the-matt-walker-podcast — #107 - Medicine 3.0 with Dr. Avinish Reddy

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Hi there, it's Matt here, and welcome back to the podcast.

Today, it's a very special episode.

I had the privilege of sitting down and doing an interview with Dr.

Avinash Reddy.

Dr.

Reddy is the founder and CEO of Elevated Medical, a concierge-style

longevity and precision health practice launched in July 2024.

If his name sounds at all familiar, it's because he worked alongside my good

friend, the great Dr.

Peter Attia, for many years.

Dr.

Reddy draws from extensive internal medicine expertise and collaborations with leading

longevity experts.

His practice uses advanced diagnostics, including full-body MRIs, genetic

analysis, cardiovascular assessments, and metabolic profiling, to create tailored

health strategies for very lucky clients.

I hope you enjoy this conversation with the wonderful Dr.

Avnish Reddy from Elevated Medical.

So with all of that said, Dr.

Reddy, welcome to the podcast.

Thanks so much for doing this.

Thanks so much for having me.

Oh, it's a privilege and a delight, and I know this is going to

be a fantastic episode.

The work that you do and the practice that you have is so profound

in terms of its general medical applicability to society, yet it is remarkably

sparse in terms of society's understanding of what this new forefront of practicing

medicine actually looks like.

I'm going to make the faux pas of calling you Avi because listeners don't

know, but you and I, we go back some years, and so I'm going

to be informal.

One of the things that you and I have spoken about previously.

Tell people how you think about your approach to medicine in the way of

combining physical health with mental health and cognitive health.

You go north of the neck.

Tell us about that integrative approach and why you took it.

Yeah, so many people talk about integration or combining these aspects of healthcare, but

I don't really even think about it like that because they're so, so related.

Everyone knows the way physical health plays a part in them feeling better or

their mood being better, but they just don't think or understand that the reverse

is true as well.

People, and unfortunately physicians also, they're overlooking the idea of social

connection and its effects on physical health.

And this isn't just subjective.

There's studies, there's objective data that tells us this also.

I mean, how much do you think social isolation is increasing your risk of

early death?

So if you'd asked me that based on the fact that I hadn't been

doing work in social loneliness and social isolation, I probably would've said 4

or 5%.

I certainly wouldn't have pegged it as perhaps as mortality deathly as

the risk from something like smoking.

But Tell us what it is.

It's 50%, and you're exactly right.

It's the same as smoking or obesity.

That's stunning.

So there is nothing that you're doing to your brain or your body in

terms of intake of poor quality diet.

You're not smoking, you're not remaining completely sedentary.

It's just the simple act of, do I interact with other human beings?

Changes my mortality risk by 50%?

Yeah, I mean, and people are so focused on macros and objective data,

but we need to place a way bigger focus on these immeasurables— the strength

of friendships, the strength of family.

10 to 15 years ago, people didn't talk about sleep the way we do

now.

CEOs were bragging about 4 hours of sleep or pulling all-nighters, and look at

the way sleep is one of the biggest pillars of health now, and even

longevity.

I look at social connection, I realize it's gotten so difficult with technology and

work from home.

My hope is that in 5 to 10 years, we'll be talking about social

connection the same way we do about sleep.

It should become a fundamental part of healthcare.

I love what you're saying.

You know, I've never thought about it like that.

Where is the last remaining pillar of manipulability that can

change our mortality risk.

And what you're telling us, I think, which is so powerful, is we absolutely

do.

And it's a huge lever.

And if you move that needle, it has manifold consequences.

Is it an issue that we need to have firstly, number one, measures of

prosocial social connection, measures of loneliness?

I know that we have some of those in psychology, but in medicine, I

don't think we have like a formal set of prosocial or asocial measures

that give doctors a sense of where does this person sit on the scale?

And even if you did have them, where is the current standard of care

protocol for improving social bonding?

That's the hard part.

We live in such a data-driven world, but people just need to take the

idea that this is immeasurable.

But it's something that I'm gonna make an effort to do.

Yeah.

And so often we'll say to colleagues or family, let's go out, let's do

something.

You stay inside too much.

Let's go out and let's meet some folks.

I think that's fine, but when it comes from family, sometimes it's just water

washing over you and that's it.

When it comes from your doctor with gravitas and with evidence, that could be

the start of something different.

At least that said though, I do want to try to walk through some

of the, at least major organ systems of the body.

How do you think about these with your patients?

I mean, you are one of the best practitioners in this space.

Your services are going to be limited because there's only a limited amount of

you.

So I know not all people will be able to gain access to the

remarkable privilege that is your care, And so I want to step people through

some of these systems.

I want to start with the cardiovascular system.

And we know that heart disease remains a leading cause of mortality.

Give us the bottom line, boots on the ground in the trenches.

What are those key contributors?

Really, it's about cholesterol, but 2 aspects that people don't really think about is

family history and lifestyle.

One of the biggest indicators of whether you're going to have a heart attack

is did your mom or your dad your grandparents have heart disease or a

heart attack or a stroke?

And the second aspect is, do you exercise?

What do you eat?

Because lifestyle makes such a big difference in inflammation and insulin resistance.

Both of these affect your endothelial health so much.

Endothelium being the lining of the blood vessels.

This is what puts you at a higher risk for heart disease.

So let's get back to cholesterol.

Most people know their LDL cholesterol or their LDL-C, but I wish more people

understood or knew about ApoB or apolipoprotein B.

LDL-C measures the amount of cholesterol inside the LDL particles, and ApoB measures

the number of particles themselves.

And that's a better predictor of heart disease risk.

Imagine we're at an airport and we're trying to prevent accidents.

ApoB is the number of planes taking off.

And LDL-C is the number of passengers on board.

It doesn't really matter how many passengers are on each plane.

What matters is how many planes are in the air.

More planes means more risk.

Same thing for physicians.

It's ApoB particle count that matters, not the LDL-C.

But the story isn't just about the labs.

There's patients with low ApoB values that still have plaque in their arteries.

At the end of the day, ApoB gives us the flight count, but we

really need to understand labs, lifestyle, family history.

They all work together to understand our heart disease risk.

And so you can't simply, as a doctor, simply rely on just that ApoB

number alone.

I'm sure it's a fantastic start, and I know that some medical practitioners now,

some doctors, are increasingly requiring it as part of your lipid cholesterol investigation.

Is it true then to say that when you look at all of those

studies that used to use the classic LDL, HDL, all of those markers to

see what was predictive of cardiovascular disease or cardiovascular death, yes,

they had some predictive value, that's why we would always focus on them, but

when people started measuring ApoB and they inserted that in addition into the statistical

models, it seemed to be that ApoB had an even more powerful explanatory

capacity on determining your cardiovascular disease risk.

Is that true?

And does that mean that we can do away with focusing on things like

LDL, HDL, VLDL?

Help me better understand that.

Right now, ApoB is the best and most accurate way to measure cardiovascular disease.

And the main reason LDL is less accurate is that as

people have metabolic disease or diabetes, there's a huge LDL discordance.

And so there's patients that have lower LDL numbers, but higher ApoB markers.

And that's specifically for the patient population that has metabolic disease and diabetes, which

is honestly becoming a huge portion of not just the US population, but the

world population as well.

Okay.

That's really helpful.

So Avi, you mentioned family history as being important, which by the way, I

always think is interesting when, if you were to ask any young doctors, you

know, you say like, what's the most important thing for you to know about

someone's cardiovascular disease?

One of the most important things, I'm sure they're all racing to speak about

the most recent lipid biomarker discoveries.

And you forget simple family history is incredibly powerful.

But what other things are you measuring when trying to understand their cardiovascular

disease risk?

We need to understand our parents' and grandparents' medical history.

We need to know whether they had heart disease and what age.

Did they have a stroke?

Did they have hyperlipidemia?

Even did they have high blood pressure?

This gives us a lot better idea of each person's risk.

It's just an easy thing to test.

You don't need to go to a lab.

You just need to ask your family.

And let's say I'm a patient who has borderline hypertension.

I'm in the typically low 130s over 80, and I go to my

physician and I say, you know, I'm interested in starting some form of a

blood pressure medication.

For whatever reason, they say, well, we did it and yes, you were 132

over 82 when you came in.

But that's probably just the white jacket scenario.

We don't need to treat.

If I were to then say, well, I understand that, but both of my

grandparents died of some form of cardiovascular disease on my mother's side.

One of them died of a stroke on my father's side.

Is it not just about you knowing your family history, but helping your doctor

if they haven't inquired about it to also understand the family history?

Can that also help them manage you better in that regard?

Yes, it should be questions that they ask you.

This is what places you in a different bucket than every other person your

age and your gender.

You need to know this type of information so we know what ApoB target

do we need, how much imaging we need to do, and how aggressive we

want to be.

These are questions that need to be asked.

And when you are seeking a potential diagnosis path, then a potential treatment

path, we've spoken a little bit about some of the biomarkers that you need

to be focused on, particularly ApoB.

What above and beyond that would you then start to think about for a

patient in terms of doing further diagnostics to really understand both where do they

sit in terms of their cardiovascular health and also by proxy, what

is their current cardiovascular disease risk?

Are there other assessments or tests, I think you mentioned imaging, that people should

be thoughtful of?

Yeah, so first and foremost, I think a lipoprotein little a.

This is a genetically determined lipoprotein.

It behaves like LDL, but with a very dangerous twist.

It's stickier and it's more inflammatory.

Generally, it means more plaque.

Here's the crazy part.

You could have a sky-high lipoprotein little a and you'd never know because it's

not included in standard labs.

It's based on your genes, so you only really need to check it one

time, but most doctors don't even run it.

So I mean, is there a reason for that?

I mean, considering how helpful at least it can be, is it just not

broadly educated in the medical curriculum, or it is but it's so costly that

insurance doesn't typically want to cover it?

Where do you see the failure there?

I think it's a treatment thing.

Lipoprotein right now currently does not have a treatment, but I don't think that's

the correct way to think about it.

We can't treat lipoprotein, but we can move this patient from a low or

medium-risk bucket to the high-risk bucket.

That's essentially the name of the game, is trying to figure out where does

each patient lie on a low, medium, high-risk strategy.

So we've measured ApoB.

That is a modifiable factor that will change.

It will change with medication and lifestyle.

Then you've got this Lp, which is only have to do it one time.

That will help structure you into one of those low, mid to high buckets.

What else should people be understanding about the different types of then assessments further

down the line?

The next thing I like to do is get imaging that we already have

that doctors just aren't utilizing enough of.

I like to use a coronary CT angiogram or a coronary calcium score.

So I'll talk about the coronary CT angiogram first.

This is where dye is shot through our veins.

It gives us an actual visualization of our coronary or heart vessels to see

whether there's any calcified or non-calcified plaque.

The second test I want to talk about is a coronary calcium score.

This is similar, but it only tests for calcified plaque.

The main reason why a calcium score is probably more common in healthcare

in general over a coronary CT angiogram is its price.

Coronary calcium score is $100.

It's quicker, it's cheaper, it's easier, and you don't need to have the

dye or radiation.

So for the CAC scan, really there, all you're going to get is a

single number.

And that single number is essentially going to represent a broad proxy of saying,

okay, in the coronary artery, this is how much calcium we have

been able to estimate.

And the amount there is a pretty good general assessment of how

the rest of your body is probably calcified versus the CT angiogram.

That's more invasive.

It requires a radioactive dye injected, but there you get a much better visualization

of the vessels throughout the heart and understanding the healthiness or lack thereof.

To make it a lot more simple, it's A CT angio detects calcified and

non-calcified plaque, whereas the calcium score only detects calcified plaque.

Is it the calcified that you're more concerned about?

It's not even that.

It's that a calcium score can have false negatives, whereas a coronary CT angio

is going to be more precise.

Gotcha.

And so at what point do you then consider doing, let's say, a CAC?

Scan or a CT angiogram?

Is it on the basis of risk?

Do you do it with your patients just de novo?

I would always be wanting to get a CAC.

How do you determine what is right and when it's right to do that

with your patients?

That's the difficult question.

Everyone should be getting one of these tests done.

The question really is when, and that's really basing on family history,

labs.

We're trying to figure out which bucket does this person fall into.

And I think by 45, everyone should have one of these tests done.

There's another test that I actually think is very important as well, and I

use it for my younger patients.

It's called a carotid intima-media thickness, CIMT.

It's way less common, but it's something that picks up early thickening of the

artery walls of the carotid artery, so the artery supplying the brain.

This checks for plaque long before it forms, even if the coronary CT is

clean.

Think of your arteries like the walls of a house.

CIMT is taking a look for early water damage by looking at the walls.

You might not see cracks or mold yet, but the wall is starting to

swell a little bit.

While a coronary CT, it's like cutting straight into that wall, looking for mold.

You know what's there.

You see the plaque, you see the narrowing, you see the calcium.

It's the stuff that actually causes the heart attack.

This is why I think a CIMT is actually pretty useful, because if we

have younger, younger patients, we may get a false negative with a coronary CTA

or from a calcium score.

And so if we're able to see that thickness from the CIMT, it shows

us the plaque process has started a little bit, and that's the window where

prevention works the best.

So using this novel carotid artery assessment, it's sort of the canary in the

coal mine.

When you mention young patients, are you talking patients in the mid to late

30s?

Are you talking even earlier than that?

Yeah, mid to late 30s is exactly what I was thinking.

You read my mind.

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Let's come on to prevention strategies.

What are your core recommendations for heart health?

You go on social media and there's all manner of strange, odd, drink this

potion and your heart is going to be the size of an, whatever it

is.

What are the real recommendations for heart health that you provide?

Then maybe we could speak about treatment options and those that you would offer

for people who are already at risk?

First thing I want to bring up is prevention needs to be started early.

The American Heart Association uses a 10-year time horizon.

That's just not nearly aggressive enough.

I would say that's almost reactive care, because when you think about a patient

that's 35 years old, whether they have a high ApoB or they have a

massive family history of heart disease, what are the chances they have a heart

attack in the next 10 years?

It's almost zero.

We need to start thinking about a person's risk decades and decades before that.

We need to understand what are the chances this patient has a heart attack

over the next 20, 30, 40 years.

That's how proactive care is.

It's about trying to treat a patient before the plaque is in their arteries.

And this is really, in some ways, this new version of medicine that I

know you and Peter has also been describing too, which is we understand

the event horizon, and then you can backcast from that really fairly

understood future risk condition.

But where you need to be intervening is just so much earlier than where

we are now.

No one's ever told me about a 20-year plan for my cardiovascular.

I mean, you start a new job and people will tell you about the

40 or a 50-year plan for your retirement, but no one's telling you that

about your heart.

I actually have a pretty good example of this.

I have a patient that's in their late 30s, I think 39 years old,

no family history of heart disease, but we did get a coronary CT angiogram

and it showed a little bit of plaque, just a tiny bit, just a

tiny bit of plaque, which puts him at the 84th percentile for his age.

He's at low risk for a heart attack for the next 10 years.

But my goal is that this patient at 39 years old won't be high

risk at 50.

Instead of him being at the same trajectory of 84th percentile, I hope when

he's 50, that same plaque will be the exact same and he'll be at

the 14th percentile risk for heart disease.

I love this example.

This is such a good, I think, demonstration to folks as to why people

are desperately clamoring onto the waitlist to get into your practice.

I mean, the fact that you can with precision be 84th percentile, that's the

level at which all of us would hope for care.

What are the lifestyle factors that you would think of as preventative strategies

in terms of improving cardiovascular health?

There's obviously 2 things, nutrition or exercise, that people always want to talk about.

When it comes to cardiovascular nutrition, there's not like a specific diet that studies

are showing that we need to follow.

I try and focus on whole foods and limiting saturated fats.

We know saturated fats increase inflammation and ApoB.

And so, as a proxy, I just try and think, what can I do

that's good for lowering ApoB and improving my endothelial

health, which we talked about earlier?

I think it's heartening that you're bombarded with this diet, this particular way of

eating, and this is such a third rail.

It's such a lightning rod that I'm sure when people hear there's not necessarily

one diet that it's sort of like the Lord of the Rings, one ring

to rule them all.

There is no diet to rule them all when it comes to heart health.

And I'm sure people will say, no, but my diet is.

But really what you're just saying is it's really about the thoughtful, sensible way

of eating, which is taking a whole foods approach, trying to watch out for

saturated fat, do that and you're probably 80% along the way to having arguably

the perfect nutritional approach to cardiovascular disease.

But having said that, you were just, I think, about to come on before

I interrupted you to exercise.

So for exercise, I like to think about it in 2 buckets, cardiovascular exercise

and strength training.

When we think about strength training, it has a very, very limited role when

it comes to cardiovascular health.

So at this time, I'll just obviously focus on the cardiovascular exercise part.

There's 2 metrics that I look at specifically.

The first one is very, very easy to do.

So I always mention it to my patients.

It's heart rate recovery.

Specifically, how much does your heart rate drop after 1 minute of peak, peak,

peak exercise?

And I like to see my patients have their heart rate drop around 25

to 30 beats per minute.

This is something that can definitely be trained.

And I think that's what motivates my patients is seeing the data and then

trying to improve upon that just gives them like a motivational factor, which I

love about this.

So let's say practically, I'm going to jump on the spin bike, I'm going

to go all out to the point where I'm, puffing and blowing and sounding

like life is soon to be ending.

At that point, I'm going to be measuring my heart rate.

It's jacked.

And then I stop.

And then the question is, how far have I come back down to baseline?

Did you say within a minute or 30 seconds?

You can measure it in different ways, but the one when I say 25

to 30 beats per minute, that's 1 minute.

But patients like to do it different ways.

You can do 30 seconds, you can do 1 minute, you can even do

2 minutes.

It's such an easy test that honestly my patients will write down all 3.

Yeah.

It's a great way to do it because obviously I know some people will

be saying, well, it depends on if I'm someone whose peak heart rate can

be up in the 180 realm, whereas someone else, their peak heart rate is

going to be, let's say, 150.

The drop is obviously going to be perhaps a little different, but really broad

brushstrokes are not a hard and fast rule, but a rule of thumb is,

let's say across 1 minute after intense exercise, you're looking to see if you

can drop by about 20 to 30 beats per minute within that 1-minute

period of time.

So if I was at 160, would you be happy if I were back

down to 130 within that first minute after stopping?

Yeah, exactly.

I think the best part is, of course, it's an objective data mark that

like everyone's gonna be like, oh, let me make sure mine's 30 right now.

But I think it's something to strive for and you'll see improvement quickly.

And you'll see improvement the more that you are committed to your cardiovascular sessions.

Exactly.

The harder you keep pushing yourself, the more you'll see that recovery rate.

And so it's a nice carrot rather than the trainer, which is the stick

telling you get on the exercise bike.

You are incentivized to try to gamify the percentage point drops as it were.

Yeah, exactly.

And I think the other thing is, this is a really good way to

measure cardiovascular flexibility and health and longevity.

Yeah.

And so tell us a little bit about VO2 max and what that is.

I think it's kind of like the new kid on the block in terms

of some of the biohacker movement folks.

I think even your Apple Watch and your Oura Ring can have a guesstimation

of it, but it really is I think just that.

Tell us a little bit about VO2 max, what it is, why it's important,

how do we measure it?

That's why I wanted to talk about heart rate recovery first.

VO2 max, I don't know if it's the new kid on the block anymore,

but it is a measurement of maximum amount of oxygen that your body can

use during exercise.

It's obviously one of the best objective measures that we have for cardiovascular fitness.

And it's one of the strongest predictors for longevity.

So I think the one data point that always gets thrown around, which I

think is really awesome, and it is so motivational, is just going from below

average VO2 max to above average cuts your mortality risk by 50%, which is

the same or more than smoking, diabetes, and hypertension.

The point behind it is you don't need to strive for the 90th percentile.

It's really about understanding that improvement is cutting mortality.

And I think the other very important fact is that that's true from going

from the 20th percentile to the 30th percentile, the same way it's true going

from the 75th percentile to the 85th percentile.

Just having that data point makes you feel like this is worth doing.

That alone to understand how that nudges your mortality risk.

And of course, it's not necessarily the measure of VO2 max itself that I

suspect is reducing your all-cause mortality risk.

It's that in part, but it's really about what it's teaching us about your

cardio metabolic health, probably your immune health, maybe some

of your hormonal health.

It's really that it's such an amazing, again, proxy for the fitness of so

many of the major organ systems.

Is that fair to say?

Yeah, I think more than anything, it's a proxy for saying, this is how

much I work out.

Exercise is important, and this is a great way to track it.

It'll be very hard for you to find someone that's at the 85th percentile

or whatever you think is a good VO2 max and they're not exercising.

Yeah, very true.

And how would you best recommend people go about assessing the VO2 max?

Now it's become so popular that there's going to be a place in the

city that you live in that can measure your VO2 max.

Of course, that's going to be probably the most accurate way you can do

that.

But Apple Watch or whatever wearable you do, it does track it.

And in general, what you're tracking is trends.

I don't think that the Apple Watch or the Whoop or whichever one you

use to track your VO2 max is accurate.

But again, directionally, the goal is to just improve.

And I try and get my patients to understand that data is there for

a reason.

And it's obviously very important.

I just mentioned 1,000 different data things that I track.

But I think it's important to understand that we're tracking trends, we're tracking

improvement, and I want my patients to feel like everything is doable

and it doesn't need to be all or nothing.

Okay.

And so really the 2 take-homes here are don't think that you have to

go to the extremity of an elite athlete to get a huge benefit.

Anything is going to be better than nothing in this regard.

And the second thing is to say, if you don't yet feel motivated to

go out there and find a place locally that can assess you in a

properly medical way for your VO2 max, maybe it's okay to look at some

of these measures.

Don't necessarily invest in the daily headline.

Instead, invest in the weekly and monthly trend line because Presumably

these devices are inaccurate.

They can't do what these tests would do, but they are at least somewhat

consistently inaccurate in how they measure your VO2 max.

And therefore, if there is a tidal change, a trend that is happening, hopefully

in the upward direction, you can at least feel confident about the trend rather

than the absolute measure.

So it's the absolute accuracy versus the relative accuracy.

Believe more the relative accuracy.

Is that a fair thing to say?

I think that's 100% true, and I think it's very important that you mention

that because I've had a patient that texted me and was like, my Apple

Watch says my VO2 max is 20, and that's probably not accurate.

Maybe his VO2 max is 18 or 23, but I can still give him

the same advice.

Oh, that means you need to do cardiovascular exercise.

And I think that's the take-home point is you don't need the perfect accuracy.

You just need the trend line like you mentioned.

So we've spoken a little bit about what blood biomarkers you could look to

to assess your cardiovascular health.

Before that, think about family history.

We've spoken about imaging and we've spoken about some of the preventative strategies

and how you can measure those.

Tell me a little bit about how you approach treatment of cardiovascular disease?

Yeah, so there's 3 main medications: a statin, ezetimibe, and then

a PCSK9 inhibitor.

So most patients are started on a statin and their dose is just continually

increased and increased until their ApoB or their LDL-C goal is reached.

But I think it's important to get a sterol test for all patients or

all people.

This gives me an idea of whether a patient's ApoB or their LDL-C is

elevated due to liver production or GI tract reabsorption.

And so, if someone's a hypersynthesizer, meaning they make too much cholesterol, then a

statin is definitely the way to go.

But if they're a hyperabsorber, then ezetimibe is the way to go.

The reason for that is a statin acts on the mechanism of synthesizing too

much cholesterol, whereas ezetimibe acts on the GI tract to prevent reabsorption of cholesterol.

The 3rd medication that we can use is a PCSK9 inhibitor.

It's a newer therapy.

Insurance doesn't really cover it, but it's amazing at reducing ApoB.

It reduces it almost 60%.

For the PCSK9 inhibitors, if folks are wondering what are

the names of those medications, if I'm taking down notes furiously, which I am

here, that I could take to my doctor, what would be some of the

common PCSK9 inhibitors that you would use?

Repatha or Praluent are the most common ones right now, and that's an every

2-week injection.

But there's newer similar medications that are coming out like Leqvio, which the injection

is needed less often, so every 6 months after a certain time.

Oh wow, that's fantastic.

And as you said, I mean, these are— because they're newer medications, they're currently

not going to be that well covered by insurance, and they can be a

costly out-of-pocket expense, at least here in the United States, where if you're not

reimbursed by insurance, you are out of pocket.

It can be covered.

It just depends on whether the patient has an allergy or is intolerant to

a statin.

Also, if they're on a statin and their calcium score or their coronary CT

angiogram continues to worsen, then insurance can cover it.

But it's just really on the patient or the physician reaching out to the

insurance and making sure that it can be covered.

And let me come on to another maybe lightning rod that we've mentioned it

here, statins.

I have been surprised just because for myself at least, I have a very

strong family history of cardiovascular disease.

And I think if there is shy of a car accident at this stage

of life, the thing that is most statistically likely for me to die of

is some form of cardiovascular disease.

And when I've spoken to other people, asked them about their family history, they've

been staunchly against statins.

Some people just have this, I mean, it's almost a conspiracy-like mentality to it.

Do you have a sense of where that comes from and do any of

your patients have that resistance initially?

And if they do, are you able to disabuse them of that?

Tell me about that experience.

I think it's tough.

But I do think that when trying to address a patient's issue

with a medication, it has to come from empathy.

And you have to understand where their knowledge is or where they're coming from.

Have they had a parent who had a bad experience with it or a

parent that had that belief?

I think it's about addressing it as a human being, you're not going to

be able to tell them this study shows that statins are great.

I've tried that so many times.

That's not the way to convince a patient.

The other thing is, as a physician, we're partners with the patient in their

healthcare journey.

So there are other options out there, like we talked about, they may not

be the most ideal, but you work with what the patient is willing to

do or willing to take.

And so Maybe ezetimibe is an option for that patient, or if they have

the money, maybe Repatha is an option as well.

But it's a very tough problem and it's a tough situation to deal with

sometimes.

This is why you're such a good doctor and you're in such high demand

with your practice, because I think that is the right approach.

You have to approach it from their perspective and their fears.

You just trying to sledgehammer them with data doesn't change an emotional response.

I don't know if you've learned that the hard way or that's just because

you're such an empath and you're so good at human interactions.

So maybe we can shift gears a little bit unless there's anything else you

want to say about cardiovascular disease risk to metabolic health.

So my 3 takeaways for cardiovascular disease is really just you have to start

thinking about cardiovascular disease and its prevention a lot earlier than you think you

need to.

The second is get imaging done.

The best way to understand your risk is to actually visualize these blood vessels.

And the third is ask your doctor to run the extra lab for ApoB

and for lipoprotein.

It's just important to understand which bucket of risk you're in.

Are you low, medium, or high risk?

Because that's how a doctor is going to decide how to treat you.

ApoB, Lp, ApoB, Lp, folks.

ApoB, Lp.

And then once you're probably north of 40, it's really time for you to

at least have some form of a CAC scan or some form of a

cardiovascular disease risk scan of some kind.

At least do that in the bare minimum and hopefully a lot more, a

lot earlier.

Yeah, summarized it.

Excellent.

ApoB, Lp, folks.

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Let's move on to the metabolic system.

Metabolic conditions like diabetes, it seems as though if you look at some of

the data, you know, it's almost epidemic levels.

They're increasing with marked rapidity.

Why do you think this is happening?

It's really a combination of diet, lifestyle, and movement.

Just look at the US.

We're like surrounded by highly processed foods.

They're very, very calorie dense.

And then the impact of technology.

Groceries are now delivered by Amazon or Whole Foods right to our door.

We really forget about movement.

I'm not saying people don't exercise.

I honestly feel like people are more into working out and exercise than any

generation before it.

But I think what's overlooked is just the general movement that we have in

society.

We work from home, or when we go to work, we're sitting on our

laptop for 10 to 12 hours or however long we work.

That just wasn't the case 15 years ago.

At least people were going in and out of meetings or meeting people for

lunch.

There was a lot of travel to and from.

It's kind of crazy, but I actually had a patient that went to Italy

for 4 weeks.

And she came back, she lost 5 pounds, and she was completely shocked.

She was confused because she ate unhealthy and she didn't go to the gym

even one time.

She even asked me beforehand, should I wear a continuous glucose monitor?

But I told her, just enjoy your trip.

It's like a once-in-a-lifetime thing.

Just enjoy your 4 weeks.

Good doctor advice.

I like it.

Which, and I mean that very sincerely, which is, for goodness' sake, in all

of this puritanical stuff that we're talking about, every now and again, joie de

vivre.

She was so shocked that she lost all this weight, and I wasn't surprised

at all.

I was asking her, What were you doing there daily?

She was sightseeing.

She was getting 15,000 to 20,000 steps.

When she's here, she's probably getting 6,000 to 8,000.

So she's not an inactive person, but she didn't work out on this trip.

She didn't eat healthy, and she still lost 5 pounds.

So what does that tell us?

General movement makes such a big difference.

Even if you're working out 6 times a week, general movement is the key.

And you have to think, I know it's climate dependent and time of year

dependent and all that good stuff, but whenever it permits, after you've had dinner

with the family, et cetera, rather than just going straight over to the television

and plonking yourself down and that's it for the evening, just saying, why don't

we just go walk the dog around the block just 15 or 20 minutes?

Just start the crawl, walk, run approach.

And I do think that it's stunning that we think to move the needle

on weight, you have to be doing the elliptical for 20, spin bike for

another 30, get on the rower, and that's great stuff.

But we forget about just the simple act of perambulating.

Walking can really drop those calories.

I completely agree.

I think people track VO2 max and all sorts of complicated things, but sometimes

the simplest thing is just tracking steps.

People wear an Apple Watch or an Oura Ring, and I don't think they

realize that they're only getting 3,000 to 4,000 steps.

And so that just small, tiny thing can make such a big difference.

Yeah.

And it's largely painless.

What tools or diagnostics do you use in your practice to try

to identify not just whether someone is in a state of metabolic dysfunction, and

here, of course, we're largely talking about what is your blood sugar situation, but

not just to assess that, but to identify early signs of metabolic dysfunction,

things like insulin resistance?

Yeah, so in primary care, we've relied on A1C and fasting glucose for a

long time, and they're great for looking at population trends, but I think when

it comes down to detecting issues early and at the individual level, They're

just not sensitive enough.

I check a fasting insulin though, because it gives us a 5-year head start

compared to A1C and fasting glucose.

We often see a fasting insulin start creeping up much earlier in their metabolic

journey, even before glucose or A1C starts to change.

But I think the problem is, again, doctors just aren't calling this into the

lab for patients to understand this data point.

And then if you want to get a little bit more technical, I even

do an oral glucose tolerance test on my patients.

Most people know this as like the pregnancy test where you drink the sugary

drink, but it's actually one of the best ways to evaluate the way your

body handles glucose and insulin.

We check your fasting glucose and insulin, then you drink the glucose load, then

we recheck your glucose and insulin at 30 minutes, 1 hour, and 2 hours.

So really what we're looking for is how quickly your blood sugar rises, and

then seeing how quickly it comes down.

We're also trying to see how high it spikes.

And then we're also going to be looking at the insulin to see how

effectively it brings your glucose up and down.

We really want to see, is your body producing too much insulin during this

test, because it's a really early sign for insulin resistance.

I think this test is super important because it's a dynamic test rather than

worrying about the fasting labs only.

It helps catch metabolic issues before they show up on routine labs and when

they're still totally reversible.

When it comes to that metabolic dance regarding insulin and how it's used

to regulate your blood sugar, maybe we could just take a step back.

When someone says they're insulin insensitive or they're insulin

resistant, How does this work?

Is it that you can have high blood sugar because you're not releasing enough

insulin?

So your body is not sensing the spike in glucose and therefore it's not

telling your body release insulin, which means that cells in the body will sort

of stick their straws out and suck in the glucose from the bloodstream.

Is that one version of it where you are just not able to sense

the spike and so you don't release enough insulin?

Versus you are releasing enough insulin, but the cells themselves

are not listening, as it were, to the insulin signal.

And so the body is having to overproduce insulin because they're really being very

stubborn and they're not responding to the insulin.

How do we understand this dynamic interplay for people?

No.

So I think it's more along the lines of a patient starts as insulin

sensitive, And as they become more insulin resistant, their pancreas needs

to release more and more insulin for the muscle cells or any cells to

pick up the same amount of glucose.

And then over time, what we're seeing with type 2 diabetes is that the

pancreas keeps releasing insulin, keeps releasing insulin, keeps releasing insulin until it's damaged

to the point where it can't release insulin at all.

And that's when you're needing to take insulin injections.

Got it.

Okay.

And so you've assessed the patient, you understand this glucose tolerance test

result, you know exactly which side of the equation you need to start treating.

How do you guide patients to manage their condition?

And perhaps someone like you, so astute with your medical practice, How do you

even go about trying to reverse conditions like prediabetes or even diabetes?

More than anything, I want people to understand that we have far, far more

tools for managing and reversing diabetes than they often realize.

In the past, people just focused on nutrition, but I want people to understand

that exercise, sleep, and stress play a very important role in this.

On the nutrition side, there's so much misinformation, especially regarding protein and carbs.

So I try and just focus on the highest yield facts, and that's, let's

cut back on processed carbohydrates, and let's increase protein and fiber intake.

And diet, it's a very personal thing.

I want them to understand their gaps, and then each person needs to go

their own way about addressing it.

That's where I really want my patients to at least try a continuous glucose

monitor, And it doesn't have to be for a year or a month.

Even 2 weeks of a continuous glucose monitor can give out so much information.

The first thing I want patients to understand is what foods cause their blood

glucose to spike, or what quantity causes their blood glucose to spike.

But secondly, and probably more important, is what foods do they really like

that they don't mind eating all the time?

Don't spike their blood sugars?

Because isn't that the real point?

Like, who cares what we can't eat?

Let's try and figure out what can we eat that's healthy.

That's such a great question.

And people, as you well know, can have such different responses to, let's say,

even just a muffin.

It's striking.

And so I like the idea of rather than doing it in broad brushstrokes,

these are the foods you cannot eat, these are the foods you must eat,

instead saying, CGM, real-time data, lets test drive a whole collection of different

experiences for you.

And that's how you're dialing your patients in, in a unique snowflake-like bespoke manner.

Is that fair to say?

Yeah, 100%.

The other thing, which maybe your audience is pretty familiar with, but sleep and

stress are just as crucial.

I see patients that are wearing a continuous glucose monitor, and it's eye-opening.

They'll have a bad night of sleep, and eat a healthy meal and their

blood glucose will spike.

This is the craziest.

I have a person that's been in a high-stress meeting, they haven't eaten all

day, and their blood sugar spikes.

It's not just diet, sleep, and stress.

Everything plays such a big part in glucose control.

Yeah, it's stunning.

I've seen this because I wore a CGM for a while.

My sleep, and I hate to say this because of course I'm going to

say it, the sleep guy, but it was striking how I would have just

something as benign as a protein and some root vegetables, really a pretty clean

dish.

But goodness, it was less about the spike.

It was more for me about the area under the curve that the persistence

of that glucose versus coming down rapidly when I had not had a good

night of sleep was striking.

That's an excellent point.

And then you'll also notice the person that eats food late at night, and

their blood glucose is just pretty much stays high for almost 3-4 hours because

they're sleeping.

And if they're wearing a sleep tracker as well, it reduces their quality of

sleep as well.

Yeah, that sustained— even just from a thermogenic perspective, we know that you have

to get cold and stay cold to get your sleep and particularly your deep

sleep.

And just maintaining a higher metabolic rate and a higher core body temperature is

going to be modifying your sleep.

So then tell me a little bit about your take on diet.

I know we spoke a little bit about this when it came to cardiovascular

disease, but what about this notion of time-restricted eating, time-restricted

feeding, whatever you want to call it, intermittent fasting?

Where do you stand on that?

I think intermittent fasting is, it's an excellent, excellent way to calorie

restrict.

It's not the intermittent fasting that helps the glucose control or the insulin sensitivity.

It's the fact that people that intermittent fast, they end up eating less calories,

which is the whole point anyways.

So for certain patients, intermittent fasting is excellent.

I think the one difficult portion that people have when they're intermittent fasting is,

how do I get enough protein?

Obviously, diet's always personalized.

So there are patients that I 100% recommend intermittent fasting for.

And that's the type of patient that has a hard time limiting calories without

using this intermittent fasting or time-restricted feeding.

Gotcha.

Okay.

And so it's not necessarily anything wondrous autophagy process

of complex downstream biochemistry.

It's really about intermittent fasting just helps you eat less.

That's the key.

The result is simple, but it is an important thing.

It's hard to reduce calories for some people, and that's a very easy way

to do that.

I know I'm going to throw you a wild card here, or curveball, whichever

the Americanism is, but in all of this, where do you stand on the

GLP-1, sort of the semaglutide, the Ozempics of this world.

Do you have a stance?

How do you think about this?

I know it's probably unfair to put you on the spot, but any thoughts?

I was waiting for this question.

I figured it was coming.

You know me too well.

I figured it was coming.

GLP-1s, they're an excellent, excellent option for diabetics and for patients

that need weight loss.

There's people that are vilifying it.

And then there's people that are saying it's the perfect magic bullet.

But I think the reality is it's somewhere in the middle.

It's not perfect for everyone, but for the right person, it's excellent.

That's what I want people to take away from these medications, is that you

can't stand on one side or the other.

It just needs to fit for that person.

And the determination really of fitting for that person is how do you

think about the GLP-1s for managing your metabolic health, meaning your blood sugar and

also your weight?

It's those 2 lenses, either one or the other or both combined, that you

would typically use to see a use case for a patient?

Honestly, it's both.

I mean, it is such a good medication for diabetics.

If you have a patient that doesn't need weight loss, but that's a diabetic,

I think that's the tough part is you don't want them to lose weight,

but it's an excellent drug for diabetics.

And then for weight loss, I don't need to say much about that.

It's obviously an excellent, excellent medication for weight loss.

And we all know that.

Let's switch systems to something that many people don't think about when it comes

to their medical health.

They'll think about how is my heart, how is my blood sugar?

Maybe they'll think about how is my VO2 max, my respiratory system?

They'll think maybe about their hormonal health, but we often don't think too much

about our musculoskeletal system.

We know that as we age, the health of both muscle and bone become

increasingly important.

What do you think are the biggest risks to the musculoskeletal system

as we age?

And is there anything that we can do about it?

I mean, help me, Obi-Wan Kenobi, you know, give me a Pollyanna if you

can.

How can we think about that?

For the muscular side, we have to focus on preventing sarcopenia, which is the

age-related loss from muscle mass, strength, and function.

And it's not just strength in the gym, because I think people are always

talking about, I'm strong, I'm strong.

But I think you have to understand that you need to build up as

much strength as you can, because it impacts how well you move as you

age.

When you see older people like your grandparents that are struggling to get out

of bed or struggling to walk up the stairs, it's generally not the cardiovascular

reason, it's the muscle strength that prevents them from being able to make those

movements.

From the skeletal side, the concern is osteoporosis, which literally means porous bones.

So as bones become less dense, they become more fragile as well.

When we talk about protecting the musculoskeletal system, the goal is to get both

of these facets as strong as possible through our 40s, 50s, 60s, and 70s.

Because after we get to that age, inevitably, we're going to be deteriorating.

And so the lifting of weights is really just to prevent you from falling

off a cliff and making it more gradual.

So it's really about how do we slow that age-related deterioration down?

And in some ways, what's most frightening is the strength of those muscles will

determine how well we move.

Because of course, one of the greatest dangers as we get older is that

we have a fall, and those falls can lead to fractures and you can

probably better tell me what that risk consequence is.

When it comes to bones specifically, unfortunately, the strength of the bones is made

through our teenage years until like late 20s.

So the goal is after the 20s, we just need to do enough strength

training to make sure that we don't deteriorate after that time period.

And for women also, hormonal replacement therapy becomes a very big option to prevent

this deterioration of bones.

You mentioned falls, and I think that's a very, very important factor for lifespan

because if you have a hip fracture after the age of 70, there's a

20 to 30% increased chance that you pass away in the next 12 months.

So let me say that again.

Goodness me.

Yeah, there's a 20 to 30% chance that you pass away within 12 months

after a hip fracture.

It's because you have surgery from the fracture, and then that means you're recovering

in a hospital bed for a certain amount of time.

You lose a lot of muscle, muscle strength and muscle mass, and you lose

strength in your bones.

And inevitably, that can lead to another fall, which leads to another hip fracture.

So it's just a cycle of inevitability and deterioration.

We all need to be doing some form of resistance training throughout our entire

adult lifehood.

But it's especially perhaps rare to make that recommendation in that older population

because that's a time when people are probably less likely to be thinking, I

should be going into the gym and lifting weights, when instead it's just as

important for them when they're in their 60s or 70s as perhaps when they're

in their 20s and 30s.

Yeah, I completely agree.

Especially as we get older, if you don't use it, you lose it, and

you lose it quickly.

And so it is very, very important that we continue to try and lift

weights and try our best to progress, even though we know we're not going

to.

It's the thought that we're trying to lift heavier and heavier.

And in that regard, I suppose it's not that difficult to assess, are my

muscles getting stronger?

If you track it, you can see your progression, et cetera.

But I think it's— people are at a loss.

If I were to say, what's the best way to measure the strength of

your bones?

Almost no one I'm passing on the street would be able to answer that

question.

How do we answer that question?

How do we measure the strength of our bones?

A DEXA scan is the gold standard, and I recommend it annually for my

patients, whether they're 65 or 40 years old.

In traditional medicine, Bone mineral density is checked by primary care doctors at the

age of 65, and it's to rule out osteoporosis, which is very, very important

as we talked about hip fractures.

The data score that it gives out is a T-score, so it compares your

bone density to a young adult.

If you are -1 to -2.4 standard deviations below average, you're osteopenic,

so you have weak bones.

And if you're less than 2.5, It means you have osteoporosis.

Both of these things mean you're at increased risk of fracture.

So I don't want to get you wrong, whether it's osteopenia or osteoporosis, the

goal is the same.

It's how can we, one, reduce your fall risk, so stability,

strength, all of those, but also continue to avoid so that your T-score

doesn't decline even more.

And would you say that most people after a certain age should get one

of these DEXA scans?

And by the way, it's D-E-X-A for those listening, and it's a low-dose X-ray

to measure bone density.

But is there a certain time in life when you would say now is

the time to do that?

And secondly, in addition to resistance training, is there anything above and beyond that

you would use as an adjunct to that to try to help strengthen or

prevent the decline in bone density.

So when should I get it done?

I'm doing resistance training.

What can I do above and beyond that are my 2 questions.

When I think about getting a DEXA scan done, it should be done annually

for patients that are above 65 to know their bone mineral density.

Why I say I get it annually for all my patients is it gives

us another data point that I use that's very important.

It measures muscle mass in a number called appendicular lean muscle mass

index, so ALMI.

It just rolls off the tongue, doesn't it?

I know, right?

Easy dinner conversation to have.

Yeah, sorry, go on.

I use this pretty often with my patients, and really it's because it helps

my patients understand where is my muscle mass compared to people of

my age and my gender.

It's a great data point to track so they can see their progress with

their current exercise regimens.

What else can we be doing if we're already strength training?

This is where I get into the idea of consistency.

I always ask my patients, how often do you lift weights?

And the answer always comes in the same frame.

I work out 2 times per week.

I really want my patients to think about this a lot differently.

How much do you work out per month?

How much do you work out per per quarter?

Because I think that gets my patients to think about this in the broader

idea of I travel, I have vacation, work gets busy.

They're always inevitably thinking about the most ideal week.

Oh, I worked out 3 times per week.

But how many weeks are you missing?

It echoes with sleep, which is regularity, consistency, bedtime, wake time.

But here, that's exactly what it is when it comes to exercise.

It's not just total count.

It's about how you spread that butter consistently over the toast of the prior

year.

But even simply as I worked out 3 days this week, and then one

week I was traveling and didn't get in one workout.

It's just, they work out 3 weeks out of the month because they travel

for that one week.

And I think it's hard to conceptualize because you're home for those 3 weeks

and you do work out 3 times per week.

But it's hard to remember that you missed an entire week.

Yeah.

And is some form of a calendar assessment to track that a helpful tool?

Because time is such a difficult thing for us to grasp as humans retrospectively.

Do you get people to log it that meticulously or is it just— give

us a general sense of what you're doing.

They have a calendar and more than logging which days they work out, because

maybe that's a little bit too meticulous.

Maybe they log the weeks they don't work out.

Because really what we're trying to identify is how many breaks are we taking.

So I traveled June 10th to June 20th, just put that in the log.

You didn't follow your current structure.

Fantastic.

Quick question about calcium supplementation.

Some people probably have heard or been recommended taking calcium supplementation to try to

help with bone strength.

Myth to be busted?

Something to be thoughtful of?

The more important number that patients need to identify is where is their vitamin

D.

On a population level, data is showing that vitamin D levels have dropped.

Probably pretty obvious.

People are not outside nearly as much as they used to be.

But I think that's one important point that I definitely look at.

Why vitamin D?

What relationship does that have to bone density?

It helps the patient absorb calcium to make sure that bones stay strong.

Fantastic.

3 big take-home messages, musculoskeletal system, if there are such a thing, what would

they be for people?

You got to strength train, get your DEXA scan annually.

That last part that we talked about, it's pretty important.

We got to stay consistent.

And it's the thought exercise of how many times did you work out over

a longer time period?

So for, oh gosh, it must be at least a decade now, I have

been an avid, probably more like rabid consumer of protein shakes.

But the hard thing, honestly, in the supplement space, if you really understand and

do your diligence, is this critical thing called trust.

It is very hard to find a brand that you can truly trust.

That's when I came across the company Puri and their really impressive founder.

Even though I'm sure it makes them less profit versus other quick and loose

companies, Puri takes quality more seriously than any company I've ever

seen before.

They have so many offerings.

Gosh, protein powders galore, but lots of other additions.

But that's what I was focusing on here.

Why did I choose them?

Well, it's really for 4 specific reasons.

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Number 2, they are free from GMOs.

Number 3, they are free of any pesticides.

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Moving on from my bones and my muscles, I want to speak about the

neurological system of the brain and cognition.

Probably the 2 of the most feared diseases in developed nations are going to

be cancer and some form of degenerative dementia, principally Alzheimer's disease.

What are the early warning signs that you and your practice look

to assess when it comes to brain health?

So I think again, with brain health, it's similar to heart health.

We want to start as early as possible.

We're looking for the earliest signs, trouble finding words you normally wouldn't forget, forgetting

memorable events, getting more irritable or anxious, changes in sleep patterns or vivid dreams.

I'm sure you can delve into this a little bit deeper.

Even processing things slowly, like reading or not following conversations.

These are all very early clues that the brain isn't functioning the way it

used to.

And it can give us an idea years and years before a diagnosis that

something's going on.

And then as a physician, I look at biomarkers like blood sugar regulation, inflammation,

and vascular health.

But I always tell my patients, if something feels off, don't track it to,

I'm just getting older, because the earlier we catch these changes in brain function,

the more we can do to try and prevent it.

And so that sort of forgetfulness, I think it's always so hard, isn't it?

This is not just, oh gosh, I've lost the keys for the car.

And sometimes that's distractibility.

Sometimes you weren't paying attention, but if that's happening somewhat consistently, and then

let's say your friend, you can't quite remember their husband's name, and you've done

that maybe 2 or 3 times and you've known them for almost 20 years.

Is that the sort of more concerning level rather than just simply saying every

now and again, I can't remember my grandchild's, the name of their best friend.

It's just, it's gone out my head.

It's the more consistency, the more things that you should expect you should be

remembering and you are not.

How do you past the worried well from the let's look into this more

bucket?

I think you nailed it on the head.

It's more of getting an understanding of, is this something important that

I forgot, or is it something more menial?

If it's something important that you generally wouldn't forget and you have now, that

means that this is a change that's occurring.

So in your practice, you will often take some approach to assessing

neurological health by looking at certain biomarkers.

When you are thinking from the perspective of Elevated Medical, which for folks, again,

this is Dr.

Eddy's practice, how do you think about inflammation and vascular health as

impacting cognitive health and your disease likelihood?

Both play a much bigger role in brain health than most people realize.

When we think about Alzheimer's, I feel like we picture memory loss, but

disease starts decades and decades before that.

It usually starts with chronic inflammation and poor blood flow that's slowly, slowly damaging

the brain.

The brain is an incredibly active organ, and it has much, much higher

demands than other organs for oxygen and nutrients.

And that supply comes from blood vessels.

If those blood vessels are inflamed or damaged, the brain doesn't get what it

needs to, to function well.

Over time, that adds up.

We see this in patients with high cholesterol, smoking, hypertension, and diabetes, which

are all risk factors for dementia.

Inflammation doesn't just limit the blood flow, it interferes with the brain's ability to

clear out waste.

Like amyloid plaques.

And that's one of the earliest, earliest triggers for Alzheimer's.

And here's the part that actually matters.

This whole process can start in your 40s or even earlier.

And so that's why I try my best not to wait for symptoms.

I like to look at vascular risk factors like ApoB, blood pressure, and insulin

resistance as the earliest, earliest signals.

Would it be fair to say that someone who has cardiometabolic ill health, so

for example, they've got high blood pressure, they've got high blood sugar, they've got

signs of vascular vessel disease, would you say it's very hard to imagine someone

who has ill health in those domains of their body to have health untouched

upstairs in the brain?

Ultimately, you made a great point.

These 2 organs are just so very related.

That, I mean, you hit the nail on the head again.

A lot of these risk factors that we're looking at, they're the same for

both.

Yeah, it's stunning, isn't it, how we forget that there is so much of

a feed-forward mechanism from body health to brain health.

To me, it only emphasizes why investing in your physical activity, taking

care of your diet, being mindful of your blood sugar, It's not just an

investment in your body.

It is as, if not more important for your brain.

Is there anything else that you would put in that bucket of strategies for

prevention of brain or cognitive decline?

What I want people to understand is that dementia or cognitive decline is not

inevitable.

There's 14 modifiable risk factors, which means that there's 14 ways that we can

change our lifestyle to reduce our risk for dementia.

45%, that's basically half of dementia cases, can be delayed or reduced.

That came from the 2020 Lancet Commission report.

A lot of them we already talked about: LDL cholesterol, smoking, hypertension, diabetes.

You mentioned physical activity.

Some of the even easier ones are wear your glasses if you have a

prescription, Wear your hearing aids if you have hearing loss.

I mean, these sound very, very obvious, but how many of us know an

elder friend or family member or a grandparent that doesn't wear their glasses or

doesn't wear their hearing aids?

Yeah, the Lancet Commission Report has set forth these 14 modifiable factors.

I was a little perturbed that sleep was not one of those.

But we will link to those in the show notes, ranging from depression, obesity,

air pollution, hypertension to, and we'll come onto it in a second, social isolation,

and together with alcohol, diet, your blood sugar, cholesterol, et cetera.

Speaking then a little bit about sleep, how do you go about approaching

sleep in your practice?

How do you think about sleep and particularly sleep in relationship the prevention of

neurodegeneration?

I think just knowing that sleep disruption increases your risk for dementia by 33%

in older adults is a data point enough to know that we need to

focus on it.

How, as physicians and people, do we put focus on it?

That's the harder question.

The way that I do it is that I want my patients to wear

a sleep tracker.

Again, doesn't need to be for 1 year or even 3 months.

I just want them to wear it for a little bit of time so

that they understand how much sleep they're getting.

Patients think that when they go to sleep at 10:00 PM and they wake

up at 6:00 AM, that they got 8 hours of sleep.

And I think wearing a sleep tracker just gives them that knowledge that not

every minute in bed means they got exactly that amount of sleep.

My goal is for me to convince them to change their behavior.

So I always tell my patients, just try and go to sleep 1 hour

earlier than you think you need to.

It's funny that you say that.

When some people will ask me in public, they'll say, so how much sleep

should I be getting?

My trite answer is usually between about 45 to 60 minutes more than you're

currently getting.

That's exactly what I recommend.

Yeah.

And it sounds like we're very aligned on that too.

With all of that said, what are the 3 takeaway messages here when it

comes to brain function and dementia risk and cognition?

Do the simple things.

Wear your glasses, wear your hearing aids, and make sure you get your vision

checked, you get your hearing checked.

Go to bed an hour earlier than you think you need to, like you

just mentioned.

And I think the third one that we're going to talk a little bit

about now is Strengthen your social life.

It's very, very important for cognitive health.

Absolutely.

Of course, we're saying go to bed an hour earlier.

That's assuming that you don't have any sleep issues or you don't suffer from

insomnia because getting into bed when you're not sleepy is sometimes not the best

piece of advice.

But you mentioned that switching gears to finally what I think is the encapsulating

penumbra of all health.

You can have exquisite body health and you can have incredible cognitive precision

and acumen, but if you are miserable, what's it for?

Which comes onto this topic of our social health, our emotional resilience, basically

our mental wellness.

So often do we talk about sleep, diet, and exercise as those pillars, social

connection, is especially important when it comes to longevity and resilience.

How do you think about the role of social health and emotional resilience in

the way that you practice medicine at Elevated Medical with your patients?

I love this question, and I love this topic because there's data points for

all those other things that we talked about, but we don't have data points

for this yet.

What we do have is numerous studies telling us that this is important.

There's a great study, the Harvard Study of Adult Development, also known as the

Harvard Study of Happiness.

It's the longest running study on health and happiness.

The number one predictor of long-term wellbeing, strong relationships.

It's not lab values, it's not macros, it comes down to relationships.

This study tells us, It's never too late to start building them or rebuilding

them.

These relationships matter.

It doesn't matter whether you're making them in your 6th, 7th, or 8th decade.

The second thing that it tells us is it's not the quantity of these

relationships, but it's the quality of these relationships that matter.

So you don't need to have a massive social circle, but it's about building

the trust in the people that you have and building those relationships.

And then leaning on those people, because when you lean on them, they'll lean

on you.

It's so important, I think, to emphasize that this is not a quantity issue.

It is the quality issue.

What do you say to people who are either in their 20s or 30s,

40s, 50s, or 65 and older?

Maybe they've lost, in that latter circumstance, they've recently lost their spouse.

And their spouse was their world.

Do you offer any strategies or recommendations as to how you can try to

increase your social connectedness?

Join a walking league, join a pickleball league.

We get so focused on thinking about exercise, diet, social connection,

like they're all separate buckets.

It doesn't need to be that way.

And honestly, it shouldn't be that way.

Why can't we incorporate exercise into social connection?

And so that's what I definitely tell all my friends, my family, and my

patients.

Join a league, any type of league that you enjoy.

And then secondly, wear your hearing aids.

As you get older, I've seen the patient, I've seen the family member that

stops wearing their hearing aid, and it affects 2 of the modifiable risk factors

for dementia.

You're one, not wearing your hearing aid, but two, you're losing that ability to

socialize.

It doesn't mean that you don't still see the grandparent or the older individual

that's at events, but you can see they can't follow conversations.

And so they're just a little bit disconnected.

Just ensuring that you do these simple things can help and go a long

way.

Incorporating all of this into your lifestyle will allow you to build these relationships.

That notion of joining social groups, it's so important.

And I know that people listening will have such an energy inertia block in

part because of fear that you are afraid of going along to something by

yourself, but rest assured that so many people have gone along to those

clubs by themselves to begin with, and they are so welcoming.

I think the other thing to get past that almost social phobia of wanting

to join something just for the sake of joining it, sometimes because we do

a lot of work in the elderly and we have a large program on

aging and sleep, when we speak to these people, yes, there is just this

rife sense of loneliness.

We often also recommend volunteering, so engaging in community service, that often

allows you to connect with other people.

And if you are worried about going along to a social group just for

the sake of trying to make friends and meet people, at least the volunteering,

the engaging in community service, it's the Trojan horse to get you into social

connection.

You're doing it because you want to help others, not necessarily because you think,

here I am, I'm a lonely person.

I think it's a great point because it gives them one gets them into

the community, but 2, it gives them purpose.

That's what we've seen too, is that you get so entrenched in your own

problems, and it's only when you look at other people and you get a

reality perspective by engaging in servicing others or serving others that

it allows you to transcend some of your own worries and concerns in a

much more healthy manner.

At Elevated Medical, you're dealing with people who are incredibly successful, major figures, high

net worth individuals who are doing everything right.

They've got their sleep dialed in, exercising.

They've got diet dialed in.

They're doing all the tracking, all the tests.

On paper, they should be living the very best version of their life.

They're surviving, but the mind isn't thriving.

Do you often see that?

I see this all the time.

You have the patient that's optimized, they exercise regularly, they track their food, they

track their sleep.

And obviously, I don't want to be a hypocrite, because I talked about so

many of the biomarkers.

I even have an Oura Ring as my wedding band.

So I'm not going to say that— I'm not going to say that data

is bad.

Likewise.

When I have patients like this, I have the question, are we optimizing too

much for data and we're not optimizing for life?

Gosh, I see the patient all the time that's running on the treadmill 7

hours a week, but they're not able to make it for family dinner.

I see the woman who skips out on dinner with friends because they chose

a pizza spot and they have no healthy meals there.

To me, that's taking it ridiculously too far.

As a doctor, I tell my patients, you need to incorporate social connection into

your life.

And kind of how we mentioned before, I want my patients to include 1

hour of exercise with someone per week.

So whether that's walking, playing basketball, being in a pickleball league, something,

they need to try and incorporate 1 hour of exercise that's a social interaction

as well.

The goal is not to be consistent for the next year or 2 years.

I see patients that can do that with their zone 2 and their zone

5 training.

Training.

The goal is, how can I keep this patient consistent over 10 years, 20

years, 30 years?

And you see the patient that's 70 years old that gets hurt.

What's their reason for wanting to get back to exercise?

It's to get back to playing with their friends.

That's what gets them back.

I love that.

We are so prescriptive in diet and sleep and exercise, we can also

be prescriptive with our social connectedness too.

I don't hear many doctors talking about an Rx for social connectedness,

and you just gave one.

In 4 words or less, because I'm such a pain in the posterior, big

picture, what is the one single most important message that you hope listeners

will take away about their health, from this conversation that they've listened to?

Don't do life alone.

Oh, mic drop.

I want to end the interview right there.

Wow.

Get me that t-shirt, will you please?

Don't do life alone.

That is amazing.

Okay.

In all of the things that we've discussed in terms of the things to

measure, if you absolutely said, look, I'm someone who is north of 40 years

old, what are the 2 things that you would say they absolutely

need to go and get measured right now?

I know, again, this is so trite of me to distill it down, but

2 things to measure.

Coronary CT angiogram or a calcium score, and then a fasting insulin.

Love it.

God, you're on a roll.

Okay, we did the one thing, we've done 2 things, I'll do 3 things.

If you could recommend committing to just 3 actions for better health, what would

those 3 things be?

Start today, move often, and connect deeply.

Excellent.

Amazing.

6 words.

No, no, no.

That's brilliant.

You've got 4 words for each one of them, so you did it in

less.

Ah, Avi, Dr.

Eddy, you're amazing.

Tell me what's next for your practice.

What's next for Elevated Medical in advancing patient care or preventative strategies?

I just wanted to take on my personality, so I want to use the

best science available, but more than anything, I want to deliver it in a

way that actually feels personal.

I want people to live longer, of course, but I want them to enjoy

their life as well.

More connection, more presence, and more things that actually fit into their

life.

I love that.

The very best of medicine delivered through the appreciation of a patient

having seen you in practice and know you in person.

I think it's one of the things that truly differentiates you in the space.

Where can people learn more about you, your practice, even though I know that

you are oversubscribed, not just nationally, but internationally, you are an incredibly

hot property, but where can people learn more about you and the practice?

You can find me on LinkedIn and Instagram, or you can go to my

website or find the practice at elevatedmedical.com.

Find Dr.

Avinash Reddy.

We will link to all of these social media handles as well as the

website.

And with that, anything else you'd like to say before I thank you with

praise of an annoyingly profuse nature?

No, I just want to Thank you for having me on, and it's been

a great conversation, obviously, as always.

Well, you are just fantastic.

I mean, your breadth and your depth of knowledge is incredible, but to me,

it's really about how you integrate all of those together into this holistic vision

of the new version of medicine in a way that back, gosh, when I

was at Queen's Medical School, it's such a radically different world.

You're so high on the empathetic sensitivity scale that you can understand a patient

so very quickly.

It's not just a do it this way or no way at all.

It's like a Savile Row suit that is tailored to every person, and it's

so different because people are so different.

Having a doctor that appreciates that rather than force-feeding you is such a refreshing

take.

Avi, who you are, what you do.

Thank you so much for coming on the show.

Thank you so much for having me.