#115 - Dr. Szymanski: Building Healthspan with Medicine 3.0

0:05Dr. Jared Szymanski:Welcome to the Insightful Investor Podcast, a weekly series that seeks to share industry, investment, and market insights. We define insights as concepts that are counterintuitive, widely misunderstood, or underappreciated. In other words, unique ideas that you probably won't hear elsewhere. I'm Alex Shahidi, the host of the podcast and co-CIO of Evoke Advisors, a leading investment advisory firm. Learn more about our show at insightfulinvestor.org.

0:38Dr. Jared Szymanski:Today, we're shifting our focus to modern healthcare, which has largely been built to react to disease once it's already obvious. But a growing movement, often called Medicine 3.0, which we're gonna talk about today, argues the real leverage comes much earlier, identifying risk, preserving function, and maximizing health span over decades. Our guest today is Dr. Jared Szymanski, who practices at the front edge of that shift, focusing on preventative and precision medicine designed to help patients stay well, not just get rescued when something goes wrong. Along the way, I'll occasionally draw parallels to investing, where the same long-horizon thinking often applies.

1:20Dr. Jared Szymanski:Thank you for joining us, Dr. Szymanski. Thank you. To start, would you share your background and what originally drew you early in your career toward preventative medicine? Yeah, so I grew up in Wisconsin, went to school to be a math and science teacher and wanted to continue going to school. So eventually I found my way going to medical school. I really enjoyed it. Most of our training during medical school and residency were working in the hospitals, were preventing a lot of death, treating a lot of disease, dealing with a lot of sick patients. And once I finished all of the training and started working in the outpatient setting, I quickly realized, hey, we were kind of taught how to treat and manage disease very well, but we weren't really taught how to prevent disease, which then led me to continue on a path of learning in order to really find out what drives disease.

2:23Found a lot of patients would come to me with health issues, that they can't lose weight, that they're having problems sleeping, all sorts of different things that we weren't really taught when working in the hospital. And I found out, hey, kind of the traditional medical model doesn't do a great job at teaching us on how to address all of the common health issues that we actually deal with in the outpatient setting.

2:51Dr. Jared Szymanski:So you mentioned traditional health care. What was it that convinced you maybe the system was intervening too late? Yeah, I would sometimes see, you know, mothers. I can think of one mother who had diabetes and she just had a lot of health issues. And I could see, you know, in her children who are 10 and 12 years old that the disease process had already started. And you can see the trajectory 20, 30 years beforehand. A lot of times in medicine, what we would look at is a specific lab value for diabetes. Somebody can be 0.1 value under the official diagnosis for diabetes for a couple of years. And all of a sudden, that lab value changes by 0.1.

3:41And now all of a sudden, hey, they're a diabetic where when we actually looked at, you know, metabolic health data, they've been essentially a diabetic for years before that lab value hit. It wasn't like she woke up one day and became diabetic. That disease process took 20 to 30 years to really develop.

4:02Dr. Jared Szymanski:Just drawing a quick parallel to investing. It's like, you know, you don't want to wait for problems to surface when it may be too late to act. versus managing risk early. And what you just described is if there's a way to see that before it hits the radar, that would be helpful because there may be things you can do earlier in the process. Correct. Yeah. And even I was never taught, hey, you know, 70 % of cases of type 2 diabetes are reversible. And I read different books on it, studied a lot on it. And one of my best friends from growing up. He called me. His blood sugar was 450. He had type 2 diabetes.

4:43I hadn't seen him for a couple of years. And when I had seen him recently, he was up to 350 pounds. And I worked with him over the course of a year. He lost about 125 pounds. And he was able to reverse is diabetes, which was pretty incredible.

5:03Dr. Jared Szymanski:So for listeners who may not be familiar with the term, what is medicine 3.0 in plain English and what problem is it trying to solve? Yeah. So, you know, with medicine, we've kind of gone through evolution. You know, initial medicine 1.0 was basically going off of theories, what might work. That's like leeches, pretty barbaric surgeries. Then with the advent of antibiotics and medications, that really became medicine 2.0, where we got really good at treating disease. Now medicine 3.0 is much more looking at what diseases do we need to prevent in this person? What we found is 85 % of people really die from the same five medical conditions.

5:51And so how do we proactively either prevent those conditions or, you know, in the case of cancer, how do we detect that condition as early as possible in order to have the best health outcome?

6:05Dr. Jared Szymanski:Is there anything that changed either scientifically, culturally, or economically that has made medicine 3.0 feasible now? Just with the advances in technology, that's really helped. We've got a lot more lab values and lab metrics. There's a couple of companies, Boston Heart and Cleveland Heart, that really allow us to really look at all of the biomarkers of how insulin resistance happens, how cardiovascular disease happens, so we can actually detect in the blood what disease process is happening and what is the mechanism behind that disease so we know how to correct it. Also, just with different wearables, we can now track and monitor how somebody's blood glucose responds in real time.

6:55So we'll start to see blood sugar spikes, insulin level spike years before the metabolic disease actually happens.

7:06Dr. Jared Szymanski:So obviously, there's a science and technology side. Is there anything else that has, I guess, coincided with that development to push Medicine 3.0 into the forefront now? We had a lot of patients kind of suffering from disease. And I think it really has come to light or started to come to light that medicine is advancing that, you know, people don't want to be sick. They're really wanting to stay healthy over the long term. People are wanting to, you know, delay their health decline as long as possible. They've watched generations before them kind of become sick. And, you know, that's what people want to prevent is that, you know, they don't fear dying.

7:54What they fear is, you know, having 10 to 15 years of life where they can't do what they want to do.

8:01Dr. Jared Szymanski:Because many of them have probably seen others go through the same thing. Correct. Yeah. There's another mindset that I've noticed is many people think they're healthy because nothing is quote unquote wrong. Why do you think that mindset may be dangerous? It's kind of like anything, you know, the heart attack, that process, it's not a specific event. It's, you know, a disease trajectory. And so the disease, we think, oh, that person had a heart attack. It wasn't a singular event where it happened that day. You know, it actually happened, you know, 20, 30 years beforehand is when the disease process started.

8:44You know, we were seeing on autopsies, even in teenage years, we're seeing cardiovascular disease starting in kids. You know, looking at all of the major risk factors, I've had patients come to me and they've said, I had a physical and I was told I was the healthiest patient. And, you know, a week later, I had a massive heart attack. And there's a certain type of genetic cholesterol called LPA cholesterol. And I can think back to a patient I saw a couple of years ago. He was 65, marathon runner, had that exact case. He had a physical told he was the healthiest patient a week before he had a major heart attack.

9:25And when I checked his LPA cholesterol level, it was off the charts. And it's like, this is why you had a heart attack at 65, despite being somebody who was super healthy, otherwise with no symptoms.

9:40Dr. Jared Szymanski:And I think about that on the investing side. You know, I'm always looking at the world through the eyes of an investor. It's like you have a portfolio and it has all these underlying risks. And until you hit the milestone where the risk shows itself, you feel like you're insulated from that risk, but you really need to understand deeper and look at all the data. Correct. And that's kind of, you know, our traditional fee-for-service healthcare model has gone based off of population data. It's, hey, how do we make healthcare affordable, screen for a lot of disease, prevent a lot of disease, you know, for 95 % of people?

10:19How do we manage that spending versus benefit risk. And what we're finding is a lot of people who, you know, have the funds to invest in their health, they found, hey, doing a full body MRI, it may not be cost effective to do on everybody in America, but, you know, six to nine percent of people find significant findings on a full body MRI. And if you have the funds to invest in that, you might be one of that six to nine percent and it's going to be super beneficial for you versus when we look at, hey, if we just scan everybody in the country, we're going to spend a lot of money and the benefit might not be there.

11:04But if if you have the funds to do it, you know, you can definitely gain a lot of advantage from looking at those things.

11:13Dr. Jared Szymanski:You touched on this notion a little bit earlier, but we're hearing more emphasis on health span versus lifespan. What are we actually trying to optimize for? Yeah. So with health span, it's not specifically how long that you're going to live. That's where medicine 2.0, we've been able to manage disease and allow people to live really long, kind of chronically ill. health span is really, hey, how do we keep people healthy for as long as possible? How do we make that last decade of life enjoyable for patients where they can still get out and hike, play tennis, do whatever they enjoy? So that way they have increasing the number of quality years, not specifically existing in a nursing home for the last 10 to 15 years.

12:05Dr. Jared Szymanski:So I suppose with that goal as what you're trying to optimize for, it's really important to catch things early so that you can kind of extend the good years as long as possible, right? Correct. And, you know, it's also, you know, a lot of the disease processes, they're not singular events. you know, we think of diabetes, hey, that's an endocrinology problem. You know, we don't think of it as a cardiovascular disease problem, where, you know, most people from who have diabetes, they die from a heart attack or stroke. And so, you know, a lot of times we're thinking of all of these disease processes as separate diseases where they actually are tied together in their mechanism of how the disease actually causes morbidity.

12:57Dr. Jared Szymanski:What do you think is the most useful mental model for thinking about chronic disease early when there's potentially more options and long before perhaps any symptoms appear? As far as the mental model goes, I think things are really focusing on managing what you can control, you know, a lot of healthspan is going to come from managing diet, exercise, really managing sleep, stress management. When we're looking at labs, you know, 88 % of Americans really have metabolic inflexibility or metabolic dysfunction. And so when we're looking at long-term disease prevention, I think it's focusing on what we can actually control there.

13:49Dr. Jared Szymanski:In your view, what are the big four issues Medicine 3.0 aims to delay or prevent? So the big issues are cardiovascular disease, that's our number one killer, and then cancer, neurodegenerative diseases, dementia, Parkinson's disease, and then diabetes tends to be the fourth leading cause of death. And do you feel like by catching those early or seeing the markers early, you can make a big difference in the potential outcome? Definitely. And that was part of what I found to be very beneficial is when we're actually digging deep into those conditions. You know, somebody's blood sugar levels might be normal, but when they see, hey, their insulin levels are high and their insulin resistance panel is abnormal, they actually have a drive in order to fix something, where before they were always told, oh, my labs are normal.

14:45When we can actually dive deeper into metabolic data, into the inflammatory markers with our lab work and some of the wearable technology, then patients can actually see what's wrong and actually be motivated to fix the underlying disease process.

15:06Dr. Jared Szymanski:So would you just walk us through your medicine 3.0 framework at a high level? Yeah. So typically when we meet with patients, we want to take a look at their body composition. One of the most important things over the long term is your muscle mass. So we do body composition testing that tells us overall muscle mass. And then it also takes a look at body fat mass and specifically visceral fat. Visceral fat is the fat that's around our organs that really drives a lot of disease. And then we're taking a look at what's called your VO2 max. VO2 max, it's where you wear usually a blue mask and you get on an exercise bike or treadmill and you start off at a very low pace and minute by minute we work you up until your maximum output.

15:59That's actually the best predictor of your overall health and how long that you're going to live. It tells us essentially how efficiently your body uses oxygen. And then we can use the data from that testing in order to help patients increase their VO2 max. When we're using that data, we can look when somebody's 30 or 40 years old, if they're on the normal trajectory of decline, that young, we can tell who's going to need to live in a nursing home versus who will be able to live independently as they age. It also gives us enough time to make changes and to alter that trajectory. Then what we're typically taking a look at is all of the advanced biometrics, how somebody's blood glucose responds in real time.

16:47If they're metabolically healthy, their blood sugar typically range from, you know, the 70 to 120 range throughout the day. We'll have patients where They put on a blood glucose monitor and they're spiking to 200, 220, 240. They really didn't have any symptoms, but that really shows us that metabolic inflexibility. And then we're really looking at all of the inflammatory markers in relation to cardiovascular disease, the size of the cholesterol, and then all of the different ways that cardiovascular disease occurs through lab work. And then what precision medicine is, is actually taking a look at your genetics.

17:36So we run genetic panels on our patients at our clinic, where we can actually see what areas do you actually have issues with? Are you most likely to develop cardiovascular disease? Are you most likely to be at risk for diabetes, neurodegenerative conditions? So that way, 20, 30, 40 years before the disease happens, we can actually look and predict which of those areas should we actually be putting our focus on for each individual patient. So it's not specifically a one size fits all. Hey, everybody should do the exact same things. it really allows us to see, hey, for each individual patient, you know, if they don't want to spend money looking at all the prevention strategies, where are they going to get the best bang for their buck?

18:28Dr. Jared Szymanski:Yeah, if I try to summarize, it sounds like for each person, you're getting their baseline for all these very important metrics. And some of those baselines can be established with just a simple test and others, it's a simple tests in a point of time, and others might be over various cycles during periods of stress and so on. And then you can project the trajectory of those metrics. And the ones that are problematic, you can potentially do something about rather than waiting until the signs show later. Correct. Yeah. So in a world of endless biomarkers, how do you distinguish signal from noise?

19:07Dr. Jared Szymanski:And I think about this on the investing side too, because there's a lot of noise in markets. But there's really only just a few important factors. How do you think about that? Yeah. So the important thing is to not obsess over each individual value. What we're really doing is we want to see trends over time. So as somebody's, you know, if they're watching their glucose, you know, on an app, we get some people that will obsess and look at it, you know. 30 times an hour, right. And they catastrophize over it or patients when they're looking at their sleep data, they're like, well, I know I sleep poorly and this just makes me more anxious.

19:52What we really want to do is focus on, hey, looking at the trends over time rather than, hey, how do we make small adjustments in order to prevent disease? A lot of our patients were looking at disease trajectory. And so we're always telling them it's okay if something's abnormal. That's what we're working on. That's what we're working to fix here.

20:20Dr. Jared Szymanski:Yeah, in my experience, and it's similar in our industry, is there's a lot of data and people have a tendency to zoom in, look at that data and extrapolate it over the long run. Whereas the professional comes in with a zoomed out perspective and they're not focused on the day-to-day, they're focused on the longer-term trends. And what I notice is there's usually a disconnect between the patient or the client and the professional, where the patient or the client is zoomed in and the professional is zoomed out and you're trying to zoom them out to see what you see. Yeah, and that's what's helpful for us is we're able to serve as the quarterback for the patient as well, that really help manage everything because, you know, the patient, you know, uses AI or they look at their own individual stuff where, you know, we've looked at thousands and thousands of patients' data where we can tell them, hey, this is normal.

21:19We see this all the time. You don't have to worry about this. You know, we're doing this in order to be proactive. And so you're not at a major risk right now. But what we're doing is we're trying to help you prevent it so it doesn't become a problem down the line.

21:34Dr. Jared Szymanski:So where does personalization genuinely change outcomes? And where is it mostly marketing? The biggest bang for your buck when it comes to your long-term health, it's going to be your diet, your exercise, your sleep, your stress management, those type of things. I think the The personalization comes down to, you know, looking at your specific genetics. But there's a lot of extra hype that's out there where there's a lot of people trying to sell a lot of things. And those things might get you that last 2 % of your health span where, you know, 98 % of it's going to come down to, hey, what's your muscle mass?

22:24Uh, what's your body fat percentage? Uh, how is your sleep? How is your recovery? How is your stress management? How is your metabolic flexibility? Um, and so, you know, really focusing on those truly important features, um, is what's really going to get people the most bang for their buck. Um, there's, you know, if somebody's doing something and then they're telling you, and here I've got this fix that I'm also selling you based off of the test I've done, I'd be more leery about that than really focusing on those kind of core elements of long-term health.

23:04Dr. Jared Szymanski:So what do you think are the most underappreciated early indicators that someone's health trajectory is quietly deteriorating? The big thing that we found, You know, when we take a look at cardiovascular disease, for example, we've got a lot of people who have high cholesterol their whole life and they never develop cardiovascular disease. We have people who have good cholesterol and they develop cardiovascular disease despite that. And when we really look at the inflammation markers and the inflammation markers in our body, I think that's where we really see a lot of disease and disease trajectory come from.

23:48So taking a look at biomarkers like somebody's high sensitivity CRP level, it's a nonspecific marker of your body's total inflammation. I think that that's really important marker to check and to monitor over time. We definitely see people even just feel a lot better when that level goes from being in the high range to being in kind of the optimal zone. And then I think the other huge driver disease in America is metabolic dysfunction. So taking a look at your fasting insulin levels, your insulin resistance panel, your C-peptide levels, just because 50 % of Americans have non-alcoholic or metabolic fatty liver disease these days.

24:40So that's one out of two Americans that's really driving a lot of disease. So I think those are kind of the big things to take a look at are the metabolic testing and the inflammation markers as far as the lab work goes. And then when it comes to best overall testing, that VO2 max test really is our best overall predictor of health. It also helps us develop a good exercise routine for our patients. You hear about zone two exercise. So that's the type of exercise that you should be doing along with some HIIT training. But with the VO2 max testing, we can tell when somebody's body's burning fat most efficiently, when they're burning carbohydrates, when they're building up lactic acid and their muscles start to fatigue.

25:31So using all of that data and information is super important.