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00:00:00.000 | [MUSIC]

00:00:02.540 | Hello and welcome to another episode of All The Hacks,

00:00:05.500 | a show about upgrading your life, money, and travel.

00:00:08.540 | Since it's the beginning of the year, I know many of you, myself included,

00:00:12.040 | are thinking a lot about how we can upgrade our health this year.

00:00:15.880 | To help make that possible, I wanted to invite Dr. Jordan Schlain on the show.

00:00:20.300 | Jordan is a physician, entrepreneur, publisher, and healthcare systems designer.

00:00:24.880 | He was one of the early pioneers of concierge medicine

00:00:27.880 | and is still a practicing primary care doctor through his practice, private medical.

00:00:32.500 | I heard Jordan talk about optimizing your health at a conference last year,

00:00:35.960 | and I have been so excited for this episode ever since he agreed to come on.

00:00:39.880 | He has such a wealth of knowledge on health and longevity,

00:00:43.040 | and we're going to try to cover as much of that as possible,

00:00:45.960 | including how you can start taking your health into your own hands,

00:00:49.080 | what to look for in a primary care doctor,

00:00:51.580 | what kinds of tests and diagnostics might make sense to consider,

00:00:55.000 | how to think about things like sleep, diet, and exercise, and a lot more,

00:00:58.660 | including some of his best health hacks.

00:01:00.920 | So let's jump right in after this.

00:01:03.420 | (upbeat music)

00:01:05.240 | Jordan, welcome to the show.

00:01:06.920 | - Thank you, glad to be here.

00:01:07.960 | - So I'll kick it off.

00:01:09.380 | What do you think the state of our current healthcare system is right now?

00:01:12.540 | - Oh, it's bad.

00:01:13.760 | It's as bad as it's ever been,

00:01:15.200 | and I think there's a lot of hype that it's gonna get better sometime soon,

00:01:19.280 | but it's been 20 years that people have been saying

00:01:21.880 | we're just about to turn the corner,

00:01:23.920 | but we're dealing with a massive cruise liner

00:01:27.000 | that turns incredibly slow

00:01:29.000 | because there's so many vested interests.

00:01:31.080 | The intellectually honest framing is this is a health insurance system.

00:01:35.740 | It's not a health care system.

00:01:38.620 | It's 85% about money and 15% about care,

00:01:42.160 | and a lot of hospital CEOs will say,

00:01:43.960 | well, no margin, no mission,

00:01:45.420 | which is a great thing for a capitalist private market company to say,

00:01:49.740 | 'cause if they don't make money, then they do go out of business.

00:01:52.240 | The thing is, is healthcare, unlike finance, unlike travel,

00:01:56.740 | unlike consumer electronics, you can map out the supply chains,

00:02:00.660 | you can map out the choke points and the efficiencies,

00:02:03.240 | and you can really streamline stuff,

00:02:04.820 | but healthcare was never designed for scale.

00:02:08.660 | It's always local.

00:02:09.820 | There's a local person.

00:02:10.900 | Very few hospitals have a national footprint,

00:02:12.620 | so fundamentally, they have different buyers,

00:02:14.620 | different supply chains, different plans,

00:02:16.360 | different states, different regulations,

00:02:17.740 | so it's not an ecosystem.

00:02:18.900 | It's a frico system, which is you can't peel back the onion

00:02:23.240 | and get other layers of an onion.

00:02:24.480 | You may get a tomato in there, you may get a grapefruit.

00:02:27.200 | Like every time you peel something back,

00:02:28.660 | there's things in there that are legacy systems that were built upon.

00:02:32.280 | They're not streamlined and thorough and simple

00:02:35.400 | in the way that most other industries are.

00:02:38.980 | So the state of the system today is it's kind of like an every person for themselves,

00:02:43.020 | and you're reliant on the insurance world.

00:02:46.060 | Everybody has insurance.

00:02:47.780 | But I'll say that if you're a person that wants to get good healthcare,

00:02:52.440 | well, it's local.

00:02:53.700 | You have to look around and what's there.

00:02:56.900 | There's not a lot of choice in medicine.

00:02:58.360 | You have free will when you have your wallet to go buy what you want,

00:03:01.240 | and healthcare, I call it tethered will.

00:03:03.280 | If you have a big cut on your arm,

00:03:05.240 | you don't get to go shopping to which store to go to.

00:03:07.560 | You're going to go to the closest one.

00:03:08.660 | You're not even paying for it.

00:03:10.160 | So it's not even your resource.

00:03:11.780 | This is called in economics, the principal agent problem,

00:03:15.440 | where you pay a third party, they pay somebody else.

00:03:17.980 | So the person that you're receiving the good or service from, you didn't pay.

00:03:22.240 | They don't feel aligned necessarily because you put your hardworking money into it.

00:03:27.820 | It may be your employer's money.

00:03:29.060 | I would say one of the biggest problems is this principal agent problem.

00:03:32.320 | But going back to the story with your headache,

00:03:34.320 | so then you see the doctor, they give you some morphine in the ER

00:03:36.780 | because it's a terrible headache.

00:03:37.820 | Then you go home and the morphine wears off.

00:03:39.520 | You still have your headache.

00:03:40.820 | So you just went to go get something, and you came back, and it's not better.

00:03:44.520 | Or it's 50% better.

00:03:46.320 | Now you have to figure out what to do.

00:03:47.780 | So you call your primary care doctor, that's a two-week wait.

00:03:51.580 | So then you ask Dr. Google and he or she basically comes back with that could be cancer.

00:03:56.060 | So now you're super anxious, right?

00:03:58.380 | And so the whole system is not designed.

00:04:01.640 | There was no designer.

00:04:04.420 | It's a patch on top of a patch on top of a patch where the money continues to flow through

00:04:10.400 | multiple middle people that like take their sliver of the money.

00:04:14.780 | And it's not getting any better to answer the question.

00:04:16.680 | I've been building my model outside of the existing system, trying to create a new design.

00:04:23.440 | Like I've designed this and we'll get into that later from scratch, which is how do you

00:04:26.800 | honor both the doctor and the patient and the data in an elegant way to try to achieve

00:04:33.680 | the best outcome the fastest.

00:04:35.580 | And I should only get paid on that.

00:04:37.600 | And I want the person to pay me for that.

00:04:39.400 | Now if they need an MRI, that's what the insurance is for.

00:04:43.200 | I should help them get the best MRI place.

00:04:45.280 | I should be the one to be their quarterback around how to receive that care.

00:04:49.600 | But really what the Affordable Care Act did, and I think this is lost on most people, is

00:04:56.200 | it set the incentive for the doctors or the medical groups or the people that own the

00:05:01.680 | medical groups to get a fixed amount of money per problem.

00:05:07.360 | For example, right now if you have a heart failure, and maybe we could take the guy Demar

00:05:12.160 | Hamlin as an example, right?

00:05:14.040 | He's a young healthy guy.

00:05:15.300 | He had a cardiac arrest.

00:05:16.800 | This is for those of you who don't know, NFL football, primetime Monday Night Football

00:05:19.800 | the other night, he fell down and they were doing CPR.

00:05:22.840 | I'll use him as a quasi example, but this isn't gonna be exact.

00:05:25.640 | The place that he gets taken care of says, "Hey, for everybody with a cardiac arrest,

00:05:29.640 | you get $10,000 to get him out of the hospital and get him home."

00:05:33.200 | It used to be, "Hey, every day he stays there, you get $3,000 in the ICU, you get all the

00:05:38.720 | money you want, whatever prescription you write, you get paid for."

00:05:42.320 | So the sicker you get or the more transactions there are, the more money the system gets.

00:05:47.440 | So there's no incentive to get that guy out fast.

00:05:49.640 | Now the doctors, my people, we of course are healers.

00:05:52.440 | We want this guy to get better.

00:05:53.920 | We want him to get better fast.

00:05:54.920 | We want to make all the right decisions at the right time for the right reason.

00:05:58.240 | The truth is there's this overlay of, "Hey, if we keep him here a little bit longer,"

00:06:02.600 | I'm not saying that...

00:06:03.600 | I think Cincinnati has got an amazing hospital system that they would do that, but in a lot

00:06:07.080 | of systems that you don't hear about where there's no oversight, they'll just keep somebody

00:06:10.520 | there for days and there's not a financial incentive to get them healthy as fast as possible.

00:06:16.300 | So the Affordable Care Act created this thing called the Accountable Care Organization,

00:06:19.520 | which is we're gonna start going with specific conditions and saying, "This is the money

00:06:23.980 | you get."

00:06:24.980 | The incentives will be aligned around good outcomes yield good incomes.

00:06:29.960 | Right now, it's bad outcomes yield good incomes, sadly, for the healthcare industry.

00:06:35.080 | And I think that is a fundamental problem.

00:06:39.200 | And there are so many middlemen, Chris, that make a little vig off of that dollar when

00:06:43.960 | you don't do well.

00:06:45.200 | From the person that sells gloves to the person that has the billing software, there's so

00:06:49.560 | much waste and fraud.

00:06:52.580 | I would say train AI on fraud and you probably save a ton of money because it's just there

00:06:57.260 | in spades.

00:06:58.260 | I would say one other thing is that with the advent of digital health, now you have fragmentation

00:07:03.840 | of medical specialty things.

00:07:06.680 | So if you wanna go get a SIBO test 'cause you think you have bacterial overgrowth 'cause

00:07:10.800 | you have some bowel problems, you can go online and order a SIBO test, okay?

00:07:13.800 | You get the results, they'll tell you what to do and you're managing SIBO, which is like

00:07:17.320 | a condition of gas bloats and cramps and can cause fatigue.

00:07:20.760 | So you have this fragment and no one's orchestrating everything.

00:07:23.880 | So now you have little windows of things that you can solve.

00:07:28.140 | But John Muir, who is a famous explorer naturalist in America, and I'd say he said, "When you

00:07:33.160 | tug on a single thing in nature, you realize it's connected to everything else."

00:07:38.640 | And in medicine, what I can tell you is if you have SIBO or if you have migraines or

00:07:43.360 | if you have whatever, eczema, there are probably multiple factors that need to come together

00:07:48.560 | to help solve that without pills, without injections, without interacting with the medical

00:07:54.280 | system.

00:07:55.280 | There's so much that you can do on your own.

00:07:56.840 | I like to say, how do you become independently healthy?

00:07:59.200 | And ultimately, health is what you can do for yourself.

00:08:02.880 | And what healthcare is, when you can't do it for yourself, you must reach out to somebody

00:08:08.280 | that can help you navigate the kind of the thicket of the healthcare system.

00:08:12.760 | It sounds like the providers are less incentivized financially to do whatever they think might

00:08:19.280 | be the best thing because the insurance company is the payer, you have this principal-agent

00:08:23.120 | problem.

00:08:24.120 | There are certain treatments, by the way, that will most likely be covered and won't.

00:08:28.020 | So to recommend someone do something that they probably can't afford or won't get covered

00:08:33.680 | by their insurance is probably not going to happen.

00:08:35.600 | But you don't even know that a priori.

00:08:37.540 | You can recommend something and only later do they find out it's not covered.

00:08:40.680 | And then that patient has to go back to the doctor and say, "That wasn't, again, no design,

00:08:44.280 | no elegance.

00:08:45.280 | It's a shit show."

00:08:46.280 | And then kind of highlighted that the most important thing might be that everything in

00:08:49.520 | your health seems connected.

00:08:50.600 | So this idea of your primary care physician seems as important as it ever was.

00:08:55.680 | But at least in my personal experience, it's been tough to find someone in the conventional

00:09:00.120 | medical care system that's covered by my insurance that actually wants to play that role of discovering

00:09:06.360 | what's wrong and trying to figure it out and being aware of all the latest medical research

00:09:10.020 | and all that.

00:09:11.020 | So I guess maybe the question is, there's one end of the spectrum, which you've started

00:09:15.080 | your own practice, which is not accessible to everyone, but gives you that quarterback

00:09:19.720 | that can kind of go through that process.

00:09:21.880 | What are people who are not at the point that's the right fit for them?

00:09:25.920 | Where should they start?

00:09:27.280 | Great question.

00:09:28.280 | So my framework in general for every person is, first of all, do you know everything about

00:09:33.320 | yourself?

00:09:34.320 | Biologically and physiologically?

00:09:35.320 | What do you know?

00:09:36.320 | Do you know what your blood pressure is?

00:09:37.480 | Do you know what your cholesterol is?

00:09:39.040 | Do you know what your family history is?

00:09:40.560 | Do you know what your genetic susceptibility to things are?

00:09:44.440 | What do you know?

00:09:45.440 | And what do you not know?

00:09:46.440 | A lot of people don't want to know.

00:09:47.440 | "No, no, no, no, no, no, no.

00:09:48.720 | I don't see it.

00:09:49.720 | I'm just going to live my life."

00:09:50.720 | And blah, blah, blah.

00:09:51.720 | Great.

00:09:52.720 | They're gambling.

00:09:53.720 | And if you're young and healthy and there's nothing wrong in your family, probably pretty

00:09:56.200 | safe bet nothing bad is going to happen to you.

00:09:58.460 | But then you always read in the paper about the sporadic person with nothing wrong and

00:10:01.440 | they just died of whatever, or they got cancer at 35.

00:10:04.200 | Those are the headlines that scare people, but they're true.

00:10:06.540 | And why would you not, with not a lot of investment, learn everything you can about yourself to

00:10:11.740 | make informed, proactive decisions to keep yourself optimized and not have to use the

00:10:18.300 | healthcare system for the rest of your life, if you could?

00:10:21.320 | If you wanted to walk through someone who maybe is thinking right now, "I haven't really

00:10:24.980 | taken my health seriously.

00:10:26.020 | What should I go and either do myself or ask my doctor to help me do?"

00:10:30.620 | You could go to quest.com, which it's a lab.

00:10:33.140 | By the way, anything I mentioned here, no conflicts of interest for me.

00:10:35.740 | I don't have any vested interest in anything.

00:10:37.260 | But Quest Labs and line up the 10 other competitors to them, you can go online and order blood

00:10:41.660 | tests and some states and cities will come to your house, they'll charge your insurance,

00:10:46.020 | they may charge you a convenience fee to do it online, who knows.

00:10:49.020 | By the way, just a thing that I found, I have no affiliation with this company, but I was

00:10:52.740 | looking at some tests that I wanted to run that weren't covered by insurance.

00:10:55.900 | And there's this site, ultalabtests.com, which basically sends the same order to Quest at

00:11:01.460 | like a third of the price.

00:11:03.040 | So if someone doesn't find something covered, I just went to Quest and got the exact same

00:11:07.140 | test done, but it was just less expensive.

00:11:09.100 | I'm not sure how that whole system works.

00:11:10.580 | Well, look, I mean, the dirty little secret here is when I have a patient who like, let's

00:11:15.180 | say lost their insurance, doesn't have insurance.

00:11:17.820 | And I say, go to Quest and order a cholesterol test, it could be $200.

00:11:21.400 | But if I order it under my account, it's like $20.

00:11:24.900 | So like there's massive margin here because there's opacity and no transparency in this

00:11:29.980 | system, even MRIs.

00:11:30.980 | I don't want to get ahead of ourselves, but let's just say you wanted to do the most thorough

00:11:35.300 | baseline understanding of who you are in the world, right?

00:11:39.140 | And you were willing to spend a chunk of change just to get to know yourself.

00:11:42.220 | Well, one of the things that you would consider is getting a brain MRI with a brain MRA.

00:11:47.980 | And I'll tell you a story about a guy that I did that on, and it turns out something

00:11:50.220 | happened to him.

00:11:51.220 | So I'm so glad we had a baseline test to compare it to, because otherwise you're flying blind.

00:11:54.800 | The problem with doing tests like that, a lot of doctors will say, well, you're going

00:11:58.900 | to find things on there that don't mean anything.

00:12:01.700 | Like if you did an MRI of a spine of every 50-year-old, they all look like shit.

00:12:05.920 | And then everyone, oh my God, I'm falling apart.

00:12:07.220 | No, that's just natural aging, but we haven't calibrated normal to not normal yet.

00:12:11.700 | It's like everything's abnormal if it's not perfect.

00:12:14.060 | But at age 24, it's perfect unless it isn't, but everything decays over time.

00:12:19.380 | So the MRI that I would order on somebody that really wanted - the MRA shows you the

00:12:24.440 | blood vessels, like three-dimensional blood vessels of your brain, because if you have

00:12:28.940 | an aneurysm in your brain, the typical way you find out about them is on autopsy.

00:12:33.440 | Your aneurysm burst and then you fell down and unless you're close to a hospital, you're

00:12:36.740 | dead.

00:12:37.740 | They're very rare, but you catch them on some people.

00:12:39.740 | But if you ordered that MRI and you walked into the place, it could be $10,000.

00:12:44.340 | If I order it through my system, like through the private pay, it's $400.

00:12:48.180 | You get the same outcome, you're just like getting hoodwinked by something you didn't

00:12:53.260 | even know.

00:12:54.260 | So that's the opacity factor that a lot of people have been trying to tackle, but there's

00:12:57.340 | a whole lot of people that don't want that opacity to be known because it's going to

00:13:01.020 | expose all these facets of the shenanigans and the chicanery that goes on behind the

00:13:06.160 | scenes to make the profits.

00:13:07.500 | But to answer your question specifically, what would you do if you were a regular person

00:13:11.740 | that just wanted to know?

00:13:12.740 | So you do like what's called a CBC, a complete blood count.

00:13:15.420 | You want to know what your immune system looks like.

00:13:17.580 | Do you have enough blood in the tank?

00:13:19.480 | There are some women that because they have heavy periods, they're anemic and they don't

00:13:22.700 | know it, but they have low energy and they don't know it.

00:13:24.500 | So you'd want to like get a baseline on where you are, whether you're anemic or not.

00:13:28.000 | You'd want to get like a chemistry panel.

00:13:29.340 | And again, these are all like almost archaic, but they're the standard of care.

00:13:33.500 | You'd want to get your cholesterol and there's like a basic cholesterol, then there's a cardio

00:13:36.560 | IQ test, which is a much more sophisticated cholesterol test that will tell you your APO

00:13:42.700 | and your LDL fractionations and all sorts of bits and pieces that will give you a little

00:13:46.180 | more color on should you be concerned or not.

00:13:48.140 | From a blood work standpoint, I like to check at least once your Westergren sed rate, which

00:13:52.940 | it's a very nonspecific test, but it shows what level of inflammation there is in your

00:13:59.380 | body.

00:14:00.380 | Again, it's a crude inflammatory marker.

00:14:02.860 | And I'll just pause and talk about something called inflammation.

00:14:05.660 | The more inflammation you have in your body, chronic inflammation, the faster you age.

00:14:09.300 | So one's goal in life should be to have a body that's not inflamed inside.

00:14:13.500 | Now when you cut your finger or you bang up your something, you see the inflammation visible.

00:14:17.320 | But when your whole body's subclinically inflamed, which can be caused by great stress from a

00:14:22.540 | bad relationship, it could be caused by untreated subclinical Crohn's disease, or we could talk

00:14:27.940 | about a lot of things.

00:14:28.940 | You're just aging faster.

00:14:29.940 | You will have problems later in life.

00:14:31.300 | And so if you try to go to your future self, what would you want to know today?

00:14:33.780 | So the sed rates one, there's something called an HS, high-sensitivity CRP, cardioreactive

00:14:38.180 | protein.

00:14:39.180 | Again, another measure of inflammation.

00:14:40.840 | These are all, I'll call blood test 1.0.

00:14:43.820 | There's a whole new set of tests, Chris, we can talk about, metabolomics, proteomics.

00:14:48.400 | There's all these new companies coming online that are creating much more sophisticated,

00:14:52.380 | much more sensitive tests.

00:14:54.180 | Those still cost 500 bucks because they're new startups and they don't have scale yet,

00:14:59.100 | but those will come down.

00:15:00.320 | If you're over 50, there's a cancer test called GRAIL.

00:15:02.900 | It's called gallery, checks for 42 types of cancers.

00:15:05.880 | It's 960 bucks right now, but you have a family history of cancer, I recommend you probably

00:15:11.380 | do that every year.

00:15:12.380 | I just caught a 38-year-old guy with a mother and a grandmother with stomach cancer.

00:15:15.940 | I checked him at 38, colon cancer, positive, stage two, surgery, chemo.

00:15:20.200 | He just got his test back yesterday, cancer-free two years later, saved his life.

00:15:24.260 | You don't normally get a colonoscopy until you're 45.

00:15:26.500 | So he's 38.

00:15:27.500 | He would be dead by the time of his first colonoscopy.

00:15:29.400 | So you have to like risk adjusting.

00:15:31.100 | Who are you?

00:15:32.100 | What are the tests that you should get?

00:15:33.260 | You should know what your blood pressure is.

00:15:34.740 | And by the way, checking your blood pressure one, does it count?

00:15:37.180 | The real way to understand what your blood pressure is, you have to check it 17 times

00:15:40.300 | at different times of the day in one month.

00:15:42.580 | Put them on a spreadsheet, average them out, that's your blood pressure.

00:15:45.620 | What should it be?

00:15:46.620 | It should be below 120/80 most of the time.

00:15:49.180 | If you just went on a run, had coffee, had sex, got in a fight, it can be higher.

00:15:52.540 | That's normal.

00:15:53.540 | Your blood pressure is supposed to get up to be high because we have a lot of resilience

00:15:55.980 | in our system.

00:15:56.980 | But at baseline, at regular, it should be like 120/80 or less.

00:16:01.080 | So those are some basic blood tests.

00:16:02.700 | A lot of this stuff has to do about what age you are and what your risk factors are.

00:16:06.820 | So if you got a family history of heart disease, my mom had a heart attack or dad, something

00:16:10.780 | like that, then you're going to want to like start doing these tests earlier.

00:16:13.180 | And if you have high cholesterol and a family history, you should think about something

00:16:16.580 | called a calcium score, which is a CAT scan that gives you a lot more data on whether

00:16:21.380 | the cholesterol - because remember, there's different genetic types of people.

00:16:25.580 | Some people can have high cholesterol all their life and never have a heart problem.

00:16:28.660 | Some people can have like moderately high cholesterol and have a heart problem.

00:16:31.820 | So you have to identify which one are you in the world.

00:16:34.220 | Like you're not like everybody else.

00:16:35.940 | You're unique.

00:16:36.940 | Part of it's your family history, part of it's your genetics and part of it's your lifestyle

00:16:39.780 | or health style.

00:16:40.780 | And so, how you exist in the world depends on the probability that one of these things

00:16:45.860 | that could happen does happen.

00:16:47.260 | So those are some baseline testing, just simple blood tests, blood pressure.

00:16:51.020 | I would say check thyroid, gland, a TSH, that's a basic blood test.

00:16:55.220 | Just a good one time to know.

00:16:57.180 | Men should probably be getting PSA checks and prostate exams after the age of 50 on

00:17:01.500 | somewhat of a regular basis.

00:17:03.180 | If there's a family history of getting prostate cancer in their 50s, then you should start

00:17:06.500 | doing that much earlier.

00:17:07.500 | Like again, the blood test.

00:17:09.040 | But a lot of these things require both experience and math.

00:17:12.020 | And the good news is with AI right now, pretty soon you'll be able to plug in all sorts of

00:17:15.220 | stuff about yourself and it'll tell you what tests you should do.

00:17:17.340 | And if those tests say this, then you should do that.

00:17:19.700 | So that's kind of this future.

00:17:21.180 | The question is, how do you execute that?

00:17:22.740 | I'll share one example.

00:17:23.780 | So I used and now partnered with this company InsideTracker.

00:17:28.860 | And it's basically do blood work and they go in and share you a lot of the data about

00:17:33.940 | where's the standard range, what's your range, what are recommendations from our team of

00:17:38.240 | researchers that say what you should do, link out to the research.

00:17:41.860 | But that's one thing I did and I did the genetic profile there so they can kind of adjust things

00:17:46.820 | based on what they learn about your genetics.

00:17:48.420 | So that's one option that I've used and we partnered with.

00:17:52.020 | So you're talking about genetics vis-a-vis like a health problem.

00:17:55.660 | There's another set of genetics coming online.

00:17:57.460 | And by the way, there's a company called Invitae.

00:17:58.980 | They're one of the bigger ones.

00:17:59.980 | They do the panel of I don't know how many genes, but they check for genes that like

00:18:04.420 | tell you what your probability of getting something is, which then can inform what your

00:18:07.660 | surveillance program should be.

00:18:09.040 | So they've got a good panel.

00:18:10.540 | But then there's a company, again, I'm just gonna name various companies, called Oneome,

00:18:16.860 | that does pharmacogenetics.

00:18:19.460 | So what's that?

00:18:20.460 | Because of COVID and because a lot of mental health issues, a lot of people are taking

00:18:22.980 | antidepressants or anti-anxiety drugs.

00:18:25.540 | We can talk about psychedelics later because a lot of people are doing that too.

00:18:28.140 | But we can tell you through, again, this science is, I'll say 75%, but it's better than 0%.

00:18:34.860 | So a lot of doctors will say, "I'm not gonna do that test because it's not 98%."

00:18:37.980 | I'm like, "Well, would you take 75% over zero?

00:18:42.660 | Right now, when someone is depressed, I'll try this drug.

00:18:45.540 | Oh, that doesn't work.

00:18:46.540 | I'll try that drug.

00:18:47.540 | Oh, that doesn't work.

00:18:48.540 | I'll try that drug."

00:18:49.540 | Well, with pharmacogenetics, they can kind of look at the processing power of your enzymes

00:18:52.220 | with respect to certain genes, and they can tell you, "Hey, this drug is probably not

00:18:57.220 | gonna work as well because it's cleared so fast," or, "This drug will work better."

00:19:00.860 | So if you're gonna embark on a kind of pharmacologic adventure to try to solve a problem, this

00:19:07.180 | is called precision medicine, we're getting better at being able to pick the right drug

00:19:11.580 | the first time.

00:19:12.940 | And that's through this venue called pharmacogenomics, which is, again, still new.

00:19:17.560 | The existing medical system is very slow to move, like I said at the beginning at the

00:19:21.140 | top of the podcast, and a lot of doctors won't do it.

00:19:23.700 | A lot of insurance companies won't pay for it because the proof isn't there yet.

00:19:28.100 | And so, they usually require five years of proof and data to do the analysis to show

00:19:31.820 | that this cost has a future cost benefit.

00:19:35.300 | And that's kind of the...

00:19:36.300 | Which by the way, you want that science and you want that rigor.

00:19:39.820 | In technology, it's move fast and break things.

00:19:42.260 | And in medicine, it's move slow and don't hurt people.

00:19:44.700 | So we do want it to move slow a little bit, but every 120 days, Chris, there's a new major

00:19:48.900 | breakthrough in medicine that like most of the medical field won't like know about for

00:19:53.220 | 10 years because they're so busy with the innovations from the last five years.

00:19:57.080 | There's this natural lag that any doctor has, or any clinic has.

00:20:03.180 | I hold myself out and we hold ourselves out as there's no lag.

00:20:07.460 | All these companies are presenting to me.

00:20:09.220 | Every other week, I've got kind of a speed dating type of companies present to my group

00:20:13.660 | of six of our doctors and we kind of like, "Does it pass the sniff test?

00:20:17.500 | Is it valuable to patients?

00:20:18.780 | Is it not like super expensive?

00:20:21.220 | Does it work?

00:20:22.220 | And then what is the science?

00:20:23.220 | And is it peer-reviewed?

00:20:24.220 | Is it validated?"

00:20:25.220 | There's a lot of people hawking a lot of stuff that's like super on the margin and on the

00:20:28.420 | bubble.

00:20:29.420 | And there's a ton of gurus, especially in the longevity space, talking about how if

00:20:32.900 | you just take this or do that, like off you go.

00:20:35.540 | But there's no proof.

00:20:36.900 | There's just no proof.

00:20:37.900 | So I generally think about just to go to that place really quick, everything should be looked

00:20:41.820 | at through the lens of safety and efficacy.

00:20:44.620 | And if it's safe and it's proven safe and there's ways to prove that things are safe

00:20:48.420 | or not, and it's not yet proven to be efficacious, thinking longevity, well, take a flyer.

00:20:55.180 | You're just gambling with your money, right?

00:20:56.980 | Why not?

00:20:57.980 | Like maybe it works, maybe it doesn't.

00:20:58.980 | But if you are going to do something that doesn't have a safety profile that is like

00:21:02.860 | really robust, I mean, this is your body, this is your health asset, this is your life.

00:21:06.360 | If you're going to take a flyer and gamble on the safety piece, because by the way, if

00:21:10.980 | we're not sure it's safe, we're not sure if it's effective, then you're gambling with

00:21:13.900 | your health.

00:21:14.900 | I call that short brevity or long brevity.

00:21:17.460 | It's not longevity, it's long brevity.

00:21:19.740 | You are just kind of hoping that it works.

00:21:22.820 | My philosophy is, hey, wait a couple of years, let the science tell you the story.

00:21:26.900 | Don't rush into gambling with your health because if it does work and you missed it

00:21:30.960 | by two years, okay, that's two extra weeks when you're like 99 to 99 and two weeks old.

00:21:36.740 | Like right now, you don't want to be mucking up with your system that can make it 99 to

00:21:42.060 | like maybe you make it to 82 because you created all this other problems.

00:21:46.380 | My job is to look at the science and I'm not well loved by a lot of people because I'm

00:21:50.180 | not making money on anything.

00:21:52.340 | Everyone else is making money on the things that they're pitching.

00:21:54.220 | So it puts me in opposition in some ways to things that are being pitched.

00:21:59.540 | So I am quite comfortable right now, which is actually true almost every day and that's

00:22:04.060 | thanks to Viore and I'm excited to be partnering with them for this episode.

00:22:08.040 | They make performance apparel that's incredibly versatile.

00:22:11.620 | Everything is designed to work out in, but it doesn't look or feel like it at all and

00:22:15.540 | it's so freaking comfortable.

00:22:17.260 | You will want to wear it all the time.

00:22:18.980 | Seriously, I am pretty sure it's more comfortable than whatever you're wearing right now, unless

00:22:23.300 | you're wearing Viore, in which case you already know what I mean.

00:22:26.300 | And it's not just for men.

00:22:27.980 | My wife is as obsessed with Viore as I am.

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00:22:33.300 | I think I have three pairs and they are probably the most comfortable pants I've ever owned.

00:22:38.020 | Their products can be used for just about any activity, whether it's running, training,

00:22:42.340 | or yoga.

00:22:43.340 | They're also great for lounging, running around town, or their MetaPants can even work for

00:22:47.460 | a night out.

00:22:48.460 | Honestly, I think Viore is an investment in your happiness.

00:22:51.860 | And for all the Hacks listeners, they are offering 20% off your first purchase, as well

00:22:56.260 | as free shipping and returns on US orders over $75.

00:23:00.980 | So you should definitely check them out at allthehacks.com/viore or in the link in the

00:23:07.060 | show notes.

00:23:08.060 | Again, go to allthehacks.com/viore and get yourself some of the most comfortable and

00:23:16.420 | versatile clothing on the planet.

00:23:19.820 | I wish I could say that I'm eating a fully balanced diet every day, but the reality is

00:23:24.300 | that I am definitely not.

00:23:26.100 | So I love having an easy way to get my daily nutritional insurance, which is why I kickstart

00:23:31.140 | my day with Athletic Greens, and I am excited to be partnering with them for this episode.

00:23:35.980 | I started taking it because I wanted to see what all the hype was about, and I've kept

00:23:39.900 | it in my daily routine for months.

00:23:42.740 | Every morning, I mix it up with some cold water, add a few ice cubes, it tastes so good

00:23:47.100 | when it's cold, and I head to my office feeling focused and energized for the day, which is

00:23:51.820 | a feeling I absolutely love.

00:23:54.340 | I also love that it's made from 75 high-quality vitamins, minerals, and superfoods, and contains

00:23:59.860 | less than one gram of sugar.

00:24:02.100 | It also has no GMOs, nasty chemicals, or artificial anything.

00:24:06.260 | To make giving it a try easy, Athletic Greens is going to give you a free one-year supply

00:24:11.420 | of immune-supporting vitamin D and five free travel packs with your first purchase.

00:24:16.920 | All you have to do is visit allthehacks.com/athleticgreens.

00:24:19.860 | Again, that's allthehacks.com/athleticgreens to take ownership over your health and pick

00:24:28.180 | up the ultimate daily nutritional insurance.

00:24:31.380 | Let's run through a couple of the lifespan things and just get your take on them.

00:24:35.500 | One of the most well-proven and well-known things for longevity is social integration,

00:24:39.920 | is having healthy relationships that are repeated in long-term.

00:24:44.340 | Are you in a book club?

00:24:45.340 | Do you go on walks with the same people?

00:24:47.540 | We often think that the body and the mind are different things, but they're the same

00:24:51.620 | thing.

00:24:52.620 | That's like saying my computer screen and my computer chip in the thing are different.

00:24:56.820 | Well, they are, but the output is like one breaks, the other one - you need both.

00:25:01.160 | And so the brain is what can cause inflammation in the body by stress or by angst or by not

00:25:06.380 | sleeping well or by having bad eating habits or by drinking too much because you're stressed.

00:25:10.980 | So this level of stress kind of goes down with social integration because your people,

00:25:14.980 | they call your bullshit in a way that you've kind of come to tolerate and realize that

00:25:19.500 | you need people to guide you and to be sounding boards so that you're not just looking for

00:25:23.380 | more likes on Twitter or getting super bummed out when you get like a criticism somewhere.

00:25:27.100 | I just also did a podcast with Eric Verdon, who's the CEO of the Buck Institute on how

00:25:32.220 | to live to 95 super healthy, and we go through a number of different strategies to do that.

00:25:36.940 | Spoiler alert, it's not rocket science right now.

00:25:40.020 | He's doing a lot of research on stuff molecularly, cellular senescence, mitochondrial decay,

00:25:45.820 | telomeres, oxidative stress.

00:25:48.040 | They're doing a lot of that research, but he'll even tell you we're not there yet.

00:25:50.980 | And then there's stem cells.

00:25:52.180 | And I think when we think of longevity, we have to think about like, well, my eyes may

00:25:55.960 | age faster than my heart.

00:25:57.500 | My liver may age faster than my kidneys.

00:25:59.980 | So longevity is like almost organ-specific and most people don't think like that.

00:26:03.660 | But the spoiler alert is, and a study came out literally, I think it was yesterday.

00:26:07.180 | A big study over lots of years and lots of people that water, hydration - by the way,

00:26:14.140 | we all know this.

00:26:15.820 | Everybody knows that like, as my father used to say, the solution to pollution - I see

00:26:19.060 | you drinking now - the solution to pollution is dilution.

00:26:22.300 | Water is a critical aspect of life and if you stop drinking for three days, you're dead.

00:26:25.940 | Let me just put a really fine point.

00:26:26.940 | If you stop drinking for three days, you're dead.

00:26:28.860 | If you stop eating, you can go on a hunger strike for a month or longer before you're

00:26:32.940 | dead.

00:26:33.940 | Without water, you're dead in three days, which is why all these people in the hospital

00:26:36.660 | are getting IVs and they never die.

00:26:39.180 | You stop the water, they're dead.

00:26:41.060 | You go out in the forest, there's all these animals out there that you can't see and can't

00:26:43.980 | hear if you're camping and there's animals dying everywhere.

00:26:47.220 | You don't hear screams.

00:26:48.220 | You don't hear moans.

00:26:49.220 | They're not in pain.

00:26:50.220 | Why?

00:26:51.220 | Because the body has come up with a very elegant mechanism for death by no water.

00:26:55.200 | As soon as you start not drinking, what happens is your kidneys which filter all the stuff

00:27:01.220 | in your body, the level of nitrogen in your body which normally gets filtered, the more

00:27:04.740 | you drink, the more nitrogen goes out.

00:27:06.340 | I mean, sodium and chloride, there's all sorts of things the kidney does, I'm being simplistic

00:27:09.420 | here.

00:27:10.420 | But the levels of nitrogen start to go up in your body, they get more concentrated.

00:27:14.180 | They're not being diluted, they're being concentrated.

00:27:16.540 | So, the higher the nitrogen is, if you've ever had nitrous oxide, you kind of get whoa,

00:27:20.540 | kind of numb and happy.

00:27:21.820 | It's the same thing.

00:27:23.040 | So, when you stop drinking, you start to get like kind of - it's like a morphine-like state

00:27:27.820 | where you kind of get happy and numb and things are kind of gleeful.

00:27:31.120 | Now, not to suggest that if you've got like terrible pain and stop drinking, like that's

00:27:34.820 | a solution.

00:27:35.820 | But people at the end of life that aren't like suffering with any painful thing, like

00:27:41.020 | they stop drinking and then they die.

00:27:42.500 | And it's a very kind of dignified biological process that like biology has figured out

00:27:48.300 | for a long time.

00:27:49.300 | They don't want death to be super painful.

00:27:51.060 | I say they, I don't know who they is, but like nature, biology.

00:27:53.780 | So, hydration is like a really important thing.

00:27:56.020 | And so, how do you know if you're drinking enough?

00:27:57.700 | They've got smart cups, they've got like all this new gadgets.

00:28:00.380 | Hey, real simple.

00:28:01.660 | If you're not going to the bathroom three times a day or more while you're awake, you're

00:28:05.720 | not drinking enough.

00:28:06.720 | And you don't need to overdo it.

00:28:07.860 | I think you should always have a glass of water around, you know, you shouldn't be chugging,

00:28:10.700 | you should be drinking.

00:28:11.700 | And I think the part two to that is alcohol.

00:28:13.660 | Like we know alcohol is a pro-aging substance.

00:28:15.780 | So, if you're one of these anti-aging people and you drink alcohol, well, then you're going

00:28:19.340 | to take some silver bullet pill that you heard about from somebody and then you're going

00:28:24.140 | to go out and have like a bunch of cocktails and go to Vegas.

00:28:26.740 | You actually have to like think long-term and what these episodes of alcohol does.

00:28:31.100 | But if you are going to drink alcohol, which most people do, glass of wine, put a glass

00:28:35.180 | of water in front of it and put a glass of water after it because then you're diluting

00:28:38.880 | the alcohol's impact because alcohol dehydrates you.

00:28:41.860 | So, the concentration of alcohol molecules in your body is higher an hour after you drink

00:28:45.700 | it than it was before.

00:28:46.700 | So, if you drink lots of water before and after, it doesn't get a chance to concentrate

00:28:50.020 | and cause problems.

00:28:51.380 | Sleep, super important one.

00:28:53.100 | I wear an Oura ring and I see you do too.

00:28:55.820 | I measure my sleep every day.

00:28:57.220 | I've been getting 90s scores on both ends since January 1st when I stopped traveling

00:29:02.500 | and my goal is to keep above 90 like all the time.

00:29:05.220 | I have patients that are like, "Yeah, I'm in the 60s, I think it's great because I was

00:29:08.740 | in the 40s."

00:29:09.740 | And I was like, "Holy moly, 40s?"

00:29:11.780 | I think a lot of people think that like I'll sleep when I'm dead, I'll have plenty of time

00:29:14.580 | for that but the truth is if you don't sleep now, you're going to die much sooner and so

00:29:19.580 | you'll have less time.

00:29:20.580 | And one of the hacks for me is I need eight hours of sleep.

00:29:23.220 | In fact, I got like almost nine last night but you should figure out when you want to

00:29:26.540 | wake up and you should set your alarm clock to go to bed.

00:29:29.260 | You should never set your alarm clock to wake up because when you set your alarm clock to

00:29:33.260 | wake up, in that last hour while you're waking up naturally, your cortisol levels which is

00:29:38.380 | an inflammatory stress molecule is going down and right before you wake up naturally, it's

00:29:43.460 | at the lowest point before you wake up and when you wake up, the world turned on and

00:29:46.920 | it spikes.

00:29:47.920 | So, your cortisol level always does this huge jump when you wake up because the world just

00:29:51.900 | turned on and now you have to like figure stuff out.

00:29:54.740 | So, ultimately, you want that cortisol level to be at the lowest before you wake up because

00:29:59.060 | if it's high before you wake up and it spikes, it just got much higher, the upper magnitude

00:30:02.740 | got higher.

00:30:03.740 | So, I like to let people wake up naturally.

00:30:06.380 | Humans are the only biological species on the planet that artificially interrupt a critical

00:30:10.360 | biological process, no bueno.

00:30:12.420 | And also, there's something called the glymphatic system in the brain which clears out all the

00:30:15.620 | metabolic junk from all the activity from the day before.

00:30:19.380 | You want that to go through its entire process.

00:30:21.380 | I think waking up is a multifactorial process which the brain feels like it cleared out

00:30:25.960 | enough stuff.

00:30:26.960 | Your cortisol level is nice and low, your circadian rhythms are this, it's time to wake

00:30:30.260 | up.

00:30:31.260 | So, sleep is critical.

00:30:32.260 | Diet is obviously super critical.

00:30:33.980 | What does that mean?

00:30:34.980 | Michael Pollan said, "Eat real food, not that much."

00:30:36.900 | And there's a big study on time-restricted eating today that came out.

00:30:39.700 | I generally don't eat breakfast.

00:30:41.920 | I've never eaten breakfast.

00:30:42.920 | If I have a breakfast meeting, I will, but I generally - I'm not hungry in the morning,

00:30:45.980 | my coffee kills my appetite, I have one cup of coffee and then I may have a cup of green

00:30:49.260 | tea throughout the day, I'll generally eat at 1 or 2, have a relatively small lunch,

00:30:54.860 | mostly vegetables, maybe a little fish and then I'll have my dinner which, you know,

00:30:59.540 | and stop eating at 8.30.

00:31:01.260 | But the truth is you should not eat things in a package.

00:31:03.600 | If it's in a package, it's probably processed and probably not the greatest thing for you.

00:31:08.820 | It's almost impossible to do that.

00:31:09.980 | So, I think if you are eating things in a package, look at the ingredient list.

00:31:14.620 | If it's a lot of ingredients, probably not good.

00:31:16.900 | If they're ingredients you can't pronounce or know, probably not good.

00:31:20.700 | And in general, the hack I have is like one apple is 70 to 90 calories depending on the

00:31:25.900 | size.

00:31:26.900 | It represents 50% of the dietary fiber you need in a day and your microbiome which lives

00:31:31.820 | in your intestine which is a separate organ that we have, feeds off of fiber.

00:31:36.340 | So, you'd rather give your microbiome, your friend that helps you live because it makes

00:31:41.420 | 80% of the serotonin in your body or 90% which is the happiness molecule.

00:31:46.380 | So, if you don't feed your gut, it's hard to be happy.

00:31:48.820 | If you don't - I mean, if you put a bunch of chemicals and crap in your gut and cause

00:31:51.740 | it to get angry, you're probably not creating an environment for your best self to emerge

00:31:56.240 | through more serotonin, less dopamine environment.

00:31:59.220 | So, I like to tell people apple, like if you want dessert or if you're hungry and you see

00:32:04.180 | a snack, eat an apple, eat two.

00:32:06.900 | You will not be hungry afterwards.

00:32:08.080 | You will not want to eat anything after two apples, you're just full because fiber slows

00:32:11.800 | everything down.

00:32:12.800 | So, diet is really important.

00:32:13.800 | I think there's a lot of movement towards no wheat, gluten-free.

00:32:17.500 | I think there's going to be some science that comes out about that in the next couple years

00:32:21.080 | that that's probably better for you, but probably based on genetics and then exercise.

00:32:25.420 | Exercise is also the other pillar of longevity and by the way, exercising outdoors, much

00:32:30.600 | better than indoors.

00:32:31.920 | Even taking walks outside, the pheromones from trees lower your cortisol level, lower

00:32:36.240 | your kind of inflammating process.

00:32:38.280 | So, people that have Pelotons and they do their one hour of hardcore inside and then

00:32:42.120 | they go work, better than nothing, but I would encourage you to get on a bike and go outside.

00:32:45.920 | Just take a walk or a jog.

00:32:46.920 | Obviously, if you live in a big city and it's freezing outside, do the Peloton.

00:32:50.300 | I do push-ups in the morning, I do sit-ups.

00:32:52.280 | My exercises, I don't have a one-hour intensive thing, I just do micro things and studies

00:32:56.340 | have shown that three to five minutes of intense exercise a couple times a day is as good as

00:33:00.980 | anything else in terms of what it does to your body in terms of resilience and restorative

00:33:06.680 | function and longevity.

00:33:07.680 | So, those are the shortcuts on the longevity thing.

00:33:09.900 | Then there's of course, all these supplements that people can take.

00:33:12.360 | There's people doing NAD drips.

00:33:14.300 | There's companies that do those all over the country, not proven.

00:33:18.160 | There's IV drips.

00:33:19.160 | I'm like, does your stomach work?

00:33:20.760 | Drink.

00:33:21.760 | If you're hungover and you just can't drink a lot, then sure, IVs are going to restore

00:33:26.920 | your fluid balance probably a little bit faster.

00:33:29.460 | But if you actually drank water while you were drinking your cocktails, you wouldn't

00:33:32.340 | need the IV drip.

00:33:33.340 | So, do you want to be proactive or reactive?

00:33:35.660 | What is the approach that you want to take?

00:33:36.660 | Who do you want to be in this world and how do you want to think about your long-term

00:33:39.660 | health?

00:33:40.660 | - So, I want to go back quickly to diet.

00:33:42.380 | I think we all know that processed foods, not good for you.

00:33:46.100 | Sugar, I assume you would say, is not a great thing to be consuming a lot of.

00:33:49.900 | Does that mean there's no place for it?

00:33:51.420 | - Great question.

00:33:52.420 | So, my rule is, you think the 80/20 rule, the Pareto thing, I think it's probably 95/5

00:33:56.940 | or 90/10.

00:33:58.300 | I have a total sweet tooth.

00:33:59.500 | You know, when I was growing up, I had Twinkies.

00:34:00.500 | I was growing up in the '70s in California and my mom, before she got like all natural

00:34:04.660 | and stuff, it was like, "Yeah, have one of these and Froot Loops and Captain Crunch,"

00:34:08.380 | but I had my apples and bananas and everything else.

00:34:10.220 | So, in general, and I started a non-profit called Eat Real, which is all about preventing

00:34:14.580 | kids from getting sugar.

00:34:15.580 | We're changing the menu of the largest fast food chain in the United States, which is

00:34:18.540 | our public school system.

00:34:20.140 | And by the way, by removing chocolate milk out of school, and we did this in the East

00:34:24.780 | Bay in the Bay Area, we eliminated 10 pounds of sugar in one child's body per semester.

00:34:30.980 | Now, just think about that.

00:34:33.420 | Just making chocolate milk to milk.

00:34:35.140 | So, 10 pounds of sugar in a kid is doing absolutely no bueno.

00:34:39.340 | So, like sugar should be, to me, for dessert, but you can't have dessert at every meal.

00:34:45.900 | Like dessert can't be your main course, your appetizer, and by the way, bread is sugar,

00:34:50.340 | but it's not processed refined sugar.

00:34:52.100 | It is a carbohydrate.

00:34:53.100 | It will go through an oxidative process that looks like sugar, but just not as corrosive

00:34:57.860 | as fructose and all these other high fructose things.

00:35:00.980 | So, for dessert last night, my wife made this amazing pasta squash soup, and I was like,

00:35:05.540 | "I need my dessert."

00:35:06.540 | So, what did I do?

00:35:07.540 | I got raw coconut shavings, no sugar added.

00:35:10.220 | I got some dark chocolate chips, which are almost little sugar, and I got some peanuts

00:35:14.460 | and a fig.

00:35:15.460 | I chopped it all up, put it in a little bowl, and that was my dessert.

00:35:18.140 | And it was all natural.

00:35:19.140 | It was a very sweet.

00:35:20.140 | It was incredibly sweet, but it was tons of fiber in there.

00:35:23.420 | And I love my sorbets, so don't get me wrong.

00:35:25.420 | I will cheat.

00:35:26.420 | If someone's got a great sorbet, I'll have it.

00:35:28.460 | If there's an amazing chocolate fudge thing, I'll have it.

00:35:31.380 | If there's an amazing cookie, there's a restaurant called Spruce around here.

00:35:34.780 | The Spruce cookies, oatmeal cookies are amazing.

00:35:36.540 | I think they're like 1,500 calories per cookie though.

00:35:39.180 | So, I think you just have to be mindful of like - and by the way, I used to eat whole

00:35:42.420 | Spruce cookies like 10 years ago, and now I realize, "Holy shit, those are loaded."

00:35:45.580 | I'll just have a few bites.

00:35:47.380 | So, have your dessert, but you'll still have it.

00:35:49.860 | But yeah, I'll still have it from time to time, but I'm much more mindful of - let me

00:35:54.300 | eat it.

00:35:55.300 | If I have a sweet tooth, let me eat an apple.

00:35:56.800 | That will kill my desire for more sweets because apples are pretty sweet, but all that sugar

00:36:02.660 | is attached to fiber.

00:36:03.940 | To illustrate one point, which I think is fascinating, one of my buddies is a researcher

00:36:08.660 | did a study in Oakland, California.

00:36:11.660 | He went to an inner city school, got two 14-year-old African-American kids, both like six feet

00:36:16.260 | tall, told them not to eat dinner.

00:36:19.140 | Show up to school and we were going to experiment with food.

00:36:22.420 | They showed up at 9 AM and one of them was told, "Drink this 16-ounce glass of orange

00:36:27.900 | juice.

00:36:28.900 | Glug, glug, glug, glug, glug.

00:36:29.900 | Drink it."

00:36:30.900 | He's hungry, grown guy, growing boy.

00:36:31.900 | Now, here's a Big Mac, the large fries and a big milkshake.

00:36:36.100 | Ate the whole thing, all of it, no problem.

00:36:38.940 | The second kid came in and we gave him six gigantic oranges - not I, he gave them - and

00:36:43.820 | said, "Peel them and eat them."

00:36:45.540 | He couldn't eat the sixth one, he was full.

00:36:48.340 | Six big oranges.

00:36:49.340 | Those six oranges is what made that orange juice for the other guy.

00:36:52.460 | So, by eating sugar with fiber, you fill up.

00:36:55.260 | Your stomach's a bag and when you wake up in the morning, your bag is like a paper bag

00:36:57.780 | that's not opened.

00:36:58.780 | As soon as you start filling up the bag with food, there are stretch receptors in the stomach

00:37:02.140 | that send signals to the brain, "Hey, we're filling up here.

00:37:04.260 | Slow down."

00:37:05.260 | So, just stretch will signal slow down, not hungry, kill appetite, in addition to the

00:37:09.820 | quality of the food.

00:37:11.500 | But six oranges is a ton of mass.

00:37:14.140 | So, I'm in the habit lately of when I'm hungry or for something sweet, I'll have an apple

00:37:18.660 | and an orange and then I am no longer hungry.

00:37:21.340 | And so, it's my hack to get all the sugar I want and you can't eat enough fruit.

00:37:25.260 | By the way, one other story is Dole pineapple in Hawaii.

00:37:29.380 | You've seen these big Polynesian Hawaiians, they're massive, they're like sumo wrestlers.

00:37:32.980 | Before Dole came in, those people ate pineapples naturally in Hawaii, no diabetes anywhere.

00:37:39.020 | As soon as Dole came in and made pineapple juice, diabetes pandemic amongst the Hawaiians

00:37:43.220 | because they took the fiber out of it and they just made it the juice.

00:37:46.100 | So, I say no juice, juice of no bueno.

00:37:48.380 | I mean, there's all these green juices now, okay, whatever.

00:37:50.900 | Like why don't you just eat the food that the juice is made of?

00:37:54.100 | Like you could do that if you wanted to, but if you just know the time, take the juice.

00:37:59.500 | But all those juices have honey, cane juice, it might as well be a Coke without all the

00:38:05.260 | hardcore chemicals.

00:38:06.260 | You got like the kale and you got all these things that look bueno and feel good about,

00:38:09.580 | but it's still got tons of sugar that's not connected to fiber.

00:38:12.380 | Okay.

00:38:13.380 | Let's say you got 12 cookies sitting in front of you and you know you're going to eat them.

00:38:17.620 | It's better to eat one a day or 12 on one day and nothing for the next 11 days?

00:38:22.380 | It's much better to eat one a day.

00:38:24.780 | Imagine you're in your car and you want to go fast.

00:38:27.820 | You could go first gear to 4,000 RPM, second gear to 4,000 RPM when cars had stick shifts.

00:38:33.800 | But the 12 cookies is taking your car in first gear to like the red line all the way to the

00:38:38.280 | end and it just stresses the system.

00:38:40.960 | Because once your blood sugar goes up with all those cookies, what happens is there's

00:38:44.520 | so much sugar in your blood that your body goes, "Okay, the red lights start flashing.

00:38:49.400 | We need to lower that sugar."

00:38:51.280 | So in order to lower that sugar, we're going to make a bunch of insulin.

00:38:54.320 | Insulin then your pancreas makes insulin and your insulin shoots up.

00:38:58.320 | And when insulin shoots up, insulin is the key that unlocks the little holes in your

00:39:03.520 | blood vessels to let sugar out of the bloodstream and go into cells.

00:39:08.140 | So when your insulin spikes, insulin is an inflammatory thing.

00:39:12.160 | It's like creating inflammation for your whole body.

00:39:15.760 | So by going to 12 cookies, you've just caused this huge glucose spike.

00:39:19.160 | That's the other thing I would recommend people who are curious and you've probably done this

00:39:22.160 | is the continuous glucose monitor.

00:39:24.360 | What causes your sugar to spike?

00:39:26.120 | And everyone's slightly different.

00:39:27.240 | I found that when I ate kimchi, my blood sugars went down.

00:39:30.200 | I love kimchi.

00:39:31.200 | By the way, fermented foods are always good for you.

00:39:33.560 | Pretty much good for your gut, good for your health.

00:39:35.800 | People underestimate and they don't eat enough fermented foods, pickles, all these things.

00:39:39.360 | But a continuous glucose monitor will tell you the truth about what's going on when you

00:39:43.080 | do things.

00:39:44.080 | So some people work glucose monitors for long periods of time.

00:39:46.720 | My thesis is wear it for a month, eat lots of things, try lots of challenges.

00:39:51.520 | But if you see a big spike in something, you should try to avoid that food.

00:39:54.840 | Or eat an apple before you eat that food and eat it again and see if the spike happens.

00:40:00.840 | The apple will slow down the absorption because the fiber just slows down absorption of sugar.

00:40:04.600 | I say an apple or some other high fiber thing.

00:40:07.400 | I signed up for Levels Health and used it for a month, which is a continuous glucose

00:40:11.080 | monitor startup that has an app.

00:40:12.560 | I use Levels too.

00:40:13.560 | I did it for a month.

00:40:14.560 | The thing about Levels and all these companies, they want you to wear them forever.

00:40:16.720 | And it's just like, yeah, no.

00:40:17.960 | If you don't do enough challenges over a month, then maybe you need to wear it longer.

00:40:20.960 | I think every minute that you're focused on your health obsessively, you're not focused

00:40:25.640 | on your life.

00:40:27.640 | And the reason we're here is to enjoy our life.

00:40:29.720 | Health is freedom.

00:40:31.080 | And if we're focusing on something for a long period of time, we lose sight of like the

00:40:35.280 | broader purpose.

00:40:36.640 | I like to get people who are like hyper freak, quantified self people to like step back from

00:40:41.640 | the ledge and stop trying to measure things.

00:40:44.280 | There's a control freak component to that, I must know everything so I can control everything.

00:40:48.440 | Guess what?

00:40:49.440 | Get the heuristic, get it and then change your behavior and then go maybe do it again

00:40:52.160 | in a year, see if it helped.

00:40:54.040 | But you're not going to notice any material difference month to month or year to year

00:40:58.640 | by continuing to do this stuff.

00:41:01.360 | Is there anything on the supplement side or things people should be taking every day that

00:41:05.520 | have nothing to do with specific health concerns?

00:41:08.360 | So supplements are an interesting category.

00:41:10.840 | They're called supplements because they are supplementing something, right?

00:41:13.880 | So let's look at the word itself.

00:41:16.600 | If you know that you're deficient in vitamin D, then you should take vitamin D. And a lot

00:41:21.560 | of people are.

00:41:22.560 | They think they get a lot of sun, doesn't matter.

00:41:24.080 | If you're deficient in vitamin B12 or folate or iron, you should supplement things that

00:41:29.120 | you're deficient for.

00:41:30.440 | In general, the human body is really good at taking the food that you eat, assuming

00:41:35.560 | it's not chemicals and it's food, and processing all the nutrients, micronutrients, metals,

00:41:42.560 | everything, and incorporating them into the body.

00:41:45.160 | If you take something on a daily basis - so I take vitamin D on a daily basis, but my

00:41:49.480 | vitamin D, it's on the bubble of like 30 if I do nothing.

00:41:52.680 | I want it to be 50.

00:41:53.840 | There's just a lot of evidence that there's a lot of benefits to having your vitamin D

00:41:57.160 | a little bit higher.

00:41:58.160 | So I'll take it every day, even though mine's ostensibly normal.

00:42:01.340 | There are people that take all sorts of vitamins every day, but as soon as you take those vitamins,

00:42:05.080 | your pee is really yellow or your pee changes color.

00:42:07.640 | It's because that's the color of money.

00:42:09.740 | That's the green dollar that you paid for, it just turned into yellow pee.

00:42:13.400 | And so like you're just peeing money out.

00:42:16.640 | So there's not a real benefit of taking vitamins every day, but because it's under the category

00:42:21.240 | of generally recognized as safe and the marketing machine there is amazing and the vitamin and

00:42:25.760 | supplement business, I don't think there's a lot of high value in it if you have an amazing

00:42:29.960 | healthy plant real food-based diet.

00:42:32.440 | You will get everything if you eat healthy food.

00:42:35.640 | If you don't and your diet is kind of crappy, then you should probably go get tested and

00:42:39.120 | see what you're deficient in and where you need help and then try to tailor your supplementation

00:42:42.720 | to that.

00:42:43.720 | But I don't think there's any good fundamental use case for taking something just because.

00:42:48.920 | There's a lot of religion around this, people like believe, "Oh, my aunt takes like 20 vitamins

00:42:53.280 | every day.

00:42:54.280 | She's been doing it for 50 years".

00:42:55.480 | No evidence there.

00:42:56.480 | There's literally no data to support taking that.

00:43:00.040 | On the longevity side, there's this thing called NAD, which a lot of people are taking

00:43:04.160 | and going back to safety and efficacy, there's lots of brands out there.

00:43:08.880 | One of them is TruNiagen and I'll only surface that one and not all the other ones because

00:43:13.120 | they've done the safety profiles.

00:43:15.080 | They know that it's safe, they've done the homework.

00:43:18.280 | They'll tell you like they can't prove to you that's going to make you live longer,

00:43:21.960 | but theoretically in mouse and in worms and maybe in dogs, like they seem to have a less

00:43:27.840 | oxidative stress on their mitochondria.

00:43:31.000 | So if it's safe and we don't know if it's effective, well, we're just spending money

00:43:34.240 | and dealer's choice.

00:43:35.240 | Then there are other ones that haven't have a safety profile and claim the same things

00:43:38.840 | based on the same studies, no safety, then you're kind of gambling with your health.

00:43:43.200 | Like why would you do that?

00:43:45.120 | The vitamins are generally recognized as safe, so that's just spending your money on something.

00:43:49.040 | I would say if you're spending money on supplements, you should take that money and find a doctor

00:43:53.160 | that's going to be in your corner to prevent things from happening or when the shit hits

00:43:56.720 | the proverbial fan.

00:43:57.720 | Unless you have a medical condition, then yes, sure, there are supplements you should

00:44:01.040 | take.

00:44:02.040 | But if you're a healthy person, there's no real data.

00:44:05.000 | - You did mention in Hawaii something about a toothpaste.

00:44:07.800 | - There's lots of organs in your body that require some attention and if you have any

00:44:11.280 | gum disease, like some people have, some people don't, your dentist should tell you if you

00:44:16.560 | have some recession.

00:44:18.520 | Because gum disease, by the way, leads to inflammation and endotoxins in your teeth,

00:44:23.640 | which can make your heart problems worse faster.

00:44:26.600 | So if you have a calcium score of two and really bad teeth, your calcium score will

00:44:30.080 | go up.

00:44:31.080 | If you have gum disease, your calcium score will likely go up faster than if you didn't.

00:44:34.960 | So I sadly, I don't know why, my buddy who was a dental guy said, "Hey, just floss the

00:44:39.160 | ones you want to keep."

00:44:40.160 | And 15 years ago, I kind of laughed at him and now I regret not flossing regularly because

00:44:46.680 | it matters.

00:44:47.680 | So there's something called MyPaste, M-I-P-A-S-T, which is kind of a special toothpaste that

00:44:51.960 | you use after your toothpaste that helps with gum health.

00:44:55.500 | We just talked about gum health.

00:44:56.500 | We could go to iHealth.

00:44:57.500 | There's 99 other versions of things that you could do depending on what the issue is, if

00:45:02.560 | there's a problem.

00:45:03.560 | And then of course, if I just flossed, I wouldn't have that problem.

00:45:06.280 | Then there's the proactive things you can do to prevent things.

00:45:08.320 | But these are investments you have to make.

00:45:09.680 | They're investments in time, investments in all these different things.

00:45:12.160 | So a lot of people, they'd rather treat the problem when it happens than spend all this

00:45:17.000 | time preventing something that they can't imagine could happen.

00:45:20.420 | So that's kind of a psychological pretzel people have to like engage in, imagining their

00:45:25.080 | future selves.

00:45:26.360 | So we started with this, "Who are you?" where you ran through a bunch of tests, a lot of

00:45:30.640 | blood work, a few other things.

00:45:32.400 | Yeah.

00:45:33.400 | I think the next one that you talk about is, "How are you?"

00:45:35.600 | So, "How are you?" is really, "What does your life look like?"

00:45:40.120 | I mean, you wake up in the morning and then you go to bed, right?

00:45:43.200 | And absent those moments when you're sleeping, what does your life look like?

00:45:47.000 | What are your relationships?

00:45:48.000 | I've come up with this concept called vitality signs, which is not vital signs and vitality

00:45:52.960 | signs are measures of your relationship with things in the world.

00:45:58.400 | So the relationship, so "How are you?" is like how is your relationship with your parents?

00:46:04.200 | How is your relationship with your children if you have them?

00:46:07.040 | How is your relationship with your primary relationship, your spouse or girlfriend, boyfriend?

00:46:12.940 | And if you don't have a spouse, girlfriend or boyfriend, how's your relationship with

00:46:16.480 | the absence of that?

00:46:18.640 | Does that cause you anxiety?

00:46:19.640 | Are you cool with it?

00:46:20.640 | Like because all these things are going to inform a bigger picture.

00:46:23.000 | What is your relationship with money?

00:46:24.760 | Are you obsessively trying to get more?

00:46:26.040 | Are you super happy with what you got?

00:46:27.240 | Like what is your relationship with it?

00:46:29.980 | What is your relationship with time?

00:46:32.360 | What is your relationship with your past?

00:46:34.400 | What is your relationship with your vanity?

00:46:36.640 | Are you obsessively concerned about how you look or do you not give a shit?

00:46:39.160 | Like it's somewhere in between.

00:46:40.340 | What is your relationship with sex and love?

00:46:43.160 | So there's all these different components and ultimately, based on these things, we'll

00:46:46.400 | start to get a framework of - like if someone doesn't talk to their parents anymore, "Oh

00:46:49.760 | yeah, I don't talk to my parents anymore" or "Me and my sister haven't talked for years",

00:46:53.120 | that person's got a - there's a problem there.

00:46:54.720 | There's a real problem there.

00:46:55.840 | Now, there's a hole in that person's life in some way or there's some deficit whether

00:47:01.040 | they blow it off or not, it's true.

00:47:03.320 | You can't skip it.

00:47:04.760 | You have to like acknowledge what that is.

00:47:07.160 | So the "how are you" is like all those things I just said from the vitality signs but more

00:47:11.720 | importantly is what do you do, what are your habits, what do you do that you should do

00:47:16.400 | more of and what are the things that you should do less of and what are the things that you're

00:47:20.960 | not doing at all that you should be doing.

00:47:23.920 | So you have to examine your habits.

00:47:26.220 | So that's the "how are you" and it's your mental health.

00:47:28.520 | Like are you in a good state?

00:47:29.520 | Do you wake up happy?

00:47:30.520 | Do you wake up upset?

00:47:31.520 | All of these things kind of ladder up to your overall - I'll call it the happiness or contentedness

00:47:38.160 | quotient with your existence, your existential quotient.

00:47:42.360 | Where are you?

00:47:43.360 | How are you?

00:47:44.360 | If I run through that thing, I'll tell you like "Oh yeah, that guy drinks a lot, doesn't

00:47:46.680 | sleep enough.

00:47:47.720 | That person over indexes on sex versus love".

00:47:50.700 | Whatever these things are, who you are and how you are, then set you on a trajectory.

00:47:56.280 | And so, the third bucket is what is your trajectory.

00:47:59.520 | I have a slide that I generally show people which shows like "Here you are when you're

00:48:03.600 | born and here's you are when you're dead".

00:48:05.780 | You can go between the ages of 0 and 24, you're growing and between the age of 24 and death,

00:48:09.600 | you're aging.

00:48:10.600 | So what is the slope of the curve of aging?

00:48:12.920 | Are you above normal?

00:48:14.300 | Are you below normal?

00:48:15.300 | Are you a super ager?

00:48:16.880 | Meaning do you age super fast?

00:48:18.620 | Those things can be measured based on who you are and how you are.

00:48:21.580 | So if you're constantly doing like a check-in on who you are and you're doing a check-in

00:48:25.060 | on how you are, you can kind of look at this trajectory and kind of know which one you're

00:48:29.580 | going to be.

00:48:30.580 | You control your destiny.

00:48:32.420 | No one's making you do the things you're doing that you shouldn't and no one's not making

00:48:35.860 | you not do.

00:48:36.860 | It's just you get in the way of yourself and nothing screws up a great story like data,

00:48:41.260 | which is why I'm super happy that there's all these devices that can measure things

00:48:44.780 | now.

00:48:45.780 | For example, there's a blood test from a company called SomaLogic proteomic test and it can

00:48:50.060 | tell you with like a high degree of accuracy what your four-year risk of a heart attack

00:48:54.340 | is.

00:48:55.340 | It's like a $600 test.

00:48:56.340 | It's a blood test.

00:48:57.340 | You don't need a calcium score.

00:48:58.340 | The world's moving to blood not scans.

00:49:00.140 | So all these fancy full body scan places are like I don't see their future much and they're

00:49:04.820 | expensive and the technology is getting so much better with AI and blood and breath.

00:49:08.340 | And there's a company called Owlstone that you can breathe into and it'll tell you how

00:49:11.740 | your liver, your kidneys are, your intestines, the health of them through volatile organic

00:49:16.820 | compounds.

00:49:17.820 | So, the cadence of check-ins, who am I?

00:49:21.260 | And then the intellectual honesty of how am I and what am I doing is what leads you on

00:49:26.940 | this trajectory.

00:49:28.060 | And if you really want to live a long and healthy life, which I think people call health

00:49:31.020 | span, just have to look at these things.

00:49:33.100 | You can't look away.

00:49:34.100 | You just need to be honest about what you're doing and who you are and what you should

00:49:37.380 | be doing more of and whether that's diagnostic, therapeutic.

00:49:41.060 | Like I have a friend who's a chef who had Crohn's disease.

00:49:43.740 | He was on methotrexate and all these hardcore drugs.

00:49:45.940 | And then one day he said, "You know what?

00:49:46.940 | I'm going to like radically change everything about my life."

00:49:49.620 | He's now off everything.

00:49:50.780 | All symptoms are gone and he just eats whole foods and he got off the pharmaceutical train.

00:49:55.340 | And Nestle, by the way, they make sugar foods and then they make diabetes pills.

00:49:59.220 | So, they've got the whole ecosystem.

00:50:00.580 | They get you sick and then they treat you.

00:50:01.900 | But that's like a vicious cycle of whatever.

00:50:03.420 | I mean, a lot of companies do that too.

00:50:05.500 | For people that want to optimize their health, they just have to look at what they're - like

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00:51:23.540 | I wish I could say I'm eating a fully balanced diet every day, but the reality is that I'm

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00:52:58.540 | So I want to take an example from this whole process, which is personal to me, which is

00:53:03.460 | had high cholesterol.

00:53:04.460 | How high?

00:53:05.460 | HDL 48, LDL 155.

00:53:07.300 | LDL 155, that's high.

00:53:10.660 | And how old are you?

00:53:11.660 | I'm 38.

00:53:12.660 | Okay.

00:53:13.660 | So over the last few years, LDL range 138 to 155.

00:53:17.900 | So I got a test, had a doctor at Sutter and it wasn't because I picked this person, turns

00:53:23.740 | out I had shingles and I just needed a doctor to prescribe something.

00:53:26.980 | They were like, "Go see your primary care physician."

00:53:28.540 | I didn't have one.

00:53:29.540 | I picked whoever had the next open appointment.

00:53:31.700 | They went in, they were like, "Let's review your blood work."

00:53:34.020 | And they went through and the advice was, and I'm reading this quote because she sent

00:53:38.300 | me a note after the blood work was done for my cholesterol, she said, "Your cholesterol

00:53:41.900 | is 206 with HDL 48 and LDL 155.

00:53:44.780 | Advise, low fat, high fiber diet.

00:53:47.060 | Let's repeat in a year.

00:53:48.060 | Take care."

00:53:49.060 | That was the message.

00:53:50.100 | My reaction to that after talking to a few friends was like, "I feel like maybe there

00:53:53.460 | should be more going on in this process."

00:53:55.500 | There's a lot more information that needs to be, yeah.

00:53:57.580 | And so a couple of friends said, "Oh, you should probably go get your ApoB tested.

00:54:01.460 | You should go look at more data."

00:54:03.820 | What ended up happening, and this took two or three years because it just did, finally

00:54:09.260 | I found a doctor who was like, "Oh, you should go get a calcium score."

00:54:11.660 | I did.

00:54:12.660 | Was that covered by insurance?

00:54:14.140 | I don't know.

00:54:15.140 | It was two weeks ago.

00:54:16.140 | So I don't know yet.

00:54:17.140 | The hospital that did it told me they pre-cleared it with insurance and I wasn't gonna have

00:54:20.500 | to pay for it.

00:54:21.500 | Great.

00:54:22.500 | But unclear.

00:54:23.500 | I haven't seen the payment come through.

00:54:24.500 | But the calcium score came back a two on one artery, zero on everything else.

00:54:29.660 | So two is a real number, by the way.

00:54:31.300 | It's not zero.

00:54:32.300 | Two is a real number.

00:54:33.300 | You have early evidence of coronary artery disease.

00:54:36.340 | Yes.

00:54:37.340 | Now, I'm not saying that three years could have prevented any of it, but the idea that

00:54:41.340 | three years ago I was messaging with a doctor whose advice was like, "Hey, just kind of

00:54:45.660 | eat healthy and we'll talk in a year."

00:54:48.060 | Seems like if I were someone going through a lot of the process that you mentioned of

00:54:52.300 | looking at some of your data, trying to take some of these tests, trying to figure out

00:54:55.500 | where you're at, how do you evaluate and analyze it when you don't have access to someone like

00:55:02.420 | you who's maybe done a lot more of the research?

00:55:04.500 | What does the average person do when they see a number?

00:55:06.820 | It seems high.

00:55:07.820 | They talk to their doctors like, "Eh, we'll deal with it later."

00:55:10.240 | Going back to the beginning of the conversation, a lot of the medical system we have is like,

00:55:13.860 | "Let's treat it when it's a problem."

00:55:15.660 | Like high cholesterol, young person, maybe it's not a problem yet.

00:55:19.380 | But clearly, if I've had high cholesterol for five, six years and I had...

00:55:22.980 | Or maybe all your life.

00:55:24.700 | All my life.

00:55:25.700 | Yeah.

00:55:26.700 | Like, maybe we could have been doing something different.

00:55:28.340 | So I guess one question is just, how do you interpret these?

00:55:32.020 | How should someone try to find the right person?

00:55:34.700 | Could you find the right primary care physician at any hospital medical practice that could

00:55:39.820 | be a partner here?

00:55:40.980 | And I just happened to have the wrong one.

00:55:42.940 | I don't know.

00:55:44.140 | So I think it starts with, if your LDL is greater than a hundred, let's just use that

00:55:49.340 | as a marker.

00:55:50.340 | Forget about all the rest of the APO and all the rest of the everything else.

00:55:53.740 | If it's greater than a hundred, then you say, "How long has it been that way?"

00:55:56.820 | We're not starting to test kids, teenagers, because we know the parents' cholesterols

00:56:02.860 | are off the map.

00:56:03.860 | When we get new members and the parents are off, we go check the kids.

00:56:06.820 | And if the kids are off, that's never been done before.

00:56:08.900 | Just a way to think about it before I answer the question specifically, because I think

00:56:11.820 | it's important.

00:56:13.240 | When people smoke cigarettes, we as doctors ask them, "How many years have you been smoking

00:56:18.000 | cigarettes and how many packs a day?"

00:56:20.640 | And we call them pack years.

00:56:22.740 | So if you've smoked one pack a day for 10 years, you have a 10-pack year history.

00:56:27.420 | If you smoked two packs a day for 10 years, you have a 20-pack year history.

00:56:32.340 | That's the same as smoking one pack a day for 20 years.

00:56:35.340 | So it's what is the load of this chemical, which ultimately ladders up to risk of heart

00:56:40.860 | disease, diabetes, and lung cancer.

00:56:43.420 | So we call them pack years.

00:56:45.780 | So now the more sophisticated libidologists are talking about LDL years.

00:56:50.780 | How long has your LDL been high circulating through your body?

00:56:55.520 | So there's LDL years.

00:56:56.520 | So if your LDL is high and you have a calcium score of 2 and you're 38, you probably had

00:57:00.220 | a high LDL for a long time, and you don't have the genetic subtype that doesn't care.

00:57:03.660 | I don't know if you smoke or there's other things that you do, but the first thing is

00:57:07.220 | get to some answer of, "Do I need to do something else?"

00:57:10.220 | And you can go deep into the weeds of LDL.

00:57:13.720 | I have patients that want to optimize their LDLs and stuff.

00:57:16.500 | They'll pay some doctors that like hold themselves out for $100,000 to optimize their LDL.

00:57:21.620 | And it's just like, you're optimizing 0.001% of your body, it's already pretty good.

00:57:27.180 | So the question is, if you did her diet, like, let's just say you followed her diet and said,

00:57:31.980 | "Okay, doc, I'm going to do that.

00:57:33.700 | When do we check it again?"

00:57:35.140 | And she said, "A year."

00:57:36.400 | My answer would be, "Well, I want to know if the diet story works sooner than later

00:57:43.100 | because I don't want to hold another LDL year to go by that high.

00:57:47.100 | So can we please check it in four to six months?"

00:57:49.500 | But you actually have to do an honest change of your diet.

00:57:52.540 | And if it goes down to like 100, you know the answer.

00:57:57.820 | You know the answer.

00:57:58.820 | Keep your diet like that.

00:58:00.460 | And even if you knew your calcium score was a two now, and you knew that you could lower

00:58:06.220 | it with diet down to like 80, and to give you a calcium score of greater than zero,

00:58:11.580 | you got to get your LDL below 80.

00:58:13.140 | That's what kind of our guidelines are here.

00:58:14.940 | If you can't do that with diet, then you need to be on something.

00:58:17.580 | You need to be on a statin, sadly.

00:58:19.340 | And if you are so adamant about taking statins, which is basically there's different kinds,

00:58:24.580 | but there's an HMG-CoA reductase inhibitor, but that's a fancy name for the molecule.

00:58:29.060 | Then you can eat red yeast rice every day because that's what is a statin.

00:58:33.740 | If you can find a way to put that in a soup and eat it every day, like, you could lower

00:58:37.300 | your cholesterol and your LDL that way.

00:58:39.500 | So I think that whenever you find out something's abnormal, you have to think about, okay, intervention

00:58:44.540 | retesting, how quickly can I find out if I can make a difference without pills?

00:58:51.300 | And if I can't, what pill do I go on?

00:58:54.560 | Because once you get a calcium score that's positive, you just know now that you're committed

00:58:58.460 | to not having that number go up.

00:59:01.020 | That number goes up with the LDL staying at 155, but then you have a heart attack at some

00:59:04.500 | point in your life and that sucks.

00:59:06.780 | So you don't want that.

00:59:07.780 | And I didn't mean, by the way, to make this about me.

00:59:09.580 | No, no, no.

00:59:10.580 | But I think if people get into your head, like hear me talk to you as though this is

00:59:14.100 | them, I think everybody can take something away from, like, if you get something that

00:59:18.260 | doesn't look right and doesn't feel right, then dig in.

00:59:20.700 | Don't let that doctor get away with eat fiber, let's check in a year.

00:59:24.660 | By the way, one thing that I realize in hindsight, a lot of people moving around a lot, I've

00:59:28.740 | probably had five primary care doctors since I graduated college.

00:59:33.300 | And I went back and looked and it's like, I don't have my blood tests too far back,

00:59:37.660 | but I've got them about seven years back and I've had high cholesterol for seven years

00:59:41.660 | at least.

00:59:43.100 | But I had one doctor and then I had another doctor, then I had another doctor, but I had

00:59:46.980 | one doctor for three or four years at that cholesterol, but never really pushed back,

00:59:51.660 | said to do anything.

00:59:52.660 | But part of that's because going back to what I was talking about earlier about like the

00:59:56.980 | medical system moves slowly.

00:59:58.660 | We never thought ever of treating a 20 to 30 year old or a 30 to 40 year old with statins

01:00:03.380 | unless they had like a credible family history.

01:00:05.540 | I mean, there are people that have heart attacks in their 30s.

01:00:07.820 | Like they have crazy genetic cholesterol problems, hypercholesterolemia, hypertriglyceridemia,

01:00:12.420 | they can get these problems.

01:00:14.300 | But the medical field, like we're not aggressive with younger people because like you said,

01:00:18.540 | the system's reactive.

01:00:19.580 | It waits for you to get sick and then they make a lot of money.

01:00:22.380 | Pharmaceutical companies make a lot of money on preventing the heart attack, but the hospitals

01:00:26.740 | and the doctors and the surgeons and the cardiologists and everybody in the food chain doesn't make

01:00:30.660 | that much money from you not having a heart attack, not to be hyper perverse about it,

01:00:35.660 | but it's just the way the system's designed.

01:00:37.500 | And oh, by the way, that doctor that saw you, they're not accountable to your future outcome

01:00:41.900 | at all.

01:00:42.900 | And they don't know you because you're moving around.

01:00:43.900 | You're just another kid in the mix coming through their system, which is why I really

01:00:47.340 | believe that these long-term relationships matter.

01:00:49.780 | I think that everyone's trying to find the quick fix, the transactional, where's the

01:00:52.640 | chat bot for healthcare so I can blah, blah, blah, blah, blah.

01:00:56.260 | I think at some point, but you really want someone that knows you, gets you and is going

01:01:00.460 | to like tell you the truth and like double check on things.

01:01:03.820 | Is there a way you'd tell someone to interview?

01:01:05.580 | Like if I'm like, okay, obviously this one wasn't a good fit, I need a new primary care

01:01:08.940 | physician.

01:01:09.940 | There's not like an easy way to find someone that I know of.

01:01:13.740 | Are there questions you would ask them to try to figure out if they're the right fit

01:01:16.580 | for you?

01:01:17.580 | I would ask everybody, what is their perspective on prevention?

01:01:20.460 | I would ask them, what is their perspective on productivity?

01:01:24.980 | I would ask them how they hold themselves accountable to your outcome, because a lot

01:01:28.620 | of doctors feel like, "Once you leave my office, how am I going to enforce anything?

01:01:32.780 | It's your life."

01:01:33.780 | So, I would say, "Hey, look, I sometimes am my own worst enemy and I'm busy.

01:01:37.720 | How can we do this together so that you hold me accountable and I hold you accountable?

01:01:41.340 | Can we both hold ourselves accountable here?"

01:01:43.060 | And if the answer is like, "I don't have time for that.

01:01:45.100 | Like I'm just too busy."

01:01:46.100 | Probably not the right one.

01:01:47.340 | And this goes to the meta theme here, which is the rise of what I'll call concierge medicine

01:01:51.300 | or what I'll call membership-based medicine.

01:01:54.300 | So, in primary care, I'm probably one of the grandfathers of the field, because I started

01:01:58.620 | a kind of a concierge practice when it wasn't really a thing in 1998.

01:02:02.740 | I gave out my cell phone.

01:02:03.740 | I said people can call me whenever they wanted.

01:02:05.140 | I would follow up with people.

01:02:06.500 | I would use email and text in the late 90s and early 2000s, because I wanted communication

01:02:11.580 | to be the most important thing, because you'll get the good outcome if you have communication.

01:02:15.800 | You won't get a good outcome if you don't have communication, because like communication

01:02:18.660 | is like more than just data.

01:02:20.960 | It's holding people accountable and building trust.

01:02:24.060 | So one medical, didn't start off as one, they're like a freshman version of a concierge practice,

01:02:29.540 | meaning that I think they charge $159 a year, but they take insurance.

01:02:32.900 | Then you have companies like MDVIP that charge $3,000 a year.

01:02:37.780 | There's a group called Roamed, R-O-A-M-D.

01:02:40.380 | It's an association that I'm part of that has doctors all around the country that like

01:02:44.600 | have doctors that are membership-based.

01:02:46.980 | And they can charge anywhere between, I don't know, $50 a month to $500 or $1,000 a month

01:02:52.060 | or $2,000 a month.

01:02:53.420 | It all depends on what level of investment you want to make based on what you think exists

01:02:58.860 | out there.

01:02:59.860 | So there are these practices out there.

01:03:01.900 | Some people call them direct primary care, DPC, direct primary care.

01:03:05.940 | Some people call it membership-based medicine.

01:03:07.340 | Some people call it concierge medicine.

01:03:08.620 | Some people call it private medicine.

01:03:10.300 | But I think that one has to look at their - if you make $100,000 a year and you say,

01:03:15.380 | "Okay, I want to invest in my health."

01:03:17.580 | What percentage of your $100,000 will you invest in your health?

01:03:23.000 | So we know that you invest a certain amount in a cell phone and a Wi-Fi package.

01:03:26.980 | And we can talk about what you invest in technology, got their own personal budget.

01:03:30.500 | I know that you talk about this a lot.

01:03:32.300 | But a lot of people will say, "Well, I have a membership to Equinox or pick the gym and

01:03:36.460 | that's, I don't know, $60 a month.

01:03:38.720 | So that's $500 a year.

01:03:40.520 | So I invest - so $500 a year is 0.5% of your income."

01:03:44.340 | I don't have a membership to Equinox, but I'm guessing you don't either because I'm

01:03:46.900 | pretty sure it's like more like $100 or $200 a month.

01:03:49.380 | There you go.

01:03:50.380 | I'm not a member of a gym.

01:03:51.380 | I have four kids and that I've got a gym in my house.

01:03:53.420 | Like I'm running around all the time.

01:03:54.920 | So even if it's $100, let's say $100, that's $1,200 a month, that's 1.2% of your budget.

01:03:59.780 | But that's not investing in your health.

01:04:01.100 | That's investing in your fitness.

01:04:02.480 | So I just want to be really clear.

01:04:03.780 | I mean, which is a subset of your health.

01:04:05.900 | But if you really want to make the big investment on a doctor to have a relationship with that

01:04:09.780 | you can go back and forth with and really build up a rapport and then kind of a bilateral

01:04:14.700 | mutual transparent accountability quotient, you should ask yourself if it's all invest

01:04:19.860 | 4%.

01:04:20.860 | If it's $4,000, you can find a lot of doctors in the membership-based world for $4,000 a

01:04:25.500 | year and they'll use your insurance to do the blood test, to get the MRI, the CAT scan,

01:04:31.020 | to send you to the specialist.

01:04:32.020 | So you're only paying for a quarterback.

01:04:34.460 | You're investing in someone to oversee it, to be your partner.

01:04:38.340 | Your insurance will still be used for everything else.

01:04:41.100 | So that's how I would think about - and by the way, this field is growing.

01:04:43.860 | There was a report by Grandview where the concierge medical market is like the fastest

01:04:49.060 | growing field in medicine.

01:04:50.780 | It's the fastest growing sector in all of health and biotech and everything.

01:04:54.380 | It's expected to double or triple in the next eight years.

01:04:56.940 | So why is that?

01:04:58.060 | Because doctors want to help people and they want that principal agent problem gone.

01:05:02.620 | They want to be accountable to you.

01:05:04.040 | So if you don't like me, if I'm not doing my job, guess what?

01:05:06.680 | You fire me, I just lost revenue.

01:05:08.780 | If I'm an insurance taking doctor and you fire me, it doesn't matter.

01:05:12.420 | Someone will fill that spot in a nanosecond because I've got a three-month waiting list.

01:05:15.680 | So I don't have to care if people like me or don't like my outcome.

01:05:20.260 | Someone's going to fill that insurance-based principal agent problem slot because there's

01:05:24.780 | no accountability.

01:05:25.820 | There's no true straight line.

01:05:28.060 | There are dotted lines everywhere.

01:05:29.300 | There's no straight lines.

01:05:30.380 | The straight line is between the doctor and the insurance company because the insurance

01:05:32.740 | company can call the doctor and say, "Hey, we're not paying you that much because you're

01:05:35.860 | not whatever.

01:05:36.860 | We don't like you."

01:05:37.860 | And one doctor against an insurance company or the hospital system will say or the employer,

01:05:41.100 | the one medicals, not to knock on them, they'll tell their doctors, "Hey, we need more revenue.

01:05:44.620 | So instead of seeing 14 patients a day, please see 15 patients a day."

01:05:48.060 | So if you're seeing 15 patients a day, that means each patient gets one less minute, which

01:05:51.300 | means that's one more email, one less minute, one more person.

01:05:54.980 | Like quality just starts to exponentially erode.

01:05:57.900 | I know that Roamed is going to be building a physician finder for somebody that wants

01:06:02.260 | high-quality private membership-based physicians this quarter or next quarter.

01:06:07.020 | That's where I'd start.

01:06:08.020 | I don't think Yelp reviews or any of these health grades reviews are useful at all.

01:06:12.060 | I don't buy them because people want to go to the Apple store, not the doctor store.

01:06:16.000 | So when you go to a doctor store to rate somebody, like unless you're like a professional rater,

01:06:20.400 | you're usually there to complain.

01:06:22.020 | I wasn't thinking about it when you started your practice, but it seemed like early on

01:06:26.260 | it was two things.

01:06:28.020 | It was the quarterback and the like 24/7 access, we'll come to your house kind of stuff.

01:06:34.720 | And what I've been looking for since is I want someone who charges enough that they

01:06:38.920 | have free time in their day to read some research or have someone on their staff to read research.

01:06:43.240 | 100%.

01:06:44.240 | Someone who's thinking proactively about my health, but like I can wait for someone to

01:06:48.220 | respond tomorrow or on Monday.

01:06:50.480 | That's right.

01:06:51.480 | So it's like that middle ground is the company that I want to see.

01:06:53.920 | And there are tons of them.

01:06:55.180 | There's nothing at scale because all the ones at scale, One, Forward, Parsley, pick the

01:07:00.600 | brand, they've all raised money.

01:07:02.720 | So they have investors.

01:07:04.160 | So it becomes a profitability story versus a great healthcare story.

01:07:08.840 | Most of the onesie-twosie small versions of concierge medicine, it's somebody that's like,

01:07:13.320 | this is my business.

01:07:14.640 | My revenue depends on me doing a great job for you, not on somebody telling me to do

01:07:19.520 | more or faster or whatever.

01:07:21.880 | So I think there's some consolidation in that space, but I think you have to be really clear

01:07:25.440 | on what drives this doctor and you want a doctor that's thinking about you when they're

01:07:29.640 | not in front of you, right?

01:07:31.640 | Doing that research, I read an article about multiple sclerosis this morning.

01:07:34.400 | I have a multiple sclerosis patient and I'm like, "Hey, guess what?

01:07:36.480 | There's this new research, just heads up and tracking this."

01:07:38.760 | Nothing to do here, but like maybe in a year or two, there'll be some interesting developments.

01:07:42.480 | And by the way, we talked about all these costs.

01:07:44.560 | If your company has an FSA plan, you could put money in pre-tax each year and be able

01:07:50.160 | to use that for your medical expenses.

01:07:51.800 | So one way, and I haven't really thought through this completely before.

01:07:55.280 | I'm not going to recommend it.

01:07:56.280 | I'm just going to throw it out there.

01:07:57.880 | You can't change it mid-year.

01:07:59.120 | So one way to force yourself to have a health budget is to just commit to put a little bit

01:08:04.560 | more in your FSA each year.

01:08:06.080 | So maybe say, "This year, I'm going to put two grand," and obviously we're recording

01:08:09.120 | this in January.

01:08:10.120 | So it's a little late for this year.

01:08:11.120 | But next year, you could say, "I'm going to put two grand or three grand in my FSA."

01:08:14.000 | You do have to use it or lose it.

01:08:15.440 | Usually, maybe you could roll over, I think this year, $650.

01:08:18.400 | But it'll kind of force you to try to get more serious about these things.

01:08:22.460 | Because if you're listening to this and you're like me, at least, it's really hard to be

01:08:26.480 | like, "Oh, do I want to do this test?

01:08:27.720 | It costs $500."

01:08:29.200 | For some reason, there are things in life that it just seems like, "I grew up, medical

01:08:33.800 | treatment should be free.

01:08:34.800 | If it's not free, it seems harder to spend."

01:08:37.480 | It's not hard for me to buy a new iPhone, but it's really hard for me to spend $200

01:08:40.940 | on my health.

01:08:41.940 | That goes back to this concept of there are no consumers in healthcare.

01:08:46.080 | I've never seen a consumer in the ICU type of a thing.

01:08:49.080 | Consumers have a profile that when you want to go to the iPhone, you have all the agency,

01:08:52.720 | all the free will, all the power, all the resources, those decisions are yours.

01:08:56.840 | When you go to the healthcare system, they're not.

01:08:58.760 | You've lost it all.

01:08:59.840 | So that's why getting a concierge doctor or a membership-based doctor is you're investing

01:09:04.220 | in somebody that's got your back, that's going to work with you, that's going to be co-piloting

01:09:09.520 | your care with you, and that's going to actually care about you and care about your outcomes.

01:09:12.900 | I believe you don't go to eight years of medical school and college and residency because you

01:09:16.340 | want to make money.

01:09:17.340 | Like you're a healer.

01:09:18.340 | There are some people that go into finance and want to be hedge fund guys or some people

01:09:20.900 | that want to be artists and architects and like everybody wants to make a good living,

01:09:24.820 | but you don't go into medicine unless you're maybe a plastic surgeon or a cosmetic dentist

01:09:29.060 | or whatever, because that's where big money is, vanity.

01:09:32.300 | That's healing like some psychological wound somewhere deep in your past.

01:09:36.380 | And so, I'll give it to them.

01:09:37.380 | There's some healing components there, but our world is like this is the everything person.

01:09:41.560 | This is like all facets of your existence and health need to be under my umbrella and

01:09:45.520 | I'm a healer and I want to help you and like we're naturally empathic.

01:09:48.880 | We're naturally long-term.

01:09:50.140 | We feel bad when something bad happens, there's a bad outcome.

01:09:52.840 | Empathy and compassion I think are part of the frameworks for going into medicine in

01:09:57.000 | the first place.

01:09:58.440 | And I think a lot of these doctors are getting burned out.

01:10:00.680 | There's a huge physician burnout because these big companies, the medical industrial complex

01:10:04.700 | is forcing them to see more faster, check more emails, like Kaiser doctors have to check

01:10:09.500 | their emails in 48 hours.

01:10:11.320 | They have 2,500 patients per doctor.

01:10:14.680 | So imagine the amount of emails with no barrier to email and they don't get paid for email.

01:10:20.360 | Like the Cleveland Clinic or the Mayo Clinic, I can't remember which one, they just announced

01:10:23.520 | a program that every email to your doctor is going to cost you 50 bucks.

01:10:27.760 | So now you have to be really thoughtful.

01:10:28.760 | You can't just like - which I think is good for doctors because then at least there's

01:10:31.440 | some barrier to someone posing some crazy question with three articles to read and look

01:10:35.720 | at what my brother said and like Kaiser will make you respond to that, which is bananas.

01:10:41.540 | These are the ways to really think about it.

01:10:42.920 | I think having someone in your corner is important even when you're young and healthy because

01:10:46.560 | you don't want to wait until you're sick.

01:10:48.320 | That's a hope strategy.

01:10:49.320 | I hope I get a good one when I'm in the ditch.

01:10:52.400 | You want to have somebody on your team because they can see the ditch coming.

01:10:56.880 | Healthcare is super predictable.

01:10:58.560 | We know you were going to have a heart attack if you didn't get on top of your lipids.

01:11:01.960 | So now you're not going to have a heart attack.

01:11:03.920 | Now let's work on everything else type of thing.

01:11:05.880 | There's lots of ways to think about medicine.

01:11:07.480 | I'm optimistic about a lot of the changes that are coming.

01:11:11.320 | I'm not optimistic that they're going to happen fast.

01:11:13.420 | I hope that I can be kind of a guiding principle.

01:11:17.080 | I hope people copy what I do all day long to create different versions of it and I'll

01:11:22.680 | say private concierge medicine, whatever.

01:11:25.320 | That's the way it used to be.

01:11:26.320 | I used to be your primary care doctor until the HMOs came in and they saw that it was

01:11:29.720 | a trillion dollar market and now it's got a financial boondoggle.

01:11:32.400 | You gave us some good tips on what we can do to try to take some of this into our own

01:11:35.960 | hands, find someone that might be a better partner.

01:11:38.440 | I think that's really helpful.

01:11:40.000 | But you write about stuff.

01:11:41.000 | You have podcasts.

01:11:42.000 | Where can people stay on top of what you're learning in your practice and online?

01:11:46.160 | So if you want to see what I'm reading and you want to get my point of view on what I

01:11:49.320 | think about the latest science because I read about five to ten articles a day is on LinkedIn.

01:11:54.880 | For now, I'm Jordan Schlein at LinkedIn.

01:11:57.000 | There's not a lot of those.

01:11:58.000 | No C in Schlein.

01:11:59.000 | It's just S-H-L-A-I-N.

01:12:00.640 | I post one or two things a day on longevity and/or science that I think is compelling

01:12:07.200 | and interesting that people need to pay attention to.

01:12:09.400 | And if you want to go subscribe to our podcast, it's Inside Medicine, you can find it on Spotify

01:12:14.920 | and Apple.

01:12:15.920 | - Or wherever you're listening to this.

01:12:17.120 | Right now.

01:12:18.120 | - Yeah.

01:12:19.120 | - Awesome.

01:12:20.120 | Jordan, thank you so much for being here.

01:12:21.120 | - Awesome, Chris.

01:12:22.120 | I am super excited.

01:12:23.120 | If you want to do this on the regular and pick a health topic and go deep, I'm in.

01:12:27.120 | - Awesome.

01:12:28.120 | Okay.

01:12:29.120 | We're definitely going to have to get Jordan back on the show because there were so many

01:12:33.560 | topics we just scraped the surface up.

01:12:35.400 | And I think it could be really cool to do a bit of a health Q&A with him next time.

01:12:39.200 | So email me any questions you want me to ask for that episode.

01:12:42.800 | Or if you have any questions on any topic, send me those as well.

01:12:45.720 | I'm Chris@allthehacks.com.

01:12:46.720 | And to all the amazing people who've been leaving five-star reviews for the podcast

01:12:51.480 | on Apple, thank you so much.

01:12:53.240 | I had a goal to get to a thousand reviews in 2022, but I came up a few short.

01:12:58.280 | So if you're on an iPhone and you find this show valuable, I'd be so grateful if you could

01:13:03.120 | just spend a few minutes to leave a five-star rating.

01:13:06.160 | If you have time to write a few words in a review as well, that'd be great.

01:13:09.640 | But even just the quick rating would be so appreciated.

01:13:13.040 | Okay, that's all for this week.

01:13:15.180 | See you next week.

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