B (3:28)

We should stay between 25 and 30. So if you have a choice about who you want to be, you want your biomarkers, you want your way to live life to be what you are at your peak. And for most people, that's 25 to 30. We know that for athletes, we just all watched the Olympics, right? We amazed that a 41 year old won, you know, a race, I think a bobsled race, right, because our bodies decline. Now. Are there exceptions? Of course. I can count them though. On one hand, over the years, I've seen thousands of people and I remember the one or two men and women who were exceptions to that rule. So you want to keep your metabolic functioning as if you're 25, 30. It doesn't mean it's perfect because we all have genetic drivers. But that is where we're going to feel our best. That's where reproduction, you know, having children is said to be the best. Being an athlete, you know, you're old as an athlete, in your 30s. And so that is the kind of double check that I think about. And we don't, most physicians don't even check testosterone, whether it's total or free, because first of all, it's not even formally approved for women in this country yet. I've been taking it for 30 years because of my risks and my risk factors, which I was quite aware of, you know, 30 years ago. And that fall is imperceptible in a way, like it begins to gradually decline, but we don't really measure it or look at it. And it's not done in conventional medicine in general because we're not Proactive. But disease starts decades before we get sick. And we're at our best and at our peak in our 20s. So if you're going to pick a decade to be healthy and so what do you want to emulate, it's recovery, it's reversing aging and keeping yourself as a 25 to 30 year old or young.

A (5:18)

What would the ideal levels in your view be for a male and female then?

B (5:23)

So ideal or optimal, if you read the literature, for men would be 180 to 250 free testosterone, and for women at least 6 and even up to 30. Now, there's a lot of fluctuation in that because some people do fine at the higher end of the spectrum, other people do okay at the lower end. Lower end because we are so individual. And the reason for free testosterone is that the total testosterone is bound up in protein. It's not free to act. But most physicians are not trained in this field in depth. And most of us don't know what the norms are because what's reported by Quest or LabCorp are kind of averages, population means. And even for testosterone for men, free would be 35 to 1 55, which is very low.

A (6:12)

So there's a hundred percent, like clarity. I'm looking at Quest right now. I see testosterone total. That's not it. And I see, then I see testosterone free and testosterone bioavailable.

B (6:24)

Right.

A (6:25)

So it's not bioavailable, it's free. Testosterone free. That is the one.

B (6:29)

Yeah. It's the easiest marker to use rather than bioavailable. And it's free to act in your system. The same is true of almost every other gland in the body. Like when you look at the thyroid gland, you should also look at the free T3 and T4. And the same is true for testosterone. You can't judge a total because there's something else in your biomarkers probably called sex steroid binding globulin. And when that is elevated, you're binding more testosterone, you're binding the sex steroids, which testosterone is one of. So what really counts for your system is free testosterone. And here's another myth. It doesn't go up when you work out. What actually does go up when you work out or you sleep well is growth hormone, IGF1, which is a reflection of growth hormone produced by the liver. Testosterone does not. What happens to all of us as we age, we get weak, we get frail, we can't maintain muscle, and that's all testosterone.

A (7:25)

So essentially, if we maintain our testosterone levels, that is the, one of the most major levers we have to stay youthful. That's what I'm hearing.

B (7:37)

Yes. It's not the only one, but it's the main hormonal version. Yes. That's why it's so important for women, too.

A (7:44)

And so in terms of tactics to keep that level high. So obviously, I think everyone listening knows about, you know, the importance of eating a, a diet that's low in ultra processed foods. Assuming everyone's doing all of the right things in terms of lifestyle and they need to turn to supplements or pharmaceutical interventions or something else, how should they approach that?

B (8:08)

That's a great question, and it's one I get a lot. And the literature and data is moving in my direction. First, you have to know my bias is that we are our genetics, basically, and aging comes whether we want it or not. The question is, how can you maintain your quality of health as you age? People in fantastic shape who do everything right. And I have a lot of those patients. I have a couple in their 60s, she's presenting with Alzheimer's and she's presenting with serious heart disease. They look perfect, their VO2s. You know, how they exercise their body composition in terms of percent body fat. For her it's like 15%. For him it's like 9%. And so what really dictates how we have to engage with our environment, how we eat, sleep, work out, is our makeup, our prototype, our genetics, and the gene variants. And those can be adjusted. The genes themselves can't be. But testosterone is a major lever that you can use because it affects every organ in the body. It affects the heart, which is a muscle, it affects brain in terms of cognition and memory, it affects bone turnover. And I've seen all of that in the work I've done over the last two to three decades.

A (9:23)

So what I'm hearing is you could have, you know, you're metabolically super fit, you got a great VO2 max your. But you got great APOB or what, you got everything. But if your hormone, if your testosterone is low, you've got an issue and we need to address that.

B (9:39)

Yes. And in general, the same is true of your genes. So what's going to start happening in the future is we're going to learn more and more about genes. I happen to be very invested. I love genetic makeup because this was not a choice. But alongside me was my identical twin sister growing up in Rockaway. So I was fortunate enough and to have an identical twin. And I knew empirically that both genetics and the way you live Life can create different outcomes because my twin and I are not exactly the same. There are issues that she has that I don't have. She had a gallbladder thing. I have a gnl, you know, my colon. I have something called ischemic colitis that I've had to deal with. She can take metformin, I can't. We both have insulin resistance. I can't do it. I can live on sushi and sashimi and she doesn't eat fish, she doesn't like it. So I knew instinctively that it didn't matter, you know, how identical you were. You could change the course of how you live life by making choices that change expression of genes. So epigenetics, and that's really where the, the kind of real meat of how we age comes into play.

A (10:54)

And so how would one approach that if they want to increase their testosterone levels in terms of looking at what's available? Because there's a lot.

B (11:02)

So there's no way artificially that I know or supplement wise to increase testosterone without either getting testosterone in a man or woman or increasing triggers of it. In men, you could use something called HCG or human chorionic gonadotropin, which is also thought of as a fertility drug because in women it stimulates ovulation and we use it routinely in in vitro fertilization. But in men, it stimulates cells in the testicles that make testosterone. But more important than that is looking at all the aspects of your health. The five biomarkers that I've come to understand is abnormal in everyone as we age. And that includes markers that look at carbohydrate metabolism. So fasting sugar, fasting insulin, hemoglobin A1C. And also to look at a stand in for cholesterol. It doesn't have to be fancy, it doesn't have to be apple B. It can be the ratio cholesterol risk ratio, which is total cholesterol divided by the good cholesterol, hdl. And you want that as low as possible. And then getting those biomarkers in conjunction with my favorite wearable, which is a continuous glucose monitor, helps you determine and keep your body in this moderate range that prevents aging in that it stops chronic disease. Because much of chronic disease comes from the fact that our body doesn't maintain glucose very readily. And as we age, the muscle disappears. Glucose is housed in muscle. We don't have an ability to sustain sugar effectively because it's a survival trait. We put on, we put on weight very easily, particularly around the middle. We gain Visceral fat. So by sustaining, you know, and knowing your own carbohydrate metabolism by where. But with the wearable, you can look at it 24, 7, you can actually aim to keep your body in as healthy a pattern and spectrum as possible.

A (13:04)

So before we go, I want to cover glucose, hemoglobin, A1C, fasting, insulin, cholesterol. I just want to, just put a pin. I want to talk about testosterone and then we'll move on. So, but like, what specifically with all the treatments, what advice do you give to someone? Because there are a lot of options if you're a man or a woman and you want hormone, you want hormone therapy. How, what, what advice do you have for someone who's taking a look at this now?

B (13:32)

Right. First, you should get a measure of your testosterone, ideally free. You usually don't get free testosterone without getting total. Once you know your free testosterone for men, if it's, it's usually what, by the time you hit your 40s, it would be rare to have a free testosterone over a hundred. I'm not saying it doesn't happen, but it's unusual. Sometimes it's as low as 50. And, you know, 50 is what a boy who starts at puberty gets. Initially, it's very low. And so the ranges that you see in Quest or LabCorp are just not reality. They are just an average. An average doesn't apply to any of us. So you want them to measure. You want to measure at least twice, and you want to measure first thing in the morning after a night's fast, so you can keep it consistent. Same thing in women. You want to try to do the same thing. Testosterone doesn't vary that much in women in their, during their cycle. So you can get it any time of the cycle, but you also want to get it fasting if you can. And you want to get at least two levels. I like to get three sometimes. Most endocrinologists do. And once you know those levels, you can decide which way you're going to go. My favorite prescription for women and for women and men are different, because men and women are different. Women can take testosterone as a cream. They can actually also take it as a pellet. Not my favorite path, because it's hard to control and a lot of times the levels get too high. So creams you apply daily, like we all apply creams of one sort or the other. Right. You can also. Nowadays there's a form of testosterone that you could take. That's oral testosterone. The details are still being worked out. But it's broken down in the lymphatic system. So you don't have to worry about its impact on the liver. Because some of the hormones, if you take it orally as you age,

A (15:24)

you

B (15:24)

can have an effect, what's called the first pass through the liver, and it's not as good for your cholesterol. So there's an oral form of testosterone now that's available in men the most effective way. And this would mean understanding what stage in life men are at. Because men age hormonally in a more linear fashion than women. We women go through perimenopause. It can start in our 30s, more commonly in our 40s, and we hit a wall. We have no more eggs in our ovary. We can't make hormones by the time we're 50 to 51 on average. I've had some women at 38 going to menopause, other women at 58. So there is this wide range in men every decade of life, their body, and the relationship between the way their testosterone is stimulated in their testes. It's manufactured in the testes, in a cell called the lining. Cell becomes less, it lowers. And the brain doesn't realize that circulating testosterone is too low. It's called a feedback loop. And so what happens when you're a young guy if your testosterone falls? Let's say you're not feeling well or you're not getting enough sleep and you have low testosterone? Your brain says, hey, wake up. Make more testosterone. It comes from your pituitary gland, your hypothalamus, pituitary gland, which then tells your testes. And to make testosterone, that starts shifting. As men get older, their testosterone gets lower and the brain doesn't pick up on it. And so they go into what I think of as a periandropausal state. Andropause in men is equivalent to menopause in women. And every decade of life, more and more men go from periandropause, meaning they have testosterone, but it's not adequate to andropause. So men, you can stimulate testosterone using a hormone that's a peptide hormone called hcg, human chorionic and atropin, or you can take testosterone as an injection. It is available as a cream. I don't think it's ideal for men because it passes through the skin and can turn into estrogen, or another hormone called dihydrotestosterone. And both of them can affect the body in a way you might not want. But there's also pellets for men and there's injections, both cartridge type of injections or just injections you can self administer.

A (17:49)

And the HCG being your top choice for men, you said that's a peptide. Is that an injectable? Is it a capsule? How, what's the delivery?

B (17:56)

It's only injectable. Although you might remember stories about the HCG diet where people took it orally. It doesn't work orally because it's one of the peptides that would get broken down by gastric juices. So you have to take it as a tiny shot twice a week because you want to create a pulsatile atmosphere in the body because that's what really triggers the release of testosterone most effectively. The downside to it is it's expensive. And so for people who can't, you know, you know, it isn't covered by insurance unless there's a infertility issue. So for young men, like in their 30s, if fertility is a question, you can test that. And HCG is sometimes used to improve fertility in men as well. But you can also take testosterone directly.

A (18:43)

Interesting. And DHEA can work, but DHEA is

B (18:48)

a pro hormone and a hormone and it's a supplement. So I have a funny story about that. But about 20 years ago, I had a guy come to me and he was leaving Pfizer. He was an executive and starting to act. He always had his card and he was always acting and he didn't tell me the supplements he was taking. And I got his testosterone back and he was in his 70s. His testosterone wasn't too bad. It was just under 100. And he gave me a call that week and he, I, he said, you know, I forgot to tell you and that I'm taking these supplements. One is called dhea. And DHEA is a building block for both testosterone and estrogen. And he was one of these folks who could convert a lot of the DHEA into making testosterone. So he had a fair amount due to the dhea. I'm a big data geek, so for me, like I'm wearing my glucose monitor on my arm. For me, I don't just tell people to take supplements, I tell them to get measured. Because you can be a 45 year young man and your DHEA could be 250 or it could be 35. And you really want your DHEA to be between 350 and 550. So you can imagine that the doses would be different and the absorption might change. But DHEA is one of those hormones that start falling in our 30s as well.

A (20:08)

Interesting. I asked just on a personal level. I think my DHEA is like 70. I'm 51, so my total testosterone is 5 40. My free is 70 and the DHEA is 70. So I'm on the low side. I feel good, but it's something I've thought about.

B (20:26)

Yes. Because you can feel good, and a lot of people do. They don't even notice. And that's what's the aging piece of like. It's silent, but it's having an effect on you. If you try to work out as hard, if you try to put on muscle, you might not even be perceiving the effect because you feel okay going day to day. Right. Just like we go back to a high school reunion. We can't believe the changes in our friends. Right. But we look in a mirror and we think we look okay. Right. It's slow and gradual, but it's happening under the surface. And that's why it's important to understand what is actually changing and what can we do to optimize ourselves largely to prevent disease and reverse biological aging so we can keep our healthful life. I've always thought about it in terms of health span.

A (21:12)

Yes. And so we'll move off of hormones. So I think everyone got the memo. Hormone health is directly related to longevity. We need to take care of that, male or female. So it feels like glucose metabolism is a big theme for you. If we're talking about fasting glucose, fasting insulin and hemoglobin A1C, they're three of your top five. And it's all related to how we metabolize glucose. So tell us more.

B (21:38)

Okay, so it's not unusual to be an endocrinologist and to sort of focus on glucose. Right. But here's the thing. I hated diabetes. I thought it was an insidious disease that caused damage to every cell in the body. And it turns out I was right. I never prescribed insulin to any diabetic except for type one. And I used to teach it at Yale. I used to teach the students about what happens as you age and you have diabetes. Because there's associated genes that relate to heart disease, kidney failure, eye disease, cancer, and neurological disease. The pins and needles that people get in their feet and hands. And so the irony is that every person I look at has less than optimal sugar metabolism. That means their insulin could be elevated, which is a sign of insulin resistance. Their glucose could be high and low, and there could be spikes and dips that create a pattern that isn't healthy for the entire body. And their hemoglobin A1C, while we all know the 7 because of Ozempic in the commercials, actually having a hemoglobin A1C above 5 is not optimal. And even under 5, and I'm in that category, doesn't really mean you're optimal. And I'll explain that in the world of conventional medicine, we aim to a hemoglobin A1C of under 7 because 6.5 and higher with diabetes is usually leads to eye disease. So that's where the cutoff very arbitrarily was made. But to be optimal, a hemoglobin A1C, which is an average glucose for 100 days, should be less than 5. But even average can be misleading, right? Because you can have 150 and 50, and then your average is 100. That's not too bad. But it doesn't mean you're healthy. So having an insulin that is detectable when you're fasting is not good. It means you have insulin resistance. And almost all of us develop insulin resistance with aging. So the combination of those three variables give you deep insight into how a person's body is handling glucose and what's going on with glucose. Because we need sugar for every part of the body.

A (23:53)

Sounds like you want hemoglobin A1C and 5 on the nose.

B (23:57)

5 or less.

A (23:58)

Or less. And like, once you get over 5, specifically like 5.5, you're getting into a place you don't necessarily want to be. Although the labs won't say that. They'll still be in the green, like, because I'm looking at my quest, and it's like, you want to be under 5.6, but you know why? Because the population's moved the median because

B (24:17)

5.7 is pre diabetes. And everybody they measure, they're taking a thousand people. And I hate to pick a state because I get made fun of if I say Oklahoma or Kansas, everybody's sick, everybody is headed towards that. So you have this average, but as you creep up to 5.4, 5.5, 5.6, you're heading toward prediabetes, which is a hemoglobin A1c of 5.7 to 6.5. So under five matters, but it does. It isn't the whole story. So in my case, right, you want to ask about another number you have? Did you get insulin?

A (24:52)

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B (25:36)

Undetectable.

A (25:37)

So like, I think the value on Quest is under three. I want to say I think that's as low as.

B (25:42)

No, the value on Quest still on some reports say up to 19, which is unbelievable. And that's because most doctors don't measure insulin. And now a lot of consumers who are interested in their own biomarkers are getting these biomarkers but not making sense of it. That's where AI can lead you in the wrong direction actually too.

A (26:02)

So for insulin, you want, you don't even want a number. So like, even if you show up as like three, in your view, that's too high.

B (26:10)

Two to five is what is considered within range but actually undetectable. Three hours after eating is ideal and optimal. So what? That's what we try to target.

A (26:23)

Okay, that's fair. So even if you come up at five in the green, you're saying we can do better. I think that's helpful. Should do better, yes.

B (26:30)

Because remember, we're looking at averages and we're looking at people who have disease that's already occurring beneath the surface.

A (26:37)

Yes. And then fasting glucose.

B (26:39)

So fasting glucose should be between 70 and 80, and then you really want to keep a tight spectrum. And this is where the, the continuous glucose monitor, which now people can just get over the counter, they can get a lingo or stella and they can monitor it themselves. It isn't tied to a practice. When we, when we treat people, we give them prescription and we can see the numbers day and night, but they can see it. And you really want to keep it between 70 and 120. So after eating, you don't want it to go much beyond 120. Now, does that mean you have to be perfect? Absolutely not. And when you work out and you hit a threshold where you need to make more, you need to release more glucose, you might have a spike, like you might go to 150 or 180, but if you're going to 200 or above, you're a diabetic even if your other numbers are fine. So that is where the continuous glucose monitor is really helpful. I've had patients and sometimes just friends and colleagues who talk to me about it. They'll go out and get one because they're in the midlife, they're in their 40s, and within a couple of months, they've lost 25 pounds. And they realize what food does to their system, what exercise does, what stress does, simply by wearing a continuous glucose monitor.

A (27:52)

So I think there are so many learnings with the cgm. I haven't worn one in a couple years, but I did for, I think, like, seven to 10 days a lot, like a couple years ago. And I thought it was so helpful in just understanding. I had fun with it. I was, you know, I would say, like, all right, like, let's have a really fun meal, and let's see how this high, high. This thing can go. And I would experiment with foods. I had a great finding that chocolate and peanut butter really had zero impact on my. I was like, this is amazing. Just throw peanut butter on chocolate.

B (28:18)

We're good Reese's Pieces.

A (28:20)

Yeah. They're a healthier version of that, though. And so it was insightful. And I think that the thing that I've. I think the takeaway, for me, it was helpful to understand what foods really drove it. But I'm also very active and very fit. And I think the key is you have a problem if you're continually driving glucose high. And what you don't want in a healthy person, it drives high. Let's say you have your piece of bread or whatever, but then it comes down. We run into problems when it's just high, high, high, high, high. And then it takes much longer to come down. That's when the.

B (28:54)

That's one of the problems for sure.

A (28:57)

Right? Like, your body just becomes metabolically, like, inflexible. Is that fair to say?

B (29:02)

Yes. But you can also run into trouble if it's too low. Like, I've had people who think their intermittent fasting is fantastic. And they'll get a glucose of 40. They'll fast all night. They won't eat until noon, and then they'll go for a long run in the morning, over two hours and 40. And that's a guarantee to give you heart disease. And you're killing off heart cells and brain cells, so it's keeping it in that moderate zone. Think of it like your temperature. You don't. You're not necessarily 98.6. Like, I. My. My baseline temperature is usually 97, 97.2. But you want to keep it in this tight zone and it keeps your body humming along. And that's really. So you don't want highs and you don't want lows. You want it somewhere in between. That's why there are some people who shouldn't fast because their sugars will go low after two or three hours. And it depends on your genetic makeup. There are some people who have what's called reactive hypoglycemia. They really should eat every two, three hours. In fact, women. There are many women I've helped indirectly conceive spontaneously before they're scheduling their in vitro fertilization because they, they're so careful about how they eat and what they do. They put on a continuous glucose monitor and they're always too low. Always. And so the minute they correct that, they get pregnant. So that has happened over and over. And it's something that I don't believe even ob gyns use. They do testing when you're pregnant, but they don't actually know this is a fact. And it is a fact.

A (30:30)

It's so interesting. I do extensive lab work, like twice a year. And with glucose specifically. So, yeah, when I do my labs, I have to fast. And sometimes I go like, you know, 13 hours, sometimes 16 hours. When I tend to fast longer, my glucose will dip to like 60. When it's more of a normal fast, it's like squarely that, like 71. And so I find that very interesting as we think about time restricted eating and fasting windows, because I would venture a guess that when I fast, I'm one of those people. If I fast a little bit longer, my glucose will drop more significantly.

B (31:14)

So I can see from your body type that you have, I guess some people might call it an ectomorph. Like, you're, you look thin. You look thin and tall.

A (31:23)

Well, I'm, you know, I got some muscle here.

B (31:25)

Yeah, yeah, with muscle. I'm not saying there's no muscle. You're lean and you may burn through glucose faster. You may have a pattern. And that's why you shouldn't fast to below 70.

A (31:37)

I also, our listeners are probably sick of me saying this, but I started working out a lot harder, specifically like VO2 max workouts, rowing. The amount of sourdough bread I'm consuming is insane. And it's not. It's just like, I need the car. Like, I'm not wearing a cgm, but like, all my markers are pretty. Like, I, I feel I need the fuel Like, I feel like I need the glucose.

B (32:01)

Have you done a body composition to see what your distribution of muscle, what your percent body fat is your visceral fat.

A (32:08)

So I've done an in body scan. I'm like just under 10% body fat.

B (32:12)

How much muscle do you have?

A (32:13)

Like 100.

B (32:14)

Did you do one where you can actually see the amount of muscle relative to body fat? Because if you use it in body, for example, you want to have a nice D, meaning your muscle extends beyond your fat. So your present body fat is fine. But I've had people at high risk with the body fat fact. The gentleman I mentioned with Alzheimer's has a VO2 in his 40s. He's in his 60s. His percent body fat is 5% and. But you need muscle. Muscle is the longevity kind of organ of longevity.

A (32:44)

I have muscle, I'm strong. So I still have. I can still do what I used to do. Like, I'm still lifting real weight, for sure. Maybe you can't, maybe you can't see. Yeah, sure.

B (32:57)

Your parents, they. How young are they and how healthy are they?

A (33:00)

So my mother is 76 and pretty healthy. She, I think, didn't focus on maintaining lean muscle mass where I've been lifting weights since I was, you know, a teenager.

B (33:13)

That's always a positive.

A (33:15)

My father passed away. God, it's like 30 years. A little over 30 years ago, he had something structurally wrong with his heart. So he died of heart disease, but it was structural and I do not have that.

B (33:28)

He had a valvular problem.

A (33:30)

Yeah, he was born with like something with a valve that he didn't. I don't remember exactly, but I remember going for extensive testing after that happened, and I do not have that. I've done a clearly exam and my heart's, you know, I've got a little plaque, but like, my APOB is 59. I'm excited about that.

B (33:46)

And so aunts and uncles, grandparents, any diabetes or heart disease in the family? How about stroke? Cancer?

A (33:56)

No stroke. I've had cancer, but late, early 90s cancer. Mid 70s cancer.

B (34:06)

What kind?

A (34:07)

Colon cancer?

B (34:09)

Yeah.

A (34:09)

One in the early 90s, one in mid 70s. Heart disease in the 50s. But we're going back like 60 years ago. So, like, no one really knows what happened or what was wrong.

B (34:22)

And you're not on any medication or taking supplements or you take some supplements.

A (34:27)

But I take a lot of supplements since we have a supplement and I take a lot. The only pharmaceutical which I just started and I've had incredible Success is ezetimibe 10 milligrams. I don't know if you know Dr. Frank Lippman. Yes, he's my doctor. At his urging. So with my apob, for example, no matter what I did, like, I could never get it below 70, even if. And if I like what. And I'm. I'm don't lack willpower. And if I ever went a little less than my. Call it 8020 diet, it would go to the 90s. And so Frank, at his urging, was like, come on, just try Ezetimibe. I went from 91 to 59.

B (35:13)

Great.

A (35:13)

In 90 days.

B (35:14)

Have you done any other cardiac testing to see what's going on in the vessels? Have you?

A (35:20)

I did the clearly exam, which I think I'm curious your take, but a lot of people think that's the gold standard in terms of the 3D MRI.

B (35:26)

So you got a C. Did you get a CT ngo and then got a clearly. And you got a CT calcium.

A (35:31)

I got zero calcium. And I did the clearly. I did both of those a couple years ago. And like, in your view, the clearly, that's what I tell people. Because calcium too, could be misleading.

B (35:42)

Misleading, but it's predictive. Like if it's elevated, but Even if it's zero, 25% of people have cardiac disease. And the clearly is now becoming a way to look inside the wall. Because it's not just stenosis in where you see it visibly on a CTA or CT angio, it's. Are the walls closing in? Is there a buildup in the walls? So it sounds good. It sounds great. I think you'd feel a thousand percent better if you took testosterone or you took hcg.

A (36:10)

I think I'm on my way there soon.

B (36:14)

Well, I don't know how hard you work out, but I will tell you that most of the men I take care of, and I take care of more men than women nowadays. But as you know, I started women's health at YALE in the 1990s, way before became very popular because no one was giving women care. And it was pms hits, perimenopause, and it's miserable. And that's when I started noticing the connection between all these numbers. And I thought every doctor did that, but I was wrong. I didn't find out that till later. So connecting the dots to me and knowing a person's health story of the sort you're sharing and made it clear to me, and men would come back after a few weeks of my treatment and say, oh my God, I feel like myself again. And these were men who, like you, thought they were fine. Now there's a bigger group of men who don't feel fine. You know, they've lost the A game in the bedroom, in the boardroom, and they're not happy about that. But more often than not, it's subtle. So you don't really appreciate the decline at all. And you, if you push yourself, but I guarantee it's harder for you to work out and recover than it would be if your testosterone was in the sweet spot. You'd feel a lot better.

A (37:22)

I agree and I think so just to build off what you said, in my view, I'm curious your take having a baseline understanding of your genetics, so what are your genes? And having an understanding, doing some lab work and why I want to double click on the lab work. I think it's so important to note. I don't know if people realize this. I don't want to freak people out. But at the same time, be aware the population has moved to such an unhealthy place. You might be in the green, but that's not where you want to be.

B (37:51)

Right? Because it's population statistics. It's not unique statistics. That's the other foundational direction that I set this up. I actually set it up as a research study. I call it n of 1. And it means that each of us has our own path and by specifically understanding. And there's a great study on glucose that you might be familiar with from the Weizmann Institute in Israel, where they didn't even have a cgm, but. But they followed sugars in a thousand men and women and they show that in one person, fructose in a banana would shoot sugar up glucose up to over 200. But in another person, it barely moved the needle. But in the person that the banana was fine, she would have ice cream and her sugar. And they have this in the paper. This is scientifically published paper. Right. The, the ice cream would cause her to have a reaction, whereas the person with the banana could do ice cream just fine. So each one of us has that predict patterns. I actually like to use. I have two patients who are brilliant, really brilliant patients, and before they met me, they had tried the continuous glucose monitor. I thought it was fun. In the same vein as you were saying, how it can affect you, but when you really understand the, the science behind it and how the body metabolizes and what it actually does, the continuous glucose monitor is a game changer along with other ways to monitor like your sleep. And you learn very quickly you know what actually works for me? Not my best friends or even my brother or sister, but for me.

A (39:24)

So I'm wearing a whoop. I'm wearing an aura. How do you look at, or do you not look at all at resting heart rate hrv as signals of we're on the right track versus the wrong track.

B (39:37)

We look at all of it, but what's really critical, because as I said, I'm a data geek and I base this on trying to figure out how you actually find personalized, precise interventions that are meaningful for each and of one person. As I mentioned, my sister and I, while we have beautiful hemoglobin A1C under 5, my sugar tends to run high regardless. Like, I can fast all day. I barely have eaten today. My sugar can stay in the 80s no matter what I do. I can fast nonstop and not have an impact on me, unlike you. But our insulin started creeping up over the last 10, 20 years, and bringing that down was critically important because it leads to almost every disease of aging that you can mention, from diabetes to stroke to cancer. And so being specific to you as a human being is critically important. I've had the patients who say we do genetic variants in them and we tell them, listen, you shouldn't fast. It's not going to have any impact. And they'll say, funny you said that. I've always tried it and it's never had an impact on me and other people like you, if you fast too long, your sugar is going to go low and you'll probably get. You can get, you know, chilled, you can get fatigued, you can get low energy, you can even get with the hangry, angry and hungry. So it's hangry. So all of that has an impact. And so that's why we look at that exactly how you described it. Yes, a handful of biomarkers are critical. Of course, I do hundreds, if not thousands of biomarkers because I look at the impact of food, I look at the immune system, I look at telomeres, I look at the brain. We're now moving into brain health and how you reverse all Alzheimer's, Parkinson's, even ADD and anxiety. These are all genetic traits, by the way, that are driven by genes.

A (41:25)

Yeah. And like, I think brain health is so fascinating right now in terms of what we know about cognitive decline, Alzheimer's, dementia, genes risk, whether you're ApoE3 or 4, the double gene, tau versus amyloid. And it's interesting because there's. I'm curious if you have a view. It seems like There's a little bit of a debate whether it's like, a chicken or the egg, unclear whether it's. You know, there are people who have Alzheimer's who have tau, high P tau, but no amyloid, and there are people who don't who have, and vice versa, amyloid tau. So it feels like we're just starting to learn. There's something with amyloid and there's something with Taurus. But just because you are high in one or the other or both doesn't necessarily mean you will suffer from. Like. To me, it's, like, sort of helpful, but I'm like, oh, God, we probably got a lot of people running around and freaking out.

B (42:25)

I know. You can even see studies. There's a group in California that started years ago to have, like, a retirement village, and they did a study on them, and they show that there are people who have tangles throughout their brain. In one person, they. They can't speak at all. They're really incapacitated completely with Alzheimer's. And the other person, at 95, is playing bridge and on her bicycle. So, you know, here's the issue. We don't know what we don't know. And that is why teasing apart these variables that I've done for so many years has been so valuable. Because I can say, yes, there's a huge spectrum. It's totally driven by genetic variants, completely. But you can have an impact on your genetic variance. You can change the way the choices you make can affect how disease is expressed or not expressed. Do those genes turn on? Can you turn them off? So picking the right choices that fit you is critical. Or me that fit me right. And that's different than what my twin sister does. So it's scary in a way. But the other good news is that even by reading my book, you'll see that there are different paths that people follow. Your future health trajectory is dependent on the fact that you work out, that you're trying to maintain muscle, that you try to eat right, that you started taking Zetia, that you are correcting variables that are genetically driven, but you are taking actions that change how they express. And that is really why I. I do love genetics and I love genetic variants. We actually do a test that looks at 1700 gene variants or more. And I could tell, for example, just this week, a patient wouldn't increase their magnesium. They were already taking four pills at night. And magnesium is critical in, like, 300, at least 300 interactions in the body. It's important for sleep. It's important for The GI tract. A lot of people have low magnesium, and you want to look at magnesium in your red blood cells, right? And it turns out they had three of the four variants that you can absorb magnesium orally. So they're going to use a magnesium cream or take a bath with Epsom salt. How would you know that? In my case, too, I have a gene that I can't metabolize B vitamins. I'm sure you've heard of mthfr. And as a result, it caused me a problem earlier in life where I lost hearing. In one year, I had sudden sensory neural hearing loss. It's also associated with deep vein thrombosis. I've had a patient who crashed his plane and almost died because he didn't know he had that. And he had been seen at Mayo. Didn't matter. He had a huge vein, he had a huge thrombosis, and he had an emboli to his lungs, which causes you to stop breathing. And so luckily, he survived the plane crash and the deep vein thrombosis. And how would you know that if you don't measure so selectively? While those five biomarkers are a great place to start, because all of us can do something about it, there's so much more that we can learn if we're interested in doing it. And a lot of it depends on your history, your family history, your own

A (45:33)

personal history, and what gene test do you like.

B (45:36)

So we start with some simple ones that you can get at Quest or LabCorp or Boston Heart, all of which looks deeper at cholesterol, sugar, immune system, things like looking at Your risk of APOE4 is a starting point, for example, for dementia and also cholesterol. It actually started with cholesterol. So if you have ApoE4, your odds ratio, if you're heterozygote, meaning one of two genes, you got it from your mother or your father, or homozygote, you got both. That's meaningful in terms of your risk, but not as meaningful as genes under that surface. It's a test I do that looks at over 1700 gene variants. That's what happened with the magnesium. We looked. We looked up what this patient's management of magnesium, and he couldn't absorb it.

A (46:24)

So was that the bus? Was that the. Which tested that?

B (46:27)

No, this is a more sophisticated test that looks. It comes out of a group in Texas, a woman named Sharon Houseman Cohn. Have you heard of her?

A (46:38)

No.

B (46:39)

So it's a test that looks at over 1700 gene variants and allows you to make decisions that go much deeper. For example, you can be APOE4 homozygote but you may not have any of the other genes that make it far more likely and it speaks to your question of tau and amyloid and all of this far more likely for you to get Alzheimer's or not. So we're just scratching the surface in some ways in terms of genetic variants I like to look at atrial fibrillation risk, cholesterol risk. I like to look at mthfr. We look at clotting factors just deciding for example whether somebody, it makes sense for somebody to take a, a low dose aspirin which I very strongly believe in. I believe most people should take low dose. There's a lot of data associated with reducing if you've been on a low dose aspirin for seven years, reducing the risk of five cancers of the midline including in your case colon cancer. So there are studies that came out of, that came out with that. There was data from the Women's Health Initiative trial that showed that women on estrogen and aspirin had a reduced risk of colon cancer. So I think we don't know what we don't know but there's a lot of work out there that can be drilled down to the singular human being.

A (47:56)

I agree and it looks like it's intel XX DNA is the company interesting.

B (48:01)

One thing that affected me when I saw it is there's a lot of breast cancer. My mother was one of eight and all of her sisters and a lot of my cousins. I had 27 first girl cousins had breast cancer. My mother didn't. She was one of the only she lived till 102 and she never got cancer. But we don't detox well and so remember I mentioned my love of fish I could live on sushi and sashimi. My mercury, I was very proud of it for a long time. My mercury was 38 which is more almost four times what it should be When I first started this work over 30 years ago and I cut it down to less than 4 whereas my sister doesn't have that impact on her system because she doesn't eat fish.

A (48:43)

So.

B (48:43)

So these are the kind of variables that you can change in your life that can make a difference, even exercise.

A (48:49)

Yeah, I'm in the same. I am mthfr c677t comti I'm a terrible detoxer. I got started on this journey, you know everything I became passionate about testing and supplementation. My homosis team was 63.

B (49:11)

Wow, that's that you beat my mercury level.

A (49:15)

My Mercury was only 38 and so I've got it. It's like in a range, it's still high. It's between called 11 and 16, but that's a hell of a lot better than 63.

B (49:27)

And you take, you take methylated folate and B12 and riboflav.

A (49:31)

Yeah, we have, we have our own methylated bees with betaine that we formulated here that we sell.

B (49:36)

And yeah, we, we, what we don't know can really hurt us. And by really understanding what these variable. But be cautious about AI because what I love AI, make no mistake, I think it's fantastic. And we have our own proprietary database because, you know, I built what I did prospectively to collect data and a proof of concept. And now I know I've proven it, I have data that shows that. But I've always wanted to be able to automatically get answers. So it's a dream come true. Because sometimes you sound like a broken record when you talk about things, right? You're repeating yourself with basics. But just like Watson, you remember Watson, garbage in, garbage out. I think AI, we're at that point in AI where we don't know if the answers are really good answers. And a lot of times they quote literature that doesn't exist. And how do you tell what's a good answer? So a lot of my patients, many of them are Silicon Valley folks and like to do these kinds of things and they'll say, how come I'm not finding this answer that you told me? And I'm. It's not out there. You know, what's out there is the World Wide Web and they can get everything. But how do you know it's good information or bad information? I remember saying that about the Internet. Everything glows. So at least in libraries, books get old with age, right? They yellow with age. You know, maybe that's old data. But on the Internet, you look it up, you look up heart disease, you'll get 25,000 or more answers. And what's the right answer for you? That's difficult to discern.

A (51:07)

I agree. I think AI is extraordinarily powerful and I leverage it and I put all my labs there. But sometimes it's wrong and you need to know when to push back. And is this the right prompt? And let's revisit this. So there are some watch outs, for sure.

B (51:20)

Just like the data you're getting on your lab reports, which is based on average population. Why would you want a population data to be translated to you 100%.

A (51:31)

So in closing the book, where can people find it? Let's close with the book so you

B (51:37)

can go to our website because we have a link to it. The name of the book is Invincible. So we can probably give you some of this data because it's not something I keep top of mind but the book is being published by Hachette Little Brown Spark and I think it's already available as a pre order and I'd love people to order it because I really do want the word to get out. I've always. I've dreamed of this for years in that Jason, I this is for everybody. And yet it's so hard to get healthy and know we. We're lucky. We have access and we have knowledge, but it isn't generally out there. Even getting medical help when you're sick is hard to get, much less to figure out what you do to stay healthy. So my dream is that it becomes a bestseller so everybody hears about it and can use it in the way they find most useful. So Invincible.

A (52:30)

The book is amazing. I encourage everyone to buy it. And Florence, thank you so much.

B (52:35)

This was fun.