes it the commonest unfelt finding on a first executive panel.
A validated home cuff, morning and evening for 7 days, every quarter. The target your physician treats to is under 130/80, lower if tolerated. Medication is a lever, and declining it is a decision with a price.
SPRINT 2015, NEJM. Ettehad 2016, Lancet.
A
04
Muscle strength and mass
16%higher mortality for every 5 kg lost from grip strength
In 139,691 adults across 17 countries, grip strength predicted death more accurately than systolic blood pressure. Resistance training of 30 to 60 minutes a week is associated with 10 to 17 percent lower all-cause mortality, independent of aerobic work. Muscle is the organ that clears glucose, survives the fall, and survives the surgery.
Two to three progressive resistance sessions a week, legs first. Track grip strength and lean mass by DEXA or BIA.
Leong 2015, Lancet (PURE). Momma 2022, British Journal of Sports Medicine.
B
05
ApoB and LDL cholesterol
22%fewer major vascular events per 1 mmol/L reduction in LDL, and about 10 percent lower all-cause mortality
Across 170,000 trial participants, every 1 mmol/L of LDL removed cut major vascular events by 22 percent. People born with a lifelong 1 mmol/L lower LDL carry 54 percent less coronary disease, which is the argument for starting early. ApoB counts the particles that do the damage and outperforms LDL-C as the number to manage.
Know your ApoB. Target under 80 mg/dL, under 60 if calcium or Lp(a) is elevated. Diet first; statin, ezetimibe, or a PCSK9 inhibitor when diet falls short, prescribed by the physician who reads the register.
1.8×all-cause mortality with diabetes. Roughly 30 percent lower mortality after sustained major weight loss
Diabetes nearly doubles all-cause mortality across 820,900 people. Sustained major weight loss lowered mortality by 29 percent over 11 years in the Swedish Obese Subjects study. Semaglutide cut major cardiovascular events by 20 percent in overweight adults with heart disease. The damage begins years before the diagnosis, in fasting insulin and waist circumference.
HbA1c under 5.6, fasting insulin under 10, waist under half your height. Pharmacology is a lever here when the numbers refuse to move on diet and training, and it is a decision you take with your physician.
Each moves mortality by 10 to 30 percent, or carries evidence one grade below Tier 1. These multiply the tier above and rarely replace it.
07
Sleep
20 to 48%lower mortality in the four more regular sleep quintiles versus the least regular fifth
Duration matters less than its reputation: under 6 hours carries roughly 12 percent higher mortality across 1.3 million people. Regularity matters more. In 60,977 adults wearing accelerometers, the four more regular quintiles had 20 to 48 percent lower all-cause mortality than the least regular fifth, and regularity out-predicted duration. The performance cost of short sleep is far larger than its mortality cost.
A fixed wake time seven days a week, then 7 to 8 hours behind it. A sleep study if you snore, wake unrefreshed, or carry resistant hypertension.
30%fewer major cardiovascular events on a Mediterranean pattern, in a randomised trial
PREDIMED randomised 7,447 high-risk adults; olive oil and nuts on a Mediterranean base cut heart attack, stroke, and cardiovascular death by about 30 percent. In the other direction, every 10 percent increase in the share of ultra-processed food is associated with 14 percent higher all-cause mortality. Protein preserves the muscle in 04. Fibre protects the metabolism in 06.
Cut ultra-processed food below 20 percent of what you eat. Protein at 1.6 g per kg, fibre at 25 to 30 g a day, olive oil as the default fat.
40 to 53%lower mortality at 8,000 to 10,000 steps a day versus the lowest quarter
Across 15 cohorts and 47,471 adults, mortality fell steeply with each step-count quartile. It plateaued around 8,000 to 10,000 steps under age 60, and 6,000 to 8,000 above it. Eight hours of sitting a day is offset by 60 to 75 minutes of moderate activity, and by little else.
A floor of 8,000 steps. Walk the calls.
Paluch 2022, Lancet Public Health. Ekelund 2016, Lancet.
B
10
Social connection
50%greater likelihood of survival with strong social ties, across 148 studies
In 308,849 people, strong relationships predicted survival as well as quitting smoking, and better than obesity or inactivity. Loneliness carries 26 percent higher mortality, isolation 29 percent, living alone 32 percent. The executive pattern is a wide network and a thin one.
One standing weekly commitment with people who would notice your absence.
Holt-Lunstad 2010, PLoS Medicine. Holt-Lunstad 2015, Perspectives on Psychological Science.
B
11
Alcohol
100 g/weekis the threshold above which life expectancy falls, across 599,912 drinkers
Under about 100 g a week, roughly six standard drinks, mortality is close to flat. At 200 to 350 g a week you lose 1 to 2 years at age 40; above 350 g, 4 to 5 years. The cardioprotective claim rests on former drinkers being counted as abstainers, and shrinks when they are removed.
Under 100 g a week. Zero costs you nothing.
Wood 2018, Lancet.
B
Tier 3
Marginal
Real signal with a smaller effect, or evidence resting on one population. Worth doing once Tiers 1 and 2 are closed. A poor place to spend money while they are open.
12
Air quality (PM2.5)
4 to 7%higher all-cause mortality for every 10 µg/m³ of fine particulate exposure
Of every environmental exposure on this page, this is the one with the evidence: half a million adults followed for 16 years, then 60 million Medicare recipients. Each 10 µg/m³ of PM2.5 adds 4 to 7 percent to all-cause mortality and about 6 percent to cardiopulmonary mortality. Saharan dust season and traffic corridors push Trinidad past that unit on bad days.
A HEPA filter in the bedroom and a PM2.5 monitor to know when to run it. Windows closed in dust season.
Pope 2002, JAMA. Di 2017, NEJM.
B
13
Sauna
40%lower all-cause mortality at 4 to 7 sessions a week versus one, in a single Finnish cohort
2,315 Finnish men followed for 20 years: frequent sauna use tracked with 40 percent lower all-cause mortality and 63 percent lower sudden cardiac death. One cohort, one sex, one country, and the frequent users were fitter and healthier to begin with. The mechanism is credible. The trial has never been run.
Four sessions a week, 15 to 20 minutes at around 80°C, once the fitness work for the day is done.
Laukkanen 2015, JAMA Internal Medicine.
C
14
Fish and omega-3
17%lower total mortality with modest fish intake, in cohort data
Fish on the plate carries consistent observational benefit: about 36 percent lower coronary death and 17 percent lower total mortality at one to two servings a week. The capsule is a different story. 25,871 adults randomised to 1 g of fish oil showed no significant reduction in major cardiovascular events. High-dose icosapent ethyl cut events by 25 percent in high-triglyceride patients, with an unresolved question about its placebo.
Two servings of fatty fish a week. Supplement only with a measured omega-3 index under 8 percent, and expect a modest return.
23%higher coronary heart disease with job strain, across 197,473 employees
High demand with low control carries 23 percent more coronary disease across 13 European cohorts. No intervention has yet been shown to lower mortality by lowering stress. The pathway runs through 03, 06, and 07: pressure, glucose, and sleep. Manage those and most of the stress risk is already priced.
HRV as a weekly marker, a hard stop to the working day, and the three levers stress acts on kept closed.
Kivimäki 2012, Lancet.
C
Tier 4
Unpriced
No human trial shows any of these lowering mortality. Some have a plausible mechanism and cheap avoidance, and those are worth the low cost. None deserves budget while anything above is open.
16
Phthalates, BPA, and endocrine disruptors
~14%higher all-cause mortality per unit of urinary phthalate metabolites, in one US survey cohort
One analysis of 5,303 US adults linked higher-molecular-weight phthalate exposure to approximately 14 percent higher all-cause mortality. It extrapolated around 100,000 excess deaths a year in Americans aged 55 to 64. Cross-sectional, one dataset, no intervention trial. The endocrine mechanism is established in animals and plausible in humans.
Nothing plastic in the microwave or holding hot food. Glass and steel where the swap is free. Expect no measurable change in any marker.
Trasande 2022, Environmental Pollution.
C
17
Lead, cadmium, arsenic
37%higher all-cause mortality at a blood lead of 6.7 versus 1.0 µg/dL
Exposure is well evidenced: in 14,289 US adults, low-level lead tracked with 37 percent higher all-cause and 70 percent higher cardiovascular mortality. Removal is a different matter. Chelation after heart attack showed a borderline 18 percent benefit in one trial and nothing in the confirmatory trial. The evidence sits with source control, and a chelation trial run twice has found nothing to add.
One blood lead test. Then remove the sources: pre-1980 paint and pipes, imported spices and traditional remedies, rice as a daily staple, and tobacco.
No signalfor mortality in the general population. 54,251 pesticide applicators showed no overall lymphoma link
IARC classified glyphosate as probably carcinogenic in 2015 on limited human evidence. The largest prospective study of the people most exposed, 54,251 licensed applicators, found no overall association with non-Hodgkin lymphoma. Dietary exposure sits orders of magnitude below occupational.
Wash produce. Buy organic if you prefer it. Budget zero.
IARC Monograph 112, 2015. Andreotti 2018, JNCI (Agricultural Health Study).
D
19
Supplements for longevity
0%mortality reduction from vitamin D, fish oil, or a multivitamin in adults who are replete
Three trials totalling approximately 69,000 adults not selected for deficiency: vitamin D, fish oil, and a daily multivitamin each failed to lower mortality, cancer, or cardiovascular events. Correcting a measured deficiency is medicine. Supplementing a normal level is expense.
Test, then replace only what is low: vitamin D, ferritin, B12, omega-3 index, magnesium.
Sold almost exclusively to people who have skipped Tiers 1 and 2.
Detox cleanses and juice protocols
The liver and kidneys already run this protocol continuously and without charge. No trial has shown a cleanse removing anything measurable from anyone.
D
Chelation for prevention
The confirmatory trial was negative. Deaths from hypocalcaemia after EDTA infusion are on record.
D
Nanobot detox
There is nothing of the kind in the body to remove, and no product that removes it.
D
IV vitamin drips
Water-soluble vitamins at high dose leave in the urine within hours. The drip changes nothing a blood test can see a week later.