The 5 Most Important Biomarkers That Influence Your Health & How To Live Better For Longer with Dr Florence Comite #666

30:41In an idea, today's episode is sponsored by Do Health, a personalized health companion that I have helped create. Now I built Do Health to transform the way we think about health. You see, for many years whilst working in the NHS, I saw the same thing over and over again. Modern medicine is really good at treating illness, but it was never designed to prevent you from getting sick in the first place, nor to optimize your health. Do Health is here to change that. It takes everything that I know about health and well-being, including my four pillars of health, and makes it personal to you. You get an initial blood test which measures and screens you for over 50 biomarkers, but then all the focus turns to the 11 core biomarkers that are scientifically proven to improve your metabolic health, including many markers which are not easy to get from your NHS GP, like fasting insulin, APOB, and homocysteine.

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32:47All you have to do is go to dohealth.co forward slash livemore and use the code livemore to gain access to the waitlist right now. In your world, how often would you track these five biomarkers in an individual?

33:17from your experience in an ideal world how often would you track these five biomarkers in an individual if you're talking about number of times a year i think that the ideal would be at least twice a year and maybe three to four times, depending on your makeup. And when I say makeup, I mean your health story. How are you living life beyond a chief complaint? Let's put aside the chief complaint of old fashioned conventional medicine, where we're treating disease and usually acute disease, although chronic disease has now taken place in a way that takes much more attention and costs us trillions of dollars.

33:59And so I believe, though, there's a far better way to do it. You should get biomarkers on some kind of regular basis. But ideally, you can manage your own sugar fluctuations. You can see if a banana raises your sugar or a cookie does because each of us as that N of 1 is unique. And there's research out of Weitzman Institute from a few years ago that has shown two different individuals, one whose sugar can go up to 150 with the banana because of the fructose, and the other one, the banana doesn't move the needle at all. The sugar stays about 85. The other person who's with a banana triggers it, a cookie does not.

34:38And the reverse is true of the person who a banana has nothing to do with their sugar. And so when you look at it that way, having the knowledge within your own system, within your own hands. So that's why I'm a strong advocate for the continuous glucose monitors, because instead of just arbitrarily getting blood and then waiting a few weeks and being told, oh, you're in the normal range or just about, or maybe it's a little high, you better get to the gym, you better eat better. You're going to be able to tie exactly the way you live life to the fluctuations in sugar. I agree that CGMs can be really powerful if you use them in the right way.

35:16And there's a really nice section in your book, actually, where you explain to people how to use CGMs, which I thought was very valuable. But I just want to get back to this point of how often to check these biomarkers. And when I was creating Do Health and I was chatting in the clinical meetings, a lot of people were saying, no, no, let's just check once a year. I said, no, guys, you cannot check these biomarkers once again. I'll tell you why. In my view, because some of the biomarkers we're checking that overlap with yours are amenable to lifestyle change. So the problem is, is if you only check it 12 months afterwards, you don't remember what you were eating or how you were working out 11 months ago or nine months ago.

36:02We have chosen initially at least to check every four months. Now, I suspect over time, if someone is in really good shape, we could probably reduce it to twice a year. Some people, we might need to raise it to four times a year because you want to know, let's say your fasting insulin is high and your HbA1c is high. So you know that there's an issue here with my, you know, I may have a degree of insulin resistance. You want to then make some changes and relatively soon after that, see, has this made a difference. And that's the most important piece to me, because I absolutely agree that, you know, four times, three times a year to get a sense of, are you making a change and what is the consequence of that change?

36:44And if you can't get that feedback, what's going to have you stick to that change? If you don't know what's happening, you're not going to stick with it because there's no positive result from it. And yet, if you know that you're defining yourself and you're CGM CGM 24-7 allows you to actually make the connection and connect the dots between the way you eat, for example, as just one example, or the way you sleep or drink alcohol, or how close to bedtime are you eating because you want to stop eating about two hours before bedtime to allow your body to clear metabolic waste from your brain and your body.

37:19And by wearing a CGM, you take control into your own hands. There's, in fact, many doctors in the United States and some very brilliant people that I've worked with, before they started working with me, tried the CGMs because they were a fun tool. They looked like they'd be helpful. Completely confusing to them. So I think part of the issue here too is how we give clarity to each person about what that number actually means. For some people having wine at dinner, a couple of glasses of wine, their sugar will go up high, but then in the middle of night, they'll have insomnia. That's a way of just seeing why you're not sleeping through the night.

37:56Because the blood sugar is dropping. to dropping. And so it is life-changing for people. So while habits make a difference, lifestyle makes a difference, in a vacuum, it really doesn't. It really can't. What do you mean by that, in a vacuum? Meaning without knowing what's really going on inside your body, you don't know that you're heading in the right direction. You may feel better, which is great. You may get more energy if you've learned to control sleep and you're not waking up at night and you're getting adequate deep sleep. Lots of us sleep through the night and don't get adequate deep sleep.

38:29If you do get good deep sleep, even if you have only a few hours, let's say four or five to sleep or less than six, then, and you feel great, it usually means you're getting adequate deep sleep. When you get less than adequate deep sleep, less than an hour, even if you sleep long, a long period of time, like 10 hours, you may not feel so well. And so we're very complex human beings. To figure out what's going on, the wearables also beyond continuous glucose monitors, for example, the Apple Watch or the Aura or the Whoop will give us insight into your own daily patterns. And I think that's a very valuable thing to own.

39:09What are some of the key things you learned about yourself from wearing a CDM? So one of the things I learned is despite my optimal hemoglobin A1C, again, the average sugar over 100 days, my sugars could go very high and very low. And when I'm sick and just a little sick, my sugar's high. It can usually range in the 90s or even over 100. When I'm very sick, I become hypoglycemic, which means my sugar falls below 70. So I've learned how to assess how I feel and tie it to the data. And as a result, I can extrapolate from that. You don't have to continue to wear like you and I do. We just shared our continuous glucose monitors on our arm.

39:52You don't have to wear it day and night. I'm a data geek. You're a data geek. We want to know. But for those of us who may not be, having that internal knowledge and then experimenting and then maybe getting blood work two, three, four times a year will help reinforce the changes you're making. Yeah, I think I've shared this before on the podcast, but I remember the very first time I wore a CGM, I was shocked by how much sweet potato wedges in the evening would send up my blood sugar. It was kind of in the pre-diabetic range. I was like, wow. Now, again, we're not necessarily here to demonize anything.

40:31For me, that's power, that knowledge, because now, armed with that information, I can now make an informed choice. Maybe on occasion I will, but generally speaking, I won't eat that much anymore. And I also learned about volume. If I halved the amount and had that and had it at the end of my meal, so I might have the salmon first and I'd leave the kind of carbs to the end. I was like, hmm, well, that's a pretty stable blood sugar. And you know why that happened? So I can explain it slightly. And I have another story about sweet potatoes, which I can talk about a little later, that affects me and the eyes.

41:10and I've given them up because of that, because it's an issue for inflammation and risk of macular degeneration. Well, please do share. But going back to it, when you have carbs and you have them before you have a protein, you're gonna send your sugar high. It's like having a bran muffin and a banana for breakfast. So your sugar goes sky high, it starts dropping, but insulin follows shortly thereafter, it goes high. So two hours later, you're grabbing a donut and a cup of coffee. When you have protein first, like eggs, or as you mentioned, salmon, and then afterwards you add, so the order of macronutrients is really critical, your sugar is going to rise slowly like a gentle mountain and the insulin follows very closely behind.

41:53So you're not going to create a situation where the sugar is really low and your insulin is making it lower. So you feel cranky, irritable, tired. You may even feel sleepy or hangry, you know, hungry and angry. And so the way the body processes food means if you learn that about yourself, you can have your sweet potatoes, but you're just not gonna overdo it and you're gonna do it in the right order. Yeah. My view on CGMs is that I think everyone would benefit at least once in their life from having it on for at least 14 days just to see what they learn. Now, I think for some people that may be all they wanna do, right?

42:31I think some people benefit from, and I used to do this. I would do it like once a quarter. You know, every three months, I'd pop one on the last two weeks. And it was just a way of seeing what's going on. It could sometimes remind me of stuff where I slipped up. At the moment, I'm wearing it quite continuously because I'm experimenting with a few things. But again, I'm not saying everyone has to do that. You know, I like learning about this stuff. I like learning about it for myself. I like learning about it so I can share it with people. I just, I think it's important to say that because some people are going to hear that.

43:03I go, well, I don't want to wear it continuously. I agree. I agree, except I'd make one little tweak. The tweak I would make is wear it for the two weeks, decide on some small step you're going to take. This is for those who may not be as invested as you and I are in health and what's happening because we want to share it with other people. We want to make sure that people can stay as healthy as possible for as long as possible. And then wear another one when you've made that change so that at least you get a, it's like a process where you can see for yourself. It's so affirming when you do that.

43:34It really is. And it really helps you. Now, I wear it continuously. I've worn it for years. I actually brought it in from another country. Before America, we had in the States direct to consumer where you had to come into the doctor with a little hard drive, a little round disc. And it's changed people's lives. I mean, it has made a huge difference. I had a patient, I recall just he stands out in my brain. He was an avid bicyclist. He would go up steep mountains, but could not lose about 15 pounds over a period of years. He was in his 50s and he was confused about it because he was pretty. He was exercising hard.

44:09And it turned out we got his body comp and then put a CGM on him. And we looked at him a month later and he said, I can't believe it. I was doing this with my daughter who's 16. And every morning he had rusk over a cup of tea. and the rusk, the biscuit with no protein caused his sugar to go up really high and then plummeted. And it showed him that if he eliminated that, he actually lost five pounds in one month. Yeah, it's so powerful. But I just wanna highlight something that I think you mentioned, you certainly talk about it in the book, this idea that all of us are prone to issues with our carbohydrate metabolism.

44:53that's i think quite a provocative statement for many people i think it's it's really interesting way to think about this and this idea that as we get older most of us are going to have a degree of insulin resistance or hyperglycemia high glucose or low glucose hypoglycemia but but broadly speaking broadly speaking that's why i don't think of it as diabetes type 2 because that sounds like it's a very neat definition of one form of diabetes versus type one. So that disorder of carb metabolism is a derivative of us living longer with less hormones, particularly testosterone that makes muscle, which packages sugar for us.

45:38So with less muscle, it's a circular thing. We have more sugar circulating around and we end up getting disorders of carbohydrate metabolism, which leads to almost every single disorder of aging from diabetes to dementia. Yeah, this is fascinating. Okay, let's go back to these five biomarkers for just a moment. We've spent a little bit of time talking about the first three, which are all to do with carbohydrate metabolism. They are all in your book, but would you mind just sharing what levels you like to see in your patients for those three things? So the fasting glucose, the A1C, and the fasting insulin?

46:14Yes. So for fasting glucose, ideally you're looking at 70 to 80. It doesn't mean if you're 81 that it's something you don't have to panic about it. It's going to fluctuate. It's going to fluctuate for a lot of reasons, what your health is like at the moment, what you've eaten, the workouts you've done. On a day you work out, you may look different than on a day you don't or the night before. Fasting insulin, you want to have no insulin in your body 12 hours or 8 to 12 hours. Actually, three hours after you eat. In the United States on one lab test, it says your insulin could be up to 19. You don't need insulin when you have no food in your body to process.

46:55So after three hours, it should be undetectable. Undetectable and hemoglobin A1C, five, less than five. And, but keep in mind that the combination here can vary and does vary from person to person. Some people can have an elevated insulin. a fasting sugar that is 70, and a hemoglobin A1c that's 5.2. And it points to different paths, and that's described in the book. Yeah. So you want all three so you can actually see the context and what's going on, which is really important. Let's not go through in detail into all of them, but because we've already mentioned A1c and the 5.9 that may be reported as normal here in the UK, right?

47:40You're saying, and this really got my attention in the book, under five is optimal. Okay. Now, that is the lowest optimal I think I've heard. I've heard people talk about five or 5.2. I've certainly seen some data showing us that as our A1C, this average blood sugar reading goes above 5.2 in a linear fashion, our all-cause mortality also increases. Okay, so just to make it clear for people who don't have a scientific background, as it goes higher way before pre-diabetes or type 2 diabetes, your risk of dying from multiple causes is starting to go up. This is this idea that health is a continuum.

48:27him. So this under five figure, to me, it sounds quite aggressive, but I know you'll have a rationale for it. Why do you think the optimal level should be under five? It's based on data. Now it's based on data that's a bit flawed because you can't look at everything. But the data in the literature that I quote, and there's references in the book, because I meant for this book to not just go to the man and woman on the street, because I want everybody to own ideas about what they can do for themselves, but to their clinicians, to their doctors, because it's referenced. So you can look this up and see what it's all about.

49:04And you can make sure that there's scientific backing to it. And the papers that have reported hemoglobin A1c of less than five is associated with less diabetes and disorders of chronic disease that you just talked about. So as hemoglobin A1c creeps up by a tenth of a point, that change is dramatic and your risk of disease as you age goes up with each tenth of a point. Do you think that these kind of optimal ranges or numbers we're looking for vary from person to person? So could it be, because we are all individual and that is one of the big themes in your book, could it be that for someone 5.2 is okay for them?

49:49That's your definition of they might be okay. We don't know. But as far as perfection goes, I don't aim for perfection. I believe in moderation and not deprivation. And I believe that, yes, there are some people that can have a combination that maybe they're 5.1 or 5.2, but they counter it with what else they might do in their life. But once you're creeping above five, you're heading towards first pre-diabetes and then diabetes. So in general, that's the case. But because we're each N of one, and I'll use my identical twin sister and myself as an example, she's on metformin. I can't tolerate metformin because of my GI tract.

50:31I have an issue in my GI tract, which I found out years ago. I have ischemicolitis when I'm dehydrated and when I'm stressed. I tend to have symptoms that aren't very much fun because I bleed and it's very painful. And I'm able to keep it under control. And so as identical twins, her numbers are going to vary a little bit more than mine. And she does great on metformin. My gut can't tolerate it. So each one of us has to walk a path that's a fit for us. We don't know what your genetic variants are. And that's far more sophisticated. I look at thousands of genetic variants. The combinations that you can have for diabetes and risk top more than 2 ,000, 3 ,000 now.

51:12There isn't like one strand. It isn't like, oh, if you have this, you're going to be a diabetic. It's actually far more complicated because it involves the entire system. It's very complex. Yeah. Okay. I want to get to testosterone because I think it may well be one of the most misunderstood hormones. So I would say that most people or many people think about it as a male hormone. And they think about things like muscle, aggression, sex drive. but in your book you very powerfully link it to insulin resistance heart health visceral fat brain fog loss of motivation so dr kamiti talk to us about testosterone what do we misunderstand about it and why do you think it's so important for men and women okay i'm happy to do so i have myself have been on testosterone for 30 years because of a high risk of osteoporosis inherited both on my mother and my father's side.

52:11I had an aunt, a maternal aunt and a paternal aunt who had osteoporosis. And I knew that one of the ways I can strengthen bone was with testosterone. So 30 years means probably somewhere in the mid nineties you were starting this. Were there many people taking testosterone in this way? No, I can pretty much assure you that if it was 5%, that was a lot. And also in this day, there aren't many because there isn't a deep knowledge of the fact that in women, testosterone is low. We lose it just like men do. It's critical for bone health, memory, cognition, muscle. And most of the men I treat, when they use testosterone and they get it into the optimal range, their sugar naturally drops, their hemoglobin A1C naturally drops.

53:01And we use testosterone, but we also use peptide agents that actually stimulate your own testosterone. So testosterone is really a critical hormone for me. And I'll tell you where the data came out for me. So I mentioned having an identical twin. We get bone dentitometries pretty much yearly. I knew I had osteopenia 30 years ago, as did my twin sister. I started then. She started about 15 years ago. And she has early osteoporosis. And I still have the same bones that I had 30 years ago, osteopenia. So now we're going to treat her for the osteoporosis, but had she been on it as long as I do, I would venture to say that she would not have osteoporosis at this point in time.

53:44So we know, for example, just to carry that a little further, that women get Collie's fractures of the wrist beginning in the 40s and 50s because the wrist is more vulnerable. We don't walk in our hands and we don't reinforce bone there. And as hormones shift, and then about 10, 20 years later, it's fractures of the hip and then shrinking spine and shrinking kyphosis and buffalo hump. In men, osteoporosis occurs in the same numbers. 25 % of all men, 25 % of all women will become osteoporotic. That one disease alone can destroy your life. You can die when you break your hip. You don't live alone afterwards of the people who remain.

54:2650 % of them can't live alone. today's episode is sponsored by lingo by abbott as many of you know when glucose is relatively stable you feel better day to day with steadier energy mood and focus but over time unstable and elevated glucose can impair your metabolic health and increase the risk of type 2 diabetes and cardiovascular disease. Globally, more than 760 million adults are estimated to have pre-diabetes and 6.3 million people in the UK are estimated to be living with pre-diabetes, many without symptoms or a diagnosis. Now the problem is that our healthcare system often waits until you get sick before taking action when we should take a proactive approach to prevent problems before they start.

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56:14Again, that's hellolingo.com forward slash live more. This episode is brought to you in partnership with Airbnb. Now my family and I have been lucky enough to have had some fantastic trips over the years. This summer we're planning to go to Greece and check out some of the beautiful islands there and we've just booked a villa on Airbnb to kick our trip off and I honestly can't wait until the holiday begins. And it did get me thinking, whilst we are away, our own house will be sitting empty. And that feels like a missed opportunity, unless of course, I list it on Airbnb. You see, if you list your own space on Airbnb while you're away, you could earn a little extra money that you can put towards that house renovation you've been thinking about, a side project, or maybe that extra cash could help you pay for all those delicious meals you'll be eating on holiday or even your car hire.

57:18It's really easy to set up and just makes sense to do. So, if you've got a trip coming up, even a few weeks away, it might be worth asking yourself what your home could be doing whilst you're gone. Your home might be worth more than you think. Find out how much at airbnb.co.uk forward slash host. And so you want to start young so that you could sustain bone turnover. And I saw that because men had stronger bones and don't start losing bone, it's about 10 years later, it made sense to me that testosterone would help prevent bone loss and would keep my bones strong. So that was for me to test and for me to find out that my twin sister, because she wasn't on it as long, had developed more bone loss than I did at that stage.

58:11This is so interesting. So people who regularly listen to this show will know, because we've spoken about it on numerous occasions, that after the age of 30, we start to lose muscle mass each year unless we do something about it. Now, as I think about what I've read from you and what I've just heard you say, it begs the question, given that we're losing testosterone, I think you're right, is it 1 % to 3 % a year after the age of 30? Is the muscle loss that we all experience, unless we do something about it, massively or largely influenced by the fact that our testosterone is dropping? I think there's a direct impact.

58:59I don't think it's the only factor, but it's the main factor. I think if you don't eat enough protein, one to two grams a day per kilogram of body weight, if you don't work out and do resistance exercises, you are going to lose muscle as well. But testosterone is the driving factor, as well as sugar management. So if we broaden this out beyond the patients in your practice, Do you think that if a society wants to age well, then most men in that society would benefit from having some form of testosterone replacement, whether it's HCG or testosterone, once they hit middle age? So let me just tweak that a little.

59:46Please. Men and women would be better off with optimizing testosterone beginning in the 30s. As a scientist and a physician, I'd like to see a measurement or two to see where we're at, particularly free testosterone, not total. As an explanation, total testosterone is caught up and bound in proteins like sex steroid binding globulin. And so when that happens, the testosterone isn't free to act on your cells. And so that's a critical piece of understanding why it's misleading to use total testosterone as the point of reference that free testosterone is the active hormone that you need to understand.

1:00:29It affects sugar. It affects memory. It affects cognition. It affects heart. It affects bone. It affects every cell in the body. And so I can point to patient after patient. And that surprised me. I have patients, I'll speak of one, who was ripped. He was in amazing shape. And he was in his 40s, close to 50s when he came to me. And yet he worked very, very hard. He's actually in the news world. And yet he came to me and he said his memory was definitely slipping. And it was affecting his profession and what he needed to do. He would forget people's names. He couldn't report on that. And he couldn't talk about things that he loved, that he was very into because he was forgetting the details.

1:01:12after a few months on testosterone, because he was doing mostly everything as well as you could, eating well, working out, sleeping. And after a few months on testosterone, his memory started returning. And for the last 15 years, he's been fine. And this is a man where Alzheimer's also runs in the family. And so his fear of going down that path contributed to his memory loss. but I've had other patients who I couldn't even take initially alone. I would have to have a loved one on the phone with them because I do a fair amount of telemedicine in introducing the ideas and what we explain. And within a few months, largely about three months, they were acting like their memory was repaired.

1:01:56So the role that testosterone and estrogen play on memory is vital. And I was surprised by that. I didn't, the data wasn't really, what is there? And you will find those papers is low testosterone is associated with every disorder of aging too in some ways like sugar your views on testosterone it's not the current prevailing view with a lot of doctors i would say how does this fit in with this idea of aging gracefully so you know that we're a very appearance orientated society, we've lost the ability to accept our mortality and the fact that you know, as we get older, we're not going to have perhaps the vitality that we had in our 20s.

1:02:46So if someone is thinking that when they hear you talk about testosterone, what do you say? I ask if it's common for people to age and stay strong or do they get weak and frail? Do they They need to depend on others to care for themselves. Are they enjoying life? Do they want to live a long life because they're not in good shape? If you ask people, most people don't want to live way beyond 90 and even short of that because they see illness. And so the whole question to me is the quality of your life. It's not really about longevity. I take that for granted if we keep people healthy and strong.

1:03:25And the natural indication is to decline. Our genes don't usually dictate living forever, although there's a group of people who do have genes that let them live for a very long life. The oldest old who have certain genes that are inherited. There's a group of Ashkenazi Jews who have lived beyond men, beyond 110 women, beyond 115. But when you ask about testosterone for everyone, I think as trained physicians, we never say 100 percent or zero because I've seen exceptions. I've had a group, I can count them on one hand, a few people who aren't on hormones and they're still thriving and their muscles are pretty standard.

1:04:06So genes are dictating how we survive and how we live, whether we live well, poorly or chronic disease. We have introduced life-saving measures like antibiotics that allows us to live longer, but not necessarily to create strength in every organ system. So to me, understanding yourself and being able to apply certain rules will allow you to live gracefully as you age. So I have two follow-ups, I think. Okay, number one is related to lifestyle. Can a man bring up their testosterone using their lifestyle? I guess that would be my first question. and the second question I think we need to cover at some point is are there risks to taking testosterone and side effects that we need to be aware of

1:05:09can a man bring up their testosterone using their lifestyle I guess that would be my first question. And the second question I think we need to cover at some point is, are there risks to taking testosterone and side effects that we need to be aware of? So the answer to lifestyle is essentially no. You cannot work out harder, do more, eat more protein, and raise your testosterone with any supplement that I've ever tested. But hold on, this is a really important point. We do know, for example, that people who sleep less, like men who maybe sleep five hours a night compared to eight hours, will have lower testosterone.

1:05:50Yes, but that's lower testosterone, not increasing testosterone. That's not optimal. If you sleep well, yes, so sleep will, it's a different question that you just asked. Okay, I got it. This is really important. Go for it. You cannot, let's say you're doing everything right and you make no changes in your lifestyle because you're sleeping well. You're sleeping maybe six to eight hours, maybe 10, but getting over an hour of deep sleep, over an hour of REM, and you're able to do that pretty regularly. Your testosterone is going to be low. The reason your testosterone is low is because you are getting older and your body isn't listening and making enough testosterone.

1:06:29I've read over and over again in Men's Health and elsewhere that working out increases testosterone. What working out does is increase growth hormone, which is a peptide hormone that's synergistic with testosterone, works together with testosterone, but doesn't increase testosterone. Now, if you aren't sleeping or you have a newborn baby or they have issues, your testosterone can fall because your body isn't in its prime. It isn't doing what it is. And when you address those things, it will go up. Yes, but that is presuming you're in your 20s or your 30s or your 40s, but it's not going to go to optimal.

1:07:03Okay, so let me just make sure I've got this point, right? So, if you're, whatever your age is, let's say you're in your 40s and your lifestyle has slipped because of life situations, young kids, elderly parents, too much work, not sleeping, whatever it might be. if you then address those factors and are able to yeah your free testosterone again may increase but there's a ceiling on that yes and you're saying that sure optimize your lifestyle as much as you can yeah that's the low-hanging fruit that will help but for some people that will not get you to optimal free testosterone levels exactly okay so that's really interesting because So that's the case then.

1:07:48As you said with that patient, he was doing, from what I recall, everything right. Like he was following all the lifestyle advice. But when you added in, was it testosterone or HCG? And maybe you should explain the difference to people. Sure. It was HCG. We tend to default to that because it's a peptide hormone that allows a man, not a woman, just a man, to produce their own testosterone. It stimulates the testicles in a way that creates a more production of testosterone. Because what's failing in men decade to decade is stimulation of the testes. So there are particular hormones that are just not paying, the brain isn't paying attention to what's going on in your body.

1:08:29And there are fewer rises in something called LH, which then leads to increasing testosterone directly for the testes. So you are making your own testosterone and particularly someone in your area of life is very likely to need that. And there are ways to tell by measuring those other hormones, their pituitary hormones, LH and FSH. If you can raise LH, which is what HCG is in effect, it acts like LH. It's a natural peptide. It's actually used in women to ovulate women because at that point in the cycle, we use LH. If you're undergoing IVF or you've been stimulated, that will release the eggs from the ovaries.

1:09:10And so is HCG in some way a more optimal way of giving testosterone? To me it is, and here's why. Yes, to me it is because there is data that is shown when men are, when their testosterone is optimal and their testes are functioning well, they live longer. Women who get pregnant later in life, same thing. So if you have the ability to procreate as you age into your 40s or 50s, and in men it could be 60s, 70s, 80s, 90s, then it is connected to biological aging, slower, slower biological aging. So active hormones with active testes, which is another reason to keep the testes performing as long as they can.

1:09:55At some point, because men are different than women, but at some point, testes may not be as responsive. It's not because of treatment. It's not because of HCG. It's because naturally as we age, cells do not as well. They do more poorly. LH and FSH from the brain aren't secreted in as regular fashion as they need to be or go as high as they need to be. It's a pulsatile system, which requires when something goes down, the brain should recognize it and push it up. That starts to fail in men in their 30s and certainly every decade beyond that. But it might fail in one man in his 40s and another man in his 80s.

1:10:33How does someone take HCG? What sort of form does it come in? It is a tiny shot. It's a small needle. So if somebody needs reading glasses, you can't see the needle. So it doesn't really hurt. So like once a week? Twice a week. Twice a week. If you take it once a week, it's insufficient and you're flattening the curve. If you take it every day, you're not enough pulsing. And I've seen all variations on this. Because sometimes a man will say, well, I think I feel well. I'm going to cut back without checking with us. And he cuts back and his testosterone falls. so if a man is becoming resistant to hcg we increase it to three times a week and in some people we use testosterone because at some point we're not going to respond men will not respond in the same fashion and it changes it's different for every male from your experience and we'll cut to females and testosterone in just a moment but from your experience with your male patients over multiple decades.

1:11:31If you have a man who is, you know, by all accounts, optimizing their lifestyle, you know, their nutrition is pretty good, their sleep's pretty good, their exercise is pretty good, they're able to manage stress pretty well. And then despite that, they have what you would call suboptimal free testosterone. When you then get their free testosterone levels into the optimal range, what are the range of things that you have seen improve? I know you've already covered a couple of them, but I think if we could just have that list, I think it'll be very useful to hear what sorts of things a man could experience on the back of that.

1:12:11So that's a great question. And since it predates GLP-1s, which did make a significant difference, I can tell you exactly that you'll see increased muscle. So your body composition will change. You will lose visceral fat and you will lose fat in your liver. Your sugars will normalize. So you will have, if you've not had optimal carbohydrate metabolism, if you become too high or too low, you're going to add muscle and that will help with sugar directly and indirectly. Memory. I've seen memory. That was quite a surprise to me, but I was delighted. And there are studies that show both estrogen and testosterone have an effect on your brain, cognition and memory.

1:12:50Lipids? To some degree, yes. They don't worsen lipids. A lot of people were afraid of that, but that's anabolic steroids. When you use steroids that aren't physiologic to the body, you can worsen lipids. You can cause a fall in the good cholesterol, a rise in the bad cholesterol. And of course, libido and things like that. I've actually seen HDL go up in men on testosterone. That first group of men that I studied and I showed it was secondary failure, meaning the testes were fine. Unlike women, where we stop being able to produce from our ovaries because we lose the eggs, they're gone. And so we need to be given estrogen and testosterone and progesterone.

1:13:30In men, it's a loss of stimulation. So is that clear? Is that okay? Yeah. So the goal would be to stimulate and to make sure you can maintain, yes, and libido and sexual function. But here's another thing. Two things I'll add. One is that I thought I would hear from men that sexual function was at risk in libido in their 30s and their 40s. And I have models of men, and this is genetic, that have early heart disease in the family. And they look at 30, they look like they're 50 from a biomarker point of view. They have fathers, mothers, relatives who have died young, getting heart attacks beginning in their 30s and 40s and dying in their 60s.

1:14:09And stroke, too, is another outcome. so um so libido and sexual function was second to energy energy and the ability to function and feel good is one of the losses you have and what most men come back and say after a few months is i feel like myself again i can act and be all who i am this is it's so interesting hearing that because many women who have struggled with hormonal fluctuations and perimenopause one of the things people will say or those women will say when they do start having hormones if it's appropriate for them is i feel like myself again yeah are there any risks that we should be aware of here because i guess again i'm always trying to think of the counter points some people may go yeah but but florence in nature or mother nature has designed this so that yes after a period of time, the testes do stop responding and they do stop making testosterone, right?

1:15:10So should we as doctors be playing with what mother nature has designed? Well, father time takes over and actually declines what mother nature has done so well. And we can talk about that with reference to women because it's an interesting way to think about it. And so it's really up to the individual and doctors should be comfortable keeping people healthy for life as opposed to watching them decline. And I think testosterone plays a major role that way. As far as side effects, if we're not managing people effectively, testosterone at two high doses, and again, there's variation in how much is absorbed, how much is stimulated.

1:15:52It's affected by the food you eat, the alcohol you drink because it's metabolized also in the liver. And so you want, and it's metabolized at different rates. So it can vary. it's not going to stay in one number the whole time. It's going to go up and down within a range that is in the sweet spot. You can have a issue where you create erythrocytosis or increased polycythemia, specifically red cells, but I'm going to use polycythemia, which means that your blood becomes a little increased blood amounts, which can cause sluggishness and blockage and deep vein thromboses. So you have to see where people come from, what they're doing with it, the doses they maintain based on the outcomes.

1:16:39And for example, if you've grown up in the mountains, I had a case of a man who we treated. He was about 40. And he came in one day and it was clear that his hematocrit and hemoglobin, red blood cells and the amount and how we look at it, were higher than they should be. And I have a very strict limit, actually less than the endocrine society, which says your hemoglobin should be 20. I actually don't like it if it comes close to 18. I see where a person starts. And we take some, we do what we call a therapeutic phlebotomy unless a man could donate blood. So that is the one side effect I've seen happen.

1:17:15That is a side effect of reaction because men who grow up in mountainous areas are going to do the best they can with generating red blood cells. It's why Lance Armstrong and others train in tents that have less oxygen because when you go to higher altitudes, you want more red blood cells to release more oxygen, right? so polycythemia or erythrocythemia which is more specific is caused by too high testosterone for that human being yeah let's talk about women and testosterone why should we be thinking about that as a woman as well we women have brains muscles hearts bones um libido and sexual function in a slightly different way it's manifested than in men and we start losing testosterone the same way in the 30s, testosterone's produced in the adrenal glands and the ovaries.

1:18:11Some natural tests of it are young women in their 20s who actually start gaining weight on birth control pills. So they're given birth control pills, which has estrogen and progesterone, but no testosterone. It's not even approved for use in the States. And they start gaining weight. They blame the birth control pill, but what's really happening is that they're reducing testosterone even at a younger age, and they gain weight. They gain truncal weight. Their bones are not as supportive. There's data that shows on birth control pills that you are more likely to become osteopenic if you're on it for 10, 20, 30 years, even though they're also protective of cancers of the reproductive system because you're lowering hormones.

1:18:51So women really need this as an essential hormone. It's part of the reason we women put on weight around our trunk in our 30s quicker than men do because you have more testosterone as a male. So testosterone also is vital. I set up a protocol when I was at Yale, when I started Women's Health in the early 90s, where I had a protocol for women who had breast cancer and had undergone mastectomies, tried to block all the estrogen in their body. They were miserable and really didn't want to live. They lost their jobs. They didn't feel well. They didn't think they looked well. They didn't have any sexual function.

1:19:26So I set up a protocol to use testosterone and block the conversion to estrogen, which turns out to be not that big a deal in women. And they thrived. And actually 20, 30 years later, Sloan is doing the exact same study. So I have used testosterone for a long time. I've used it. I started with women who had breast cancer and did not tolerate their quality of life really was bad. And now we use it all the time. I don't always use estrogen in women with breast cancer because there's a fear. I don't believe estrogen is responsible for cancer. And I actually know from the data that testosterone and progesterone actually are protective.

1:20:06They kind of work against the risk of cancer. So there's data in the book that people can read and find. And so we women need it. Now, we women hit a wall when we go through menopause because we used up all the eggs. Unlike men, we are very complex, each one of us. I think all men would agree. And each one of us, when I'm stopped at a meeting at a convention and somebody in the field is trying to learn what this is all about, and they'll say, can you just give me something about women? And I'll say, yes, unlike men, each woman is different. You cannot judge each woman by the next woman. Some women go into menopause overnight in their late 30s.

1:20:45Other women, I've had sisters where one has gotten pregnant in their 50s and the other one's in menopause in her 30s. And so there's a variety of the way we express genes. It is not like set in stone from our DNA, but because of epigenetics, the way we live life, the choices we make and our genes, we may express them in different ways. So when women, they need to take estrogen, progesterone and testosterone. And in fact, in the perimenopause, more women than not have irregular menses. You have to be careful with that because sometimes it's only estrogen that they're seeing. They're not seeing progesterone.

1:21:21You want to protect the endometrium to avoid endometrial cancer. And I've had sad stories of women who aren't seen because the doctor says, well, it's perfectly fine having irregular cycles. You're not ovulating. Don't worry about it. But in fact, with unopposed estrogen for more than three months, there's data that shows that you can get more likely to get endometrial cancer, which is curable if you find it early enough, but then you need a hysterectomy. So testosterone for women does exactly what we want it to do for men. We increase endurance, VO2 increases. Your heart performs better. You lose visceral fat.

1:21:59You lose truncal fat. So all of that leads to chronic diseases of aging. And so why wouldn't women be on testosterone? And yet even in the States, it's not approved formally. A doctor can use it if they have a reason, a category, and they justify it. And as an endocrinologist and a reproductive endocrinologist, I've been lucky enough to be exposed to all of that. So I think slightly differently than most physicians. What's actually taught is sad because the group of people who really know about women, gynecologists, some of them even go on and train as infertility, fertility experts. But they don't really train in menopause and change of hormones.

1:22:40That's just beginning in the last maybe decade. and so I'm thrilled to see that I'd like to see the same happen for men because I think men are underserved in terms of all their hormones it's not just testosterone for men either I mean in the last 10 years there has been a woman's health revolution more awareness yes with that awareness comes controversy you know different people disagreeing but there's no doubt that female hormonal health is much more on the radar today than it was 10 years ago, which I think is definitely a good thing. And it's kind of interesting to hear you with all your knowledge and expertise and experience saying that it's time for men to have one as well.

1:23:24Yes, that's gonna happen. I'm predicting it. Do men have hormones or not? Well, I guess it's because maybe for men, it's less obvious in the sense that with women, there's a set point where you stop ovulating, right? It's more like a cliff. There can be a lead up to the cliff. Well, go on. How would you put it? Yeah. I think it's having menstrual cycles. I think we women are programmed to see a physician. In the States, it's every year. Here, it's every four years, which I'm kind of shocked about. And maybe that came about because of the HPV vaccine. But we women are trained to have pelvic exams and pap smears and visit at least your gynecologist once a year.

1:24:06If you're having babies, it's even more often, right? Men finish college or school where there might be requirements to see and get certain treatments, and then they stop seeing physicians. So men don't have that awareness of what is going on and why. And they're also not as open. They're not going to chat with their male friends necessarily and say, hey, I noticed my energy is dragging. You know, my libido isn't what it used to be. I just don't feel like myself. My memory is slightly on the fringe. And so I think sharing of information and that knowledge, those relationships really help women.

1:24:40Well, it sort of goes back to what you're saying before. We know that, you know, it's a bit of a cliche, I guess, within medicine, but it's certainly been true in my experience that a lot of men just don't want to go and see the doctor. Absolutely. And it is not been uncommon over the years to have men coming in. With a heart attack. Well, yeah. But also the first thing they'll often say is, hey, doc, sorry to waste your time. my wife made me make the appointment. Exactly. It is a cliche, but it happens to be true as well. But I think if we rewind a little bit to the start of this conversation, this idea that we're trained, that certainly in this country, and I think very much so in America, although I think it's a bit different, as you say then with the gyne checks, right?

1:25:25Because we're a publicly funded system. What I've learned as I've become, you know, more experienced in my career is that sometimes decisions are made to do with finances. Absolutely. It's like, well, how many can we actually afford to see? It's not always done with what is the best for individual health. That's not always top. And I think people may be surprised to hear that. And look, a publicly funded system does have to make certain choices. It cannot. Let's be clear. Even in the states where it's not publicly funded, there's population studies. It's applied to the individual. We don't think about the human being and proactively keeping them healthy.

1:26:06You started the whole podcast talking about it's not a health system. It's a disease centric model of healthcare. You get sick, whether acutely or chronically, that's when you see a doctor. Yeah. And I guess what I'm trying to sort of bring in here is this idea that if we understood that modern medicine is primarily a disease management system, then we go, okay, great, let it do that. Okay. But we need to also make sure that we are part of a health creation system, right? A proactive aging system. I love that term, health creation, because I think we want to create health in people who, as we age, are bound to decline based on our genetic makeup, which drives a lot more than we actually thought.

1:26:54We actually put way too much emphasis on lifestyle and habits And we've kind of ignored for lack of knowledge what is going on in our genes and what our genes, which is translated by family history. Because family history is expression of genes. If you have dementia in your family, if you have osteoporosis, like I knew I had, if you have heart attack and stroke, you are at risk if your genes express themselves. So what can we do as both an individual and a society to change that paradigm, to have people own their future health by understanding they are at risk? let's get to genetics let me just close off what i think is an important point which is if we got in the habit of checking these biomarkers early regularly reviewing them seeing trends and patterns then those men who at the moment are perhaps not going in too embarrassed to go in don't think they should be in this country we have a thing about wasting the doctor's time, right?

1:27:56Well, if you owned your own health data and you could see, hey, wait a minute, why was it that two years ago, my HbA1c was 5.1 and now it's 5.6? Well, if you can see that and you have a nice graph or something showing you, suddenly, I think that will land in people's head a bit differently that, oh, I might need to do something. Or, you know, your fifth biomarker is the free testosterone, if you saw that year on year starting to plummet and drop, you might be triggered earlier to say, actually, I need to see someone. I need to see a healthcare professor who can help me. Is this an issue? Do I need to do something about it?

1:28:39Is it okay? So I think that whole model needs to change. But I really want to touch on what you said about genetics here. I've heard, what have you previously said? Can I comment on what you just said? Please, please. So in the States, and I don't know if it's really available here, you can get biomarkers almost anywhere now. What's missing is that interpretation from knowledge to wisdom. So I absolutely agree with you. If you can see those biomarkers, if you know, I have a perfect example. I'll call him Max, real patient. He was part of the app I was developing to give the information into the hands of an individual to practice virtual medicine, which I believe is absolutely the way we need to go for health creation, a term I'm going to steal from you and use.

1:29:22And when I looked, I made it a point, unlike the center, where people come in and it was more of the old-fashioned family medicine meets futuristic medicine because I see the patient. And I made it a point of not getting a story, but rather just asking a series of limited questions, which was limited from the usual questionnaire, but what I thought was critical. His biomarkers were terrible. His testosterone was 52, not even 90, as you mentioned, and he was only 30. He had recently married and his libido was decreased, not because he married, but because he saw that it was decreasing from his 20s.

1:30:00He was putting on a little weight, even though he was really active, but he was putting weight around the middle and he didn't feel great. When I looked at the history, his family history, his father had had multiple heart attacks and strokes beginning in the 40s. I didn't ask if his father was alive or not. He didn't put anything in about his mother, which was kind of interesting because he actually lived with his mother. He had a sister from another mother who was only five months difference in age. And he had a certain makeup where his father was Ashkenazi Jewish. His mother was Puerto Rican.

1:30:32And I looked at the pattern. I went to see him. I asked to see him. And I said, how's your father doing? Well, his father died of a massive heart attack at 60. This man in his biomarkers was showing changes that you typically see in a man 10 or 20 years older. His numbers and his combination, his hemoglobin A1C was perfect. It was 4.9. But his fasting sugar ranged from like 75 to 95. And his testosterone was 52. His cholesterol risk ratio was 5.8 as opposed to being ideal at under two. And so you put that all together and you saw a man who was actually aging exactly as his father was, which is a syndrome we learned about.

1:31:13I learned about in medical school. When you have early heart disease in a family, it's hereditary. We just didn't understand the factors around it. And so we completely reversed that. This gentleman is like in amazing shape. We increased his testosterone with HCG. who was able to come off of it because by triggering in a younger man, and I have a set of those for other reasons, for lots of other reasons, we can actually get function back and they can take off on their own. You can actually, once you hit the 40s, it's much harder. I've had a handful of men in their 40s where I could stop using HCJ.

1:31:50So if that makes sense to you, I totally agree that getting biomarkers in front of you, it's hard to ignore. When I started Women's Health, I would show women their bone density and I would say, do you see that your bones are very thin and that if they continue in this direction, you're going to have osteoporosis, you're going to fracture a hip, you're going to shrink. It's the trends that, you know, as humans, we only, we only know hot because of cold, right? We only know black because of whites. we see changes we observe and experience changes in things right that's how we operate um why would your health biomarkers be any different you know a one-off reading yes has value but it's so much more powerful to see how this is changing over time you can't assume anything because numbers can vary naturally so what do you but it lands with you when you see that something in you has changed.

1:32:49It's like you can't unsee what you've just seen in a CGM. When I eat that meal, this is what happens to my blood sugar. You may still choose to do it, but you can't unknow what you've just learned. You can't unknow, but I will tell you that there are groups of men and women who are basically in denial. They may see it, but it's like, well, I don't believe that's real. And I'm going to age gracefully as father time dictates, which means getting weaker and getting chronic disease because I really don't want to intervene, which is fine. You know, people are entitled to live the life they want to live.

1:33:21Exactly. But what I really do like about your approach, or one of the things, as many things I like about it, is it's very empowering and hopeful for people. You're sort of presenting this vision. I mean, you say in the subtitle, right? Well, the book's called Invincible. The subtitle is Defy Your Genetic Destiny to Live Better Longer. okay who doesn't want to live better for longer generally speaking or they're happy to live longer if they can live better whilst they're doing it right so i think it is a hopeful message and of course i'm sure some people may have a different view on hormones perhaps and hopefully we've tried to tackle you know your perspective on this and why you think this is an important part of aging but but i want to get back to genetics well i want to come to genetics i also want to just discuss what we said about virtual.

1:34:11And I've heard you in a previous conversation, I heard you talk about this idea that health can be seen off in a similar way to banking, which I thought was quite interesting. And to sort of set this up, I think there's no question that the ideal scenario for most people would be to have a clinician like yourself, who they could see, get their biomarkers done, and then sit down for an hour with to discuss some more than detail. Okay, sure, that would be best. And given the rates of chronic disease that we're seeing in your country and in my country, and most countries around the world, the world, basically, we simply do not have enough doctors and resources to do that.

1:34:59Totally agree. And so I also do like this simplistic, I mean, you're trying to do it with your app in America, I'm trying to do it with my Do Health app here in the UK, is really try and get it out to the masses. Say, you don't need to test everything, but these, you know, I really focus on metabolic health with Do Health, okay? I go, if we can help you take ownership of your metabolic health early, in your 20s, your 30s, your 40s, your 50s, two things are going to happen. Number one, you're going to feel better in the short term, right? Because that's, it's not just about reducing risk of disease in the future, you're going to have more energy, focus, vitality, and you're also going to reduce your risk of pretty much every chronic disease you've got, right?

1:35:44So I want to acknowledge that in person with a really well-qualified and well-knowledgeable physician with time may be the best, but as you've discovered and you talk about, which is what I've learned here as well is that virtual, like this app-based approach to it can also help. So talk a little bit about that and also this comparison of health to banking, which I found very interesting. So I'll start at the beginning briefly. I had three epiphanies. I was able to look at numbers and connect people through their system, their entire system, a system-based approach to health. And it was about health, not about disease.

1:36:26I reported on that in a journal club to three different departments of endocrinology at Yale many years ago, like in the early 90s. I said, why are we letting people decline when it's evident in their biomarkers? At that point, we were calling them lab tests, right? And then the added benefit of having an identical twin who is not exactly the same. So even though we inherited a rough draft of DNA that was identical, we are changing the way that DNA expresses the epigenetics piece of it, which you wanted to get to, because of the way we live life or where we implanted in utero. It started in utero.

1:37:01Just like Siamese twins who stay attached, they're not completely identical. Just like in your own body, your right side of your face does not look like your left side of your face. There's a mismatch because genes can express differently. is very vividly seen when someone has a blue eye and a green eye. Why? They inherited the same genes. It goes to their eyes. Why does one express his green and one blue? So epigenetics has the power, that's why defy your genetics, to change the direction and the choices. That's why I strongly believe in the lifestyle changes, the little baby steps, or as I think of it, atomic habits for longevity, where you compound changes, small changes over time.

1:37:41Ultimately, I think the way we want to go is to be able to offer these kinds of insights, not just by influencers who do it for themselves and don't really take care of human beings and don't see the outcomes, do it in a way that's legitimately medical. That is, you mentioned credentialed. My Yale background, my NIH, being a scientist as well as a physician allowed me to devise and see things that I was confident, though nervous about, because no one else believed me. I'd wake up with a cold sweat when I started a women's health and I was too young to be a menopause thinking, this is so obvious.

1:38:20Why isn't everybody doing it? And so my belief and why I compare it to banking is how many of us have to go into a bank nowadays, at least in the US, you can do everything through your apps, you get information. So I've been asked... There's hardly any banks anymore. They're all closing down. Exactly. Exactly. It's like phone booths. You have nice phone booths in London, but no one's really using them. They're all on their cell phone. They're taking photos for Instagram on them. Let's bring medicine to a point. Let's bring health creation where we can give true basic knowledge, credentialed knowledge, scientifically based, not necessarily in a millions of people where you then get regression to the mean and you get averages and a one size fits all, but specific to that human being virtually.

1:39:03And that was always my dream. The book was part of it. The app is part of it. Because even if I want to, I can't see millions of people. And it's not realistic from a resource point of view. This is expensive. But if you can own a part of it, if you can share it in partnership and you can get guidance and AI will make a huge difference in that based on proprietary database. That's what I have. I have a proprietary database that I've developed over the years because of my research. What does that mean? proprietary database. That means the work I've done, I've collected every bit of data was done as a protocol prospectively, billions of data points in individual people.

1:39:38I think of it as a little big data, you know, big data that everyone collects. NHS collects it. There's collections all over the world. NIH actually did 25 years after I started, it started collecting like a million lives to try to look at the differences between human being, recognizing that we don't do a good job of that. We treat everybody with the same drug. Nicholas Stork wrote a paper back. He worked with Craig Venter, who discovered the genome, called N of One. And one is a very simple paper from 2015, I think in Nature, that says like a lot of the drugs we use may work only in a portion of people where we study them.

1:40:16For some people, they may not work. For some people, they may be hurtful. He wrote a more extensive paper about N of One. So to me, marrying the notion of N of 1 and individuals that can own their own health destiny is a no-brainer. Yeah. I want to finish off with a question that you ask your readers in the book. Who do you want to be when you're 100? Why do you think people should ask themselves that question? I think if they recognize that they are going to develop in some ways that is dictated by genes, But do you want to live in a healthy body, in a body that can enjoy life to the best of your ability?

1:40:57Or do you want to be on a porch in a rocking chair or with a stroke where you can't really, or your neurons are not popping the way they should. And so your brain isn't working as clearly. You can't read a book that you used to love to do, or you can't ride a bike. I'm not saying that all of us should run marathons at 100 or 120. I'm not saying that all of us have that capacity. but the longer we can invest in ourselves, the better off we'll be as the future unfolds. And I think that's what I'm hoping for, for everyone. It's a very empowering message as the entire book is. The new book is called Invincible, Defy Your Genetic Destiny to Live Better, Longer.

1:41:37Florence, it's been a joy talking to you. It's been a joy reading your book. Thank you so much for coming on the show.

1:41:46Really hope you enjoyed that conversation. Do you have a think about one thing you can take away and apply in your own life? And also one thing you could teach to someone else. Remember, when you teach someone else, it not only helps them, it also helps you learn and retain the information. Now, before you go, I just wanted to let you know about something I'm really excited about. On July the 1st, I'm kicking off my first ever 21-day energy reset. It's a simple challenge built around the four pillars of how you feel each day, how you relax, eat, move and sleep. And if you're someone who's tired of feeling tired, then this challenge is for you.

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