Follow the data.
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Focus on the leading causes of death and disability.
Playing with your grandchildren?
First, start with you!
We will spend the first visit or two getting to know each other. I will seek to understand your goals and preferences so we can tailor the care plan to your objectives, concerns, budget, risk tolerance, etc. Though I list many possible tests and interventions below, you may decide that some or most of them are not for you–and that is perfectly fine! Other folks may want to explore even beyond what I’ve outlined below.
An analogy I use with patients: Your ship is your body, and you are the captain of the ship. Your job is to keep your ship in the best possible condition to take you through your life’s voyage. You may have the opportunity to get a tune up, or swap a part, but this body is the only one you’ll get.
You get to decide whether I qualify to be your first mate. In that role, my job is to advise you, present a relevant care plan, prescribe the most appropriate medications and testing, suggest specialists when needed, and recommend the maintenance that includes preventive care and lifestyle changes. Your job is to decide whether or not to implement my suggestions.
Below, you’ll get a sense of my approach to the most common threats to healthspan.
Cardiovascular disease
The number one killer but also the most preventable. Starting early is critical because risk factors (cholesterol, blood pressure, smoking, etc) have a cumulative effect. Remember: if you don’t develop heart disease, you can’t die of it. We can use a variety of specialized testing to understand your baseline (advanced lipoprotein and metabolite testing, home blood pressure, coronary artery calcium +/- coronary CT angiography with Cleerly AI plaque analysis). Then we can develop a plan to aggressively prevent or even regress existing disease.
Our office has a research grade unattended automated blood pressure monitor that was used in the SPRINT trial as well as access to novel patch-based 24 hour continuous BP monitors and camera-based BP monitors.
Detailed family history
Advanced lipoprotein testing (ApoB, Lp(a), LDL-TG, OxPL-ApoB, F2-isoprostatanes, etc)
Coronary calcium scan +/- CCTA w/ Cleerly
Metabolic optimization; dietary, supplement and exercise interventions
Liberal use of PCSK9 inhibitors to achieve aggressive ApoB goals titrated to risk
Cancer
The number two killer, still with a significant preventable component, primarily through lifestyle interventions and thoughtful screening. We can do genetic testing for hereditary cancer syndromes and screen for early stage pre/cancer when it is most treatable. We’ll take a personalized approach to your cancer screening which would include traditional strategies (eg, colonoscopy, HPV testing, low dose lung CT) but could also include newer approaches (eg Grail Galleri blood testing and/or Prenuvo MRI). As always, discussion of benefits and drawbacks to these approaches is essential. If cancer is found, getting you to the right specialists is critical. Lifestyle factors remain hugely important in adjuctive treatment for cancer (exercise, metabolic techniques such as fasting and/or ketosis).
Preventive lifestyle strategies
Genetic screening for cancer syndromes
Thoughtful screening using existing approaches
Nuanced discussion about pros and cons of newer approaches (Grail, Prenuvo)
Referrals to leading cancer centers
Neurodegenerative disease
A diverse group of diseases with many disparate causes and mechanisms, the most common diagnosis being Alzheimer’s dementia. Starting with understanding family history and genetic baseline (ApoE), we can develop preventive approaches using best practices in diet, exercise, sleep, cognitive engagement, stress management, supplements (B-vitamins, lithium, Omega index, etc.), and discussion of HRT. For patients with existing symptoms or disease, we can discuss neuroimaging, treatments (eg, ketosis) and referrals.
Family history and ApoE status
Optimizing diet, sleep, micronutrients
Exercise protocols to increase BDNF
Advanced testing (eg p-tau217, NeuroAge)
Discussion of research on medications like DORAs, rapamycin and estradiol on brain health
Metabolic disease
An umbrella term for a diverse set of diseases that are all related primarily by insulin resistance. Best understood as a spectrum: on one end imagine an optimally healthy athlete who can utilize, store, and switch between fuel sources such as carbohydrate and fat efficiently without significant increases in blood sugar or insulin; on the other end of the spectrum, a person with type 2 diabetes who has both high blood sugar and high insulin, and a diminished ability to burn fuel for energy. In the middle of the spectrum are common conditions such as “prediabetes”, non-alcoholic fatty liver (NAFLD/MASLD), metabolic syndrome, or even normal blood sugar with elevated fasting or post-meal insulin levels. Your position on the spectrum determines your risk of not just developing end-stage metabolic disease (diabetes) but also a variety of other chronic diseases (cardiovascular disease, cancer, dementia, etc).
Because metabolic health is foundational to healthspan, we will strive for optimal metabolic health. We will first get baseline data with lab testing, CGM +/- oral glucose tolerance testing, DEXA body composition scan, VO2max testing. Then we will develop a plan which includes exercise and dietary prescriptions, repeat testing at close intervals and frequent iteration. We may use a variety of medications/supplements as well on a case-by-case basis (GLP1, SGLT2i, metformin, acarbose, etc).
Advanced lab/metabolite testing
CGM +/- OGTT
Serial DEXA scans, lactate threshold and VO2max testing
Targeted dietary, fasting and exercise prescriptions
Choosing the optimal medications and supplements for you
Emotional health, stress and sleep
This is arguably the most important component of healthspan of them all. Mood disorders have a disproportionate effect on healthspan relative to lifespan though on average they do also shorten lifespan. I am well-versed in diagnosing and treating common mood disorders using traditional approaches (medications, therapy) but also evidence-based lifestyle approaches (HIIT, dance, keto, mindfulness), supplements, and can refer for extremely effective novel approaches like ketamine-assisted psychotherapy, transcranial magnetic stimulation, etc. For patients with and without overt mood disorders, we can also discuss stress management, living authentically, defining priorities (eg, emphasizing “eulogy” rather than “résumé” virtues), and ways to optimize mental health and sleep just as we do physical health.
Mood assessment
Traditional and novel approaches to treatment of anxiety and depression
Treatment of insomnia and sleep optimization
Stress management with lifestyle and complementary approaches
Referrals to highly trained therapists and psychiatrists
Cardiorespiratory fitness and strength
VO2max is the single best predictor of longevity. Risk of early death is 200% greater for sedentary people vs highly fit people (for comparison, smoking is 40% higher). Strength is the second best predictor of longevity. These are not just vague numbers that affect chronic disease and mortality risk in some abstract way–they also concretely determine, for example, if you will be capable of lifting grandchildren or walking up a flight of stairs. Though they typically decline with age, they can increase at any age with sustained training.
We will start by measuring baseline fitness and strength/muscle mass with a variety of functional and imaging studies. Then we can apply proven techniques (eg, Zone 2, Zone 5, progressive overload) to improve these measures over time. We’ll discuss supplements (eg, creatine, omega-3, HMB) and screening for hormonal causes of low muscle mass. Referral to physical therapy and/or personal trainers versed in skills like dynamic neuromuscular stabilization as appropriate.
Baseline cardiopulmonary exercise testing (VO2max, Zone 2/lactate testing)
DEXA and functional strength testing
Individualized exercise prescriptions working alongside physical therapists and trainers
Supportive medications and supplements as indicated
Non-disease specific longevity
In concert with addressing disease-specific threats to your health, we can consider interventions which have a more generalized effect on slowing aging. These are drugs and supplements which generally haven’t been subject to long term human clinical trials but have strong animal data (eg from the NIH Interventions Testing Program). Rapamycin is an mTOR inhibitor with a strong track record and safety data. Other molecules of interest are GLP1/GIP drugs, SGLT2i, acarbose, glycine, Klotho, urolithin A.
Rapamycin and other rapalogues
SGLT2 inhibitors, GLP1/GIP, acarbose, glycine, urolithin A
Ongoing careful attention to developing research, eg Klotho