#1 Aging Expert: Dementia, Diabetes & Heart Disease Start After 40 When You Ignore This

Key Takeaway

Start tracking your fasting insulin now, not when you're sick. This single biomarker can reveal insulin resistance decades before diabetes symptoms appear, giving you years to reverse the trajectory through targeted lifestyle changes. Unlike waiting for your A1C to hit pre-diabetic levels, elevated fasting insulin shows your body struggling to maintain blood sugar control while everything still looks 'normal' on standard tests. Use this early warning to take action today.

Episode Overview

Dr. Florence Comite, a pioneering endocrinologist and clinical scientist, shares her revolutionary approach to proactive health management through five key biomarkers that predict aging patterns decades in advance. She explains why the current reactive healthcare system fails us, how insulin resistance develops silently for years before diabetes diagnosis, and why tracking trends in your biomarkers every 3-4 months—rather than annual checkups—is essential for reversing disease and maintaining vitality throughout life.

Full Transcript

Transcript of #1 Aging Expert: Dementia, Diabetes & Heart Disease Start After 40 When You Ignore This from Feel Better, Live More. Auto-generated from episode audio; may contain minor errors.

Staying youthful, strong, and mentally sharp as you age is the most important investment you can make in yourself and for the people you love. Yet, so many accept physical and cognitive decline as unavoidable, unavoidable, unavoidable, doing little to interrupt the hallmarks of aging. of aging. of aging. If this is the most important investment we can make, why are so few people making it? I think we don't know enough and there's nothing in the medical world that actually treats you proactively. It's all about you getting sick and it's a reactive health care system in most places in the world, certainly in the US and presumably in the UK.

So there's no real basis for understanding what you're looking for, what you need to do, not just to prevent disease, but actually proactively reverse it and own your own health destiny. health destiny. health destiny. Yeah. Yeah. Yeah. In your book and your wider work, you talk a lot about this concept of healthy aging. aging. aging. What do you mean or what should we be thinking of as individuals when we think about that term aging? I think we should be grateful for aging because if we're not aging, then we've died young.

And so I'm not in favor of the term necessarily anti-aging. I'm pro-agging, but pro-aging in fantastic health, so you can live life to the fullest and be vital to the very last moment. More and more of us are living beyond 100. Antibiotics brought that to the 20th century. This century equivalent to that is GLP1s, I believe. And we are going to be living to beyond 100, beyond 122, I believe. But without investing in keeping our body strong, healthy, without heart disease, stroke, dementia, cancer, we're not going to enjoy those years.

So living long without health may not be as much fun as we have had the rest of our lives. Yeah. In that same section of the book, you basically reference what you have just been talking about, the kind of aliveness we all want. We want to be biologically youthful, engaged, and healthy. no matter how many candles adorn our birthday cake, which I really like. But I want to talk to you about this concept of biologically youthful because I'm trying to sort of understand in my head the tension that some people may have between growing old gracefully and accepting the aging process at the same time whilst trying to stay biologically youthful.

Are those two things in opposition to each other or is it possible to do both? Well, my career has been built on it's possible to do exactly that because you do chronologically age. You do get a candle every year. But we allow our bodies to decline because life expectancy before antibiotics was much younger than it is today. And we don't invest in our health in the way we invest in finances to stay a well and to be able to live well. Right? But how where do you live in your body?

If you're going to age, don't you want to be in charge of all your facilities? Don't you want to be able to play paddle ball, tennis, ball, tennis, ball, tennis, any one of the sports, and also dance maybe at your great granddaughter's wedding? wedding? wedding? Um, and really enjoy everything life has to offer. And there's data and clear-cut studies published Michael Snyder in Nature showing that aging happens and poor health begins to be obvious and palpable in the 40s and then again in the 60s and once you hit 70s you there's a group of people that can go on and continue neurologically sound but for the most part we are declining and in order to not decline we have to be proactive.

proactive. proactive. What would you say are some of the most prevalent myths that exist in society or beliefs that exist out there about the aging process? aging process? aging process? The biggest myth is that you can wait. You can wait until you're sick because we tend to reinforce that. When do we see a physician? When does a physician actually start exploring? A lot of physicians feel that by looking at your tests, by understanding what's going on at the cellular level, we can just keep an eye on it or it's all in the normal range.

And both of those statements are outrageously wrong. outrageously wrong. outrageously wrong. Yeah. Yeah. Yeah. The way you write and the things you talk about in terms of how you've practiced for many years resonated so deeply with me. This idea of every patient being an individual and actually we need to find the right approach for them. What you you know the term you coined the N equals 1 medicine right? So I I really enjoyed that. I enjoyed this idea that there are seven aging patterns that you have recognized which I'd love to talk about but also this idea that whatever we're doing whatever we want in health health health ultimately you've identified five key biomarkers biomarkers biomarkers that can give us a representation of how well we're doing.

I very much like that approach because I think these days there's so much data out there and I think it can become very overwhelming. So we'll definitely get to those five key biomarkers shortly. But this idea about aging, you mentioned Michael Schneider's work and what happens at 40 and at 60. I've heard you talk before about this idea that it's in your 30s where people suddenly start to feel things going wrong. Can you elaborate on that a little bit? Yes. So Abby Hoffman, I don't know if you recall who he was, it ends at 30.

And that's because in our 20s, I think we can compensate well. We can burn the candle at both ends. We can ski all day, party all night, and still get up the next day and ski. And we don't pay a huge price for it. But as we enter our 30s, biologically, metabolically, hormonally, our system is changing. [snorts] It may not change in a way that's palpable. It may not change in a way where symptoms have emerged, but we know that because we know men begin to get heart disease in their late 30s.

We know women begin to put on a few pounds around their waist. And we know hormonally it's driven even if you're trying to do everything perfectly. Let's rule out the fact that in our 30s, which is used as excuses for the most part, real excuses. We're raising children, we have a busy career, we may have aging parents, we're coping with things, and we may not get into the gym. We may not eat correctly. We may not be able to get enough sleep. But if you do all of that, you are still aging.

And you're aging in a way metabolically that undermines your health for the future. And by thinking that way, that's the way I began. And looking at where peak health happens, and we know that because of athletes, we know that 27 or 25 to 30 is a perfect time to have children where supposed to be optimal. You can still see disease and you can still assess it in the 20s, even in the teens and even in children. But where it begins to matter is our 30s because that's when hormones really start to decline and that's when metabolism changes because hormones are declining and you can't maintain muscle in the same way even if you do everything you've done before.

Yeah, this is really interesting that by the time modern medicine gets involved, you are way down the road to getting sick. sick. sick. Absolutely. In fact, diabetes, heart disease, dementia, that's not overnight. It's not what happens from one week to the next. Your heart attack has been brewing generally under the surface for decades. Insulin resistance is seen decades before fluoride signs of diabetes, whether it's tingling in the feet and hands, whether it's eye disease, kidney disease, any number of issues. And yet, we don't look for it until we're aggressively active.

We have symptoms and they've emerged because medicine, the way we practice it today, is about disease. It's reactive. So, we're 10, 20, 30 years down the line already and we've been dealing with these conditions under the surface. Yeah. Here in the UK, we have the National Health Service and that has been fantastic for many years and elements of it continue to be fantastic. fantastic. fantastic. But But But what I don't think there has been is a recognition recognition recognition of what it actually is. It is a disease management service.

Exactly. Exactly. Exactly. And sometimes it can do that exceptionally well. exceptionally well. exceptionally well. it is not a health creation service. But also this idea that actually it does prevention prevention prevention is is unfortunately very very misplaced because the current NHS's idea of prevention and I get I'd love to get your take on this is once you hit 40 you will be invited in for a very basic blood panel. So, lipids, you know, fasting glucose, um maybe an A1C, an average blood sugar, and a blood pressure reading.

If it's deemed normal, not optimal, normal, that's it. You you just you'll have a blood pressure reading. You you crack on with your life. That that's prevention done. And if there's a issue there that they pick up, yeah, they might see you again. But I feel it's so dated. But of course, you've been practicing a true preventive model, a true health creation model for several decades now. So firstly, what is your take on what I just said in terms of what you are offered currently in the UK on the National Health Service?

I can't speak intimately to the UK because I am not as closely knowledgeable as you are with how they operate. I will tell you I've had patients in the UK and I've had interactions even this week alone as I talk about Invincible and the book that I hope to get in everybody's hands because people have complained to me and said they have symptoms, they have vague symptoms, they're in their 40s and they're not getting any direction. they've gone to five or more doctors and no one can help them both figure it out and also put in place ways to stop the diabetes their mother had or the heart attack their father or dementia in their grandfather.

And so to me what I think about is proactive prevention, not just reactive prevention, which is what you described. And a one-time measurement is meaningless because what you have to do is look at trends. Yeah, you're told you're normal, but that normality, what so-called normal is based on a derivative of average of one-sizefits-all in a sick population because there's no telling where those blood results have come from. They're measuring a thousand, even a million people and the ranges are broad and you fall anywhere. It's population dynamics.

It's not about you distinctly you and it's not about the ins and outs of where you go as you travel in you go as you travel in life. And so it is similar in the US. We probably have a little more access. We've lost the art of family medicine because it's gone. Most people use urgent care. But in the UK, from what I've seen, and I've counseledled people about even getting an appointment based on symptoms. I tell them, I I had a young woman in her 20s who worked for me, and she looked incredibly pale.

Um, it might have been her complexion, but she was feeling weak and not so well. She could not get an appointment. And I said to her, "Listen, you might want to tell whoever you need to tell to get an appointment that you feel faint when you get up, when you go from sitting to rising. You feel weak. You feel like um you're um losing weight and you need a workup." And so she got an appointment and the workup consisted of a stethoscope on her chest and she was told she was fine.

And two weeks later, she was hospitalized because she was profoundly anemic. And so nobody looked at I told her the options are anemia, thyroid disease. She was only in her 20s. And so I think less is more in medicine. Like it is not about searching for abnormalities. Is about looking for how an individual is evolving and particularly looking at an individual, not at the population. Yeah. Yeah. Yeah. I think the the problem is is that the medical system is a massive institution that has been set up a certain way and certainly what I've seen in the UK is that when the NHS was set up, you know, many decades ago now, the health landscape was completely different.

Mhm. Mhm. Mhm. I think back in its inception days, people would generally go to their doctors with an acute problem. Exactly. In the days what we were taught medicine, it was a chief complaint. You come in with a chief complaint. Now, if you're lucky enough to go once a year, you get seven minutes, even in the US. What can you learn in seven minutes about a human being? So, to me, a chief complaint was mostly outdated. And I don't know when the inception was of NHS.

I'm sure you can enlighten me. I think it was around late 40s. Okay. Late Late Late 1940s, right just after that is when antibiotics became available. life expectancy did not incorporate chronic disease because we didn't live long enough to make it a burden to make it difficult on the individual, on the family, on the country. And so we've completely changed how we've evolved and where we're going. We're living longer but not better. So the first generation that lived longer was the great generation. The generation born before the baby boomers from the baby boomers are 46 to 64.

This was the generation just before that. They're living longer, but they're sick. And that has put another burden on the health care system. And as a result of that, we're seeing that we're waiting way too long to intervene in when somebody to to figure out what your health where it's going. What is your future health trajectory actually look like? You know, what diseases are brewing under the surface? Because to me, it's like a crystal ball. You look at certain numbers. you do u you wear a few wearables and certainly a continuous glucose monitor will tell you what your glucose is doing in your body based on your genetics and your heritage which is very different maybe between you and I and certainly other people.

Um and so if you get that data you can begin to invest in your own health and do it in such a way that hopefully ultimately will align with a health care a true health care system. Yeah. Yeah. Yeah. Yeah. Let's talk about these five biomarkers of true health as you call them. I'm interested as to how you came up with these five, what these five actually represents for us and then we can go through them one by one and sort of try and figure out what are the levels we should be looking for.

for. for. Sure, love to. So, let me be clear. When I set up what I did and I set it up as realworld data, my background is as a clinical scientist. I trained at Yale and the National Institutes of Health in Bethesda, Maryland. And there I I was guided by brilliant mentors that actually helped me design protocols and understand clinical research in people because we as people are very complex. How do we figure out what's going on? [snorts] In general, research is done in people where you have exclusion and inclusion criteria, even if it's a thousand people.

So, you're ruling out all the um anomalies and issues that may complicate findings and outcomes because we are so complicated, right? We simplify it. So the five markers that I came to believe in were out of the work I did and the research I did and they include looking deeply at carbohydrate metabolism which is fasting sugar, hemoglobin A1C which is an average of 100 days, fasting insulin which almost nobody measures, cholesterol risk ratio which takes the standard lipid test but you're looking at the average of total cholesterol divided by HDL or high density lipoprotein.

And the final one which is almost never looked at even by people knowledgeable in the field of male hormones and female hormones and that's free testosterone. Not total testosterone but free testosterone. Yeah. Yeah. Yeah. Before we go into them in detail, one of those that people in the UK really will struggle to get on the NHS is fasting insulin. And you know I don't want to get into it now but one of the reasons I created do health this preventative model of healthcare in the UK is to ensure that people do have access to fasting insulin because I think it's very important.

Let me put it to you Florence. Why do you think fasting insulin is such an important biomarker to check? As an endocrinologist and when I was at Yale, I was in triple I had a triple appointment in adult endocrine which as you know is diabetes, thyroid, osteoporosis, lipids osteoporosis, lipids osteoporosis, lipids um and children. So I I took care of children. I worked in peptides for both children and adults, pediatric endocrine growth and development. I was fortunate enough to see every decade of life. Beyond that, I was trained in reproductive endocrine, which is the way the brain engages with the gonads, the testicles in men and the ovaries in women and the adrenal glands.

And so I felt that the reason why fasting insulin was so critical is it changes decades before we get diabetes. And diabetes or abnormalities of the carbohydrate metabolism system, carbohydrate disorder is ubiquitous, meaning it's occurring in everyone. And I have yet to find a person with five biomarkers that are optimal. The reason being is we've survived from past generations of ancestors that had to live through famine and lean times. In doing so, we inherited their genes. If you couldn't put fat on your bones, we weren't going to survive.

Now we have Uber Eats. We can have processed food and ultrarocessed food. And we're doing our body a disservice. And therefore, by not looking at insulin, we're giving diabetes a chance to grow for decades before we're symptomatic. I mean, I I just want to highlight what you just said because I think it's such an important point. We've already spoken about this idea that modern medicine, the way it is currently practiced, is reactive. reactive. reactive. It waits until you get sick or very close to getting sick before it tends to get involved.

That's the whole model. And people will have heard of type 2 diabetes. They will have heard me talk about this idea that in the UK, and I know it's subtly different in America, but the HBA1C or average blood sugar, you know, when it's 6.5 or above, that's type 2 diabetes. That's the same in America as it is here. In the UK, once you hit uh 6.0, it's called pre-diabetes. So, in the US, you hit pre-diabetes at 5.7, I believe. Exactly. Exactly. Exactly. Right. Which means, and this may surprise you, uh, worry you, I don't know until I say it to you, but there will be patients today in the UK who have had an HBA1C done and it will come back as 5.9 and they will be told it's normal.

So I think of normal as a bad word because there's nothing that's normal and it's certainly the next onetenth of a point which is going to happen is almost inevitable unless there's some kind of intervention that's specific for that human being. It could be sleep, it could be food, it could be exercise, it could be testosterone. And all of those variables are so simple that in fact when I've treated thousands of people over the years, I have never prescribed insulin because I reverse disease even if they come in with a hemoglobin A1C of 7.9.

7.9. 7.9. Yeah. And also I want to say this because I think it really frames the rest of our discussion today. You write about this in your book that as of yet you have not had a patient experience a heart attack when they are continuing on your program. your program. your program. That is staggering. That is the kind of thing that most clinicians would want to be able to say. And of course you have a specific type of practice which not everyone has. I get all those things.

But nonetheless, that is very impressive to hear. to hear. to hear. 5.9. And the reason why I brought that up is because it goes back to the fasting in point that we're making which is a I think it is wrong to call an A1C of 5.9 normal, right? Because it is you are so far on the continuum to getting type 2 diabetes. You know, yes, in the UK you're not pre-diabetic yet, but you you're you're as close as you can be. What you're saying is that it's a false standard.

And it is. It is a false standard standard standard because we're not looking at a human being as where are they trending. We're looking at a human being being as if one number defines them and that number is actually telling us that you are unhealthy, you're just not quite unhealthy. Do you know that the reason why 6.5 was picked as a diabetic framework was based on the fact that they found eye disease very prevalent at 6.4 for and even in the US today when you hear commercials about uh GLP1s you're looking at let's make it below seven and below seven as we just pointed out in both of our countries is still diabetes.

So, we're willing to live as a sick community and deal with it instead of having people own their own health trajectory, make decisions so that they can use changes in the way they live life, maybe medication, maybe supplement, maybe exercise, food, sleep to actually alter their path and own their health for life. Yeah, fasting insulin I agree with you is critically important because that HBA1C marker and I'm I know you know this I'm just spelling it out so that everyone listening or watching gets this as well is this idea that that is quite late or it can be quite late and fasting in will likely and many people go up as you said decades earlier way earlier when your body is having to work a little bit harder to maintain your blood sugar.

And that's why I find it staggering that we don't offer fasting insulin here in the UK. UK. UK. The reason it's doing that is it's actually called insulin resistance. Our body and our cells are not responding to insulin. And so it's critical to think of that. Here's where a human being could make a change by knowing what their sugars are doing. Because you can have a perfect A1C to set this up as a devil's advocate, which I do. I have had it for years below five and yet if sugars vacasillate high and low both of which is not acceptable the average can look beautiful.

look beautiful. look beautiful. Yeah. Yeah. Yeah. And so you need to look at those three of the five variables that I picked out were because they lead to every disease of aging. Elevated insulin is not just about diabetes. It's about cancer because it's an inflammatory marker. It's about osteoporosis because of the way it interacts with the cells of the bone, the bone cells. And so all of that is critical for people to understand. Yeah. I mean the aging patterns you talk about the first one of course is carbohydrate metabolism disorders.

And it's interesting that although the those first three biomarkers fasting glucose, HBA1C and fasting insulin, they directly relate to carbohydrate metabolism disorders. Of course, they're also going to be linked to some of the other aging patterns as well because you know it's such a fundamental process in the body, right? Well, you know that that somebody who has diabetes has the same risk of a heart attack as someone who's already had a heart attack. So, the effect of these cells, the sugary red blood cells on the heart, on the brain is really detrimental.

And so you have to look at these disorders of aging as basically being a factor of sugar abnormalities or carbohydrate disorders. As I mentioned earlier to you when we were chatting, type 2 diabetes in my mind is a gazillion types of diabetes depending on your gene variance, the way you live life, your ethnicity, and a number of other factors. So I can't even think of it as type two because there are many varieties of type two diabetes. You mentioned before that a one-off biomarker reading biomarker reading biomarker reading is limited in the sense it gives you an idea of where you are, but what you're really looking for are trends over time.

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

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

The sugar stays about 85. The other person who's the where the banana triggers it, a cookie does not. And the reverse is true of the person who a banana has nothing to do with you know with their sugar. And so when you look at it that way having the knowledge within your own system within your own hands. So that's why I'm a strong advocate for the continuous glucose monitors because instead of just arbitrarily getting blood and then waiting a few weeks and being told, "Oh, you're in the normal range or just about or maybe it's a little high.

You better get to the gym. You better eat better." you're going to be able to tie exactly the way you live life to the fluctuations in sugar. I agree that CGMs can be really powerful if you use them in the right way. And there's a really nice section in your book actually where you explain to people how to use CGMs which I which I thought was very valuable. But I just want to get back to this point of how often to check these biomarkers. And And And when I was creating do health and I was chatting in the in the clinical meetings a lot of people were saying no no let's just check once a year.

I said no guys you cannot check these biomarkers once a year. And I'll tell you why in my view because because because some of the biomarkers we're checking that overlap with yours are amanable to lifestyle change. So the problem is is if you only check it 12 months afterwards, you don't remember what you were eating or how you were working out 11 months ago or 9 months ago. We have chosen initially at least to check every four months. Now I suspect over time if someone is in a really good shape, we could probably reduce it to twice a year.

Some people we might need to raise it to four times a year because you want to know, let's say your fasting insulin is high and your HBA1C is high. So you know that there's an issue here with my you know I may have a degree of insulin resistance. you want to then make some changes and relatively soon after that see has this made a difference and that's the most important piece to me because I absolutely agree that you know four times three times a year to get a sense of are you making a change and what is the consequence of that change change change and if you can't get that feedback what's going to have you stick to that change if you don't know what's happening you're not going to stick stick with it because there's no right there's no positive result from And yet, if you know that you're defining yourself and your CGM 24/7 allows you to actually make the connection and connect the dots between the way you eat, for example, as just one example, or the way you sleep or drink alcohol, or how close to bedtime are you eating because you want to stop eating about two hours before bedtime to allow your body to clear metabolic waste from your brain and your body.

And by wearing a CGM, you take control into your own hands. There's in fact many doctors in the United States and some very brilliant people that I've worked with before they started working with me tried the CGMs because they were a fun tool. They look like they'd be helpful. Completely confusing to them. So I think part of the issue here too is how we give clarity to each person about what that number actually means. For some people having wine at dinner, a couple glasses of wine, their sugar will go up high, but then in the middle of night they'll have insomnia.

That's a way of just seeing why you're not sleeping through the night because the blood sugar is dropping. The blood sugar is dropping. And so it is lifechanging for people. So while habits make a difference, lifestyle makes a difference in in a vacuum. It really doesn't. It really can't because that in a vacuum meaning without knowing what's really going on inside your body. You don't know that you're heading in the right direction. You may feel better, which is great. You may get more energy if you've learned to control sleep and you're not waking up at night and you're getting adequate deep sleep.

Lots of us sleep through the night and don't get adequate deep sleep. If you do get good deep sleep, even if you have only a few hours, let's say four or five to sleep or less than six, then and you feel great, it usually means you're getting adequate deep sleep. When you get less than adequate deep sleep, a less than an hour, even if you sleep long, a long period of time like 10 hours, you may not feel so well. And so there's a we're very complex human beings [clears throat] to figure out what's going on.

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So, one of the things I learned is despite my optimal hemoglobin A1C, again, the average sugar over a 100 days, um, my sugars could go very high and very low. And when I'm sick, and just a little sick, my sugar's high. It can usually range in the 90s. When I'm or even over 100. When I'm very sick, I become hypoglycemic, become hypoglycemic, become hypoglycemic, which means my sugar falls below 70. So, I've learned how to assess how I feel and tie it to these the data and as a result, I can extrapolate from that.

You don't have to continue to wear like you and I do. We just shared our continuous glucose monitors on our arm. You don't have to wear it day and night. I'm a data geek. You're a data geek. We want to know. But for those of us who may not be, having that internal knowledge and then experimenting and then maybe getting blood work two, three, four times a year will help reinforce the changes you're making. Yeah. I think I've shared this before on the podcast, but I remember the very first time I wore a CGM, I was shocked by how much sweet potato wedges in the evening would send up my blood sugar.

It's kind of in the pre-diabetic range. I was like, "Wow." Now again, we're not necessarily here to demonize anything. For me, that's that's uh power, that knowledge, because now armed with that information, I can now make an informed choice. Maybe on occasion, I will, but generally speaking, I won't eat that much anymore. But, and I also learn about volume. If I h haveved the amount and had that and had it at the end of my meal, so I might have the the salmon first and the, you know, I I'd leave the kind of carbs to the end.

I was like, hm, well, that's a pretty stable blood sugar sugar sugar and you know why that happened. So, I can explain it slightly. Um, and I have another story about sweet potatoes which I can talk about a little later that affects me and the eyes and I've given them up because of that because it it's an issue for inflammation and risk of macular degeneration. macular degeneration. macular degeneration. But going back to it, when you have carbs and you have them before you have a protein, you're going to send your sugar high.

It's like having a brand muffin and a banana for breakfast. So your sugar goes skyhigh. It starts dropping, but insulin follows shortly thereafter. it goes high. So two hours later you're grabbing a donut and a cup of coffee. When you have protein first like eggs or as you mentioned salmon and then afterwards you add so the order of mac macronutrients is really critical. Your sugar is going to rise slowly like a gentle mountain and the insulin follows very closely behind. So you're not going to create a situation where the sugar is really low and your insulin is making it lower.

So you feel cranky, irritable, tired. You may even feel sleepy or hangry, you know, hungry and angry. angry. angry. And so the way the body processes food means if you learn that about yourself, you just you can have your sweet potatoes, but you're just not going to overdo it and you're going to do it in the right order. Yeah. My my view on on CGMs is that I think everyone would benefit at least once in their life from having it on for at least 14 days just to see what they learn.

Now, I think for some people that may be all they want to do, right? I think some people benefit from and I used to do this. I would do it like once a quarter, you know, every three months I'd pop one on. They last two weeks and it was just a way of seeing what's going on. It could sometimes remind me of stuff where I slipped up. At the moment, I'm wearing it quite continuously because I'm experimenting with a few things. But again, I'm not saying everyone has to do that.

You know, I like learning about this stuff. I like learning about it for myself. I like learning about it so I can share it with people. I just I think it's important to to say that because some people are going to hear that go, "Well, I don't want to wear it continuously." I agree. I agree. Except I'd make one little tweak. The tweak I would make is wear it for the two weeks. Decide on some small step you're going to take. This is for those who may not be as invested as you and I are in health and what's happening because we want to share it with other people.

We want to make sure that people can stay as healthy as possible for as long as possible. and then wear another one when you've made that change so that at least you get a it's like a process where you can see for yourself. It's so affirming when you do that and it really helps you. Now I wear it continuously. I've worn it for years. I actually brought it in from another country um before America we had in the states direct to consumer where you had to come into the doctor with a little hard drive the little round disc and it's changed people's lives.

I mean it has made a huge difference. I had a patient I recall just he stands out in my brain. He was an avid bicyclist. He would go up steep mountains but could not lose about 15 [clears throat] pounds over a period of years. He was in his 50s and he was confused about it because he was pretty he was exercising hard. And it turned out we we got his body comp and then put a CGM on him and we looked at him a month later and he said, "I can't believe it.

I was doing this with my daughter who's 16 and every morning he had rusk over a cup of tea and the rusk the biscuit caused it with no protein caused his sugar to go up really high and then plummeted and it showed him that if he eliminated that he actually lost 5 lbs in one month. Yeah, it's so powerful. But but I just want to highlight something that I think you mentioned you certainly talk about it in the book. this idea that all of us are prone to issues with our carbohydrate metabolism.

carbohydrate metabolism. carbohydrate metabolism. That's I think quite a provocative statement for many people. I think it's it's a really interesting way to think about this and this idea that as we get older, older, older, most of us are going to have a degree of insulin resistance insulin resistance insulin resistance or hypoglycemia, high glucose or low glucose, hypoglycemia. But more but broadly speaking, broadly speaking, that's why I don't think of it as diabetes type two because that sounds like it's a very neat definition of one form of diabetes versus type one.

So that disorder of carb metabolism is a derivative of us living longer with less hormones, particularly testosterone that makes muscle, which packages sugar for us. So with less muscle, it's a circular thing. we have more sugar circulating around and we end up getting disorders of carbohydrate metabolism which leads to almost every single disorder of aging from diabetes to dementia. Yeah, this is fascinating. Okay, let's go back to these five biomarkers for just a moment. We we've spent a little bit of time talking about the first three which are all to do with carbohydrate metabolism.

carbohydrate metabolism. carbohydrate metabolism. They are all in your book, but would you mind just sharing what levels you like to see in your patients for those three things? So, the glucing glucose, the A1C, and the fasting insulin. Yes. So, for fasting glucose, ideally, you're looking at 70 to 80. It doesn't mean if you're 81 that it's something you don't have to panic about it. It's going to fluctuate. It's going to fluctuate for a lot of reasons. how what your health is like at the moment, what you've eaten, the workout you've done.

On a day you work out, you may look different than on a day you don't or the night before. Um, fasting insulin, you want to have no insulin in your body 12 hours or 8 to 12 hours. Actually, 3 hours after you eat. In the United States, on one lab test, it says your insulin could be up to 19. You don't need insulin when you have no food in your body to process. So after 3 hours it should be undetectable. Undetectable and hemoglobin A1C five less than five.

And but keep in mind that the combination here can vary and does vary from person to person. Some people can have an elevated insulin, a fasting sugar that is 70 and a hemoglobin A1C that's 5.2. And it points to different paths and that's described in the book. Yeah. So you want all three. So you can actually see the context and what's going on which is really important. Let's not go through in detail into all of them but because we've already mentioned A1C mentioned A1C mentioned A1C and you know the 5.9 that that may be reported as normal here in the UK right you're saying and this really got my attention in the book under five is optimal.

Okay. Now, that is the lowest optimal I think I've heard. I've heard people talk about five or 5.2. I've certainly seen some data showing us that as our A1C, this average blood sugar reading goes above 5.2 in a linear fashion, our all cause mortality also increases. Okay. So just just to make it clear for people who don't have a scientific background, scientific background, scientific background, as it goes higher way before pre-diabetes or type two diabetes, your risk of dying from multiple causes is starting to go up.

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

So, you can look this up and see what it's all about, and you can make sure that there's scientific backing to it. and the papers that have reported hemoglobin A1C of less than five is associated with less diabetes and disorders of chronic disease that you just talked about. So as hemoglobin A1C creeps up by a tenth of a point that changes dramatic and your risk of disease as you age goes up with each tenth of a point. Do you think that these kind of optimal uh ranges or numbers we're looking for vary from person to person?

So could it be because we are all individual and that is one of the big themes in your book. Could it be that for someone 5.2 is okay for them? for them? for them? That's your definition of they might be okay. We don't know. But as far as perfection goes, I don't aim for perfection. I believe in moderation and not deprivation. And I believe that yes, there are some people that can have a combination that maybe they're 5.1 or 5.2, but they counter it with what else they might do in their life.

Okay? And but once you're creeping above five, you're heading towards first pre-diabetes and then diabetes. So in general, that's the case. But because we're each N of one, and I'll use my twin, identical twin sister and myself as an example, she's on metformin. I can't tolerate metformin because of my GI tract. I have an issue in my GI tract that um which I found out years ago. I have a schemacolitis when I'm dehydrated and when I'm stressed, I tend to have uh symptoms that aren't very much fun because I bleed and it's very painful.

Um and I'm able to keep it under control. And so as identical twins, her numbers are going to vary a little bit more than mine. And she does great on metformin. I my gut can't tolerate it. So each one of us has to walk a path that's a fit for us. We don't know what your genetic variants are. And that's far more sophisticated. I look at thousands of genetic variants. The combinations that you can have for diabetes and risk uh top more than 2 three,000 now.

There isn't like one strand. It isn't like, oh, if you have this, you're going to be a diabetic. It's actually far more complicated because it involves the entire system. It's very complex. Yeah. Okay. I I want to get to testosterone because I think it may well be one of the most misunderstood hormones. So, I would say that most people people people or many people think about it as a male hormone and they think about things like muscle, aggression, sex drive. But in your book, you very powerfully link it to insulin resistance, heart health, visceral fat, brain fog, loss of motivation.

So, Dr. Kami, talk to us about testosterone. What do we misunderstand about it? And why do you think it's so important for men and women? women? women? Okay, I'm happy to do so. I have myself have been on testosterone for 30 years because of a high risk of osteoporosis inherited both on my mother and my father's side. I had an ant in a maternal ant and a paternal ant who had osteoporosis. And I knew that one of the ways I can strengthen bone was with testosterone.

testosterone. testosterone. So 30 years means probably somewhere in the mid '9s you were starting this. Were there many people taking testosterone in this way? No, I can pretty much assure you that if it was 5% that was a lot. And also in this day there aren't many because there isn't a deep knowledge of the fact that in women testosterone is low. We lose it just like men do. It's critical for bone health, memory, cognition, muscle. And most of the men I treat, when they use testosterone and they get it into the optimal range, their sugar naturally drops, their hemoglobin A1C naturally drops.

And we use testosterone, but we also use peptide agents that actually stimulate your own testosterone. So testosterone is really a critical hormone for me. And I'll tell you where the data came out for me. So I mentioned having an identical twin. identical twin. identical twin. We get bone densitometries pretty much yearly. I knew I had osteopenia 30 years ago as did my twin sister. I started then she started about 15 years ago and she has early osteoporosis and I still have the same bones that I had 30 years ago osteopenia.

So now we're going to treat her for the osteoporosis but had she been on it as long as I do I would venture to say that she would not have osteoporosis at this point in time. So we know for example just to carry that a little further that women get colleies fractures of the wrist beginning in the 40s and 50s because the wrist is more vulnerable. We don't walk in our hands and we don't reinforce bone there and as hormones shift and then about 10 20 years later it's fractures of the hip and then shrinking spine and shrinking uh kyphosis and buffalo hump.

In men, osteoporosis occurs at the same in the same numbers. 25% of all men, 25% of all women will become osteoporotic. That one disease alone can destroy your life. Can you can die when you break your hip. Um you don't live alone afterwards of the people who remain. 50% of them can't live alone. So you're going to affect family members. family members. family members. And so you want to start young so that you could sustain bone turnover. And I saw that because men had stronger bones and don't start losing bone.

It's about 10 years later, it made sense to me that testosterone would help prevent bone loss and would keep my bone strong. So that was for me to test and for me to find out that my twin sister, because she wasn't on it as long, had developed more bone loss than I did at that stage. This is so interesting. So people who regular listen to this show will know because we've spoken about it on numerous occasions that after the age of 30, 30, 30, we start to lose muscle mass each year unless we do something about it.

Now, as I think about what I've read from you and what I've just heard you say, it begs the question, given that we're losing testosterone, I think you you write, is it 1 to 3% a year? 1 to 3% of you after the age of 30. Is the muscle loss that we all experience unless we do something about it it it massively or largely influenced by the fact that our testosterone is dropping. I think there's a direct impact. I don't think it's the only factor but it's the main factor.

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

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

It affects sugar. It affects memory. It affects cognition. It affects heart. It affects bone. It affects every cell in the body. And so I can point to patient after patient. And that surprised me. I have patients, I'll speak of one who was ripped. He was in amazing shape and he was in his 40s, close to 50s when he came to me. And [snorts] yet he shared a he worked very very hard. He's actually in the news world. And yet he came to me and he said his memory was definitely slipping and it he it was affecting his profession and what he needed to do.

He would forget people's names. He couldn't report on that and he couldn't talk about uh things that he loved that he was very into because he was forgetting the details. After a few months on testosterone, because he was doing mostly everything as well as you could, eating well, working out, sleeping, um and after a few months on testosterone, his memory started returning. And for the last 15 years, he's been fine. And this is a man where Alzheimer's also runs in the family. And so his fear of going down that path contributed to his memory loss.

But I've had other patients who I couldn't even take initially alone. I would have to have a loved one on the phone with them because I do a fair amount of tele medicine in introducing the ideas and what we explain. And within a few months largely about 3 months, they were acting like their memory was repaired. So the role that testosterone and estrogen play on memory is vital. And I was surprised by that. I didn't the data wasn't really yet. What is there and you will find those papers is low testosterone is associated with every disorder of aging too.

too. too. Uh in some ways like sugar. Your views on testosterone. It's not the current prevailing view with a lot of doctors. I would say how does this fit in with this idea of aging gracefully? So, gracefully? So, gracefully? So, you know that we're a very appearanceorientated appearanceorientated appearanceorientated society. We've lost the ability to accept our mortality and the fact that, you know, as we get older, we're not going to have perhaps the the the vitality that we had in our 20s. So, if someone is thinking that when they hear you talk about testosterone, what do you say?

say? say? I ask if it's common for people um to age and stay strong or do they get weak and frail? Do they need to depend on others to care for themselves? Are they enjoying life? Do they want to live a long life because they're not in good shape? If you ask people, most people don't want to live way beyond 90 and even short of that because they see illness. Yeah. illness. Yeah. illness. Yeah. And so the whole question to me is the quality of your life.

It's not really about longevity. I take that for granted. If we keep people healthy and strong and the natural indication is to decline, our genes don't usually dictate living forever. Although there's a group of people who do have genes that let them live for a very long life. The oldest old who have certain genes that are inherited. There's a group of Ashkanazi Jews who have lived beyond men beyond 110, women beyond 115. But when you ask about testosterone for everyone, I think as trained physicians, we never say 100% or zero cuz I've seen exceptions.

I've had a group, I can count them on one hand, a few people who aren't on hormones and they're still thriving and they're test and their muscles are pretty standard. So genes are dictating how we survive and how we live. whether we live well, poorly or a chronic disease, we have introduced lifesaving measures like antibiotics that allows us to live longer but not necessarily to create strength in every organ system. So to me, understanding yourself and being able to apply certain rules will allow you to live gracefully as you age.

So I have two follow-ups I think. Okay, number one is related to lifestyle. Can a man bring up [clears throat] their testosterone testosterone testosterone using their lifestyle? I guess that would be my first question. And the second question I think we need to cover at some point is are there risks to taking testosterone and side effects that we need to be aware of. So the answer to lifestyle is essentially no. You cannot work out harder, do more, eat more protein, and raise your te raise your testosterone with any supplement that I've ever tested.

tested. tested. But hold on, let's this is a really important point. We do know, for example, that people who sleep less, like men who maybe sleep 5 hours a night compared to 8 hours, will have lower testosterone. testosterone. testosterone. Yes, but that's lower testosterone, not increasing testosterone. That's not optimal. If you sleep well, yes. So, sleep will It's a different question that you just asked. Okay, this is really important. go for it. [snorts] it. [snorts] it. [snorts] You cannot, let's say you're doing everything right, um, and you make no changes in your lifestyle because you're sleeping well.

You're sleeping maybe 6 to 8 hours, maybe 10, but getting over an hour of deep sleep, over an hour of REM, and you're able to do that pretty regularly, your testosterone is going to be low. The reason your testosterone is low is because you are getting older and your body isn't listening and making enough testosterone. I've read over and over again in men's health and elsewhere that working out increases testosterone. What working out does is increase growth hormone, which is a peptide hormone that's synergistic with testosterone, works together with testosterone, but doesn't increase testosterone.

Now, if you aren't sleeping, your or you have a newborn baby or they have issues, your testosterone can fall because your body isn't in its prime. It isn't doing what it is. it is. it is. And when you address those things, it will go up. Yes. that that is presuming you're in your 20s or your 30s or your 40s, but it's not going to go to optimal. Okay, so this is let me just make sure I've got this point right. So if your uh whatever your age is, let's say you're in your 40s and your lifestyle has slipped because of life situations, young kids, elderly parents, too much work, not sleeping, whatever it might be.

If you then address those factors and are able to, yeah, your free testosterone again may increase, but there's a ceiling on that. Yes. And you're saying that sure, optimize your lifestyle as much as you can. Yeah. That's the low hanging fruit and that will help, but for some people that will not get you to optimal free testosterone levels. Exactly. Okay. So, that's really interesting because So, that's the case. Then as you said with that patient, that patient, that patient, he was doing from what I recall everything right.

everything right. everything right. Like he was following all the lifestyle advice. But when you added in tes, was it testosterone or hCG? And maybe you should explain the difference to people. Sure. Uh it was hCG. We tend to default to that because it's a peptide hormone that allows a man, not a woman, just a man, to produce their own testosterone. It stimulates the testicles in a way that creates more production of testosterone because what's failing in men decade to decade is stimulation of the testes. So there are particular hormones that are just not paying the brain isn't paying attention to what's going on in your body and there are fewer rises in something called LH which then leads to increasing testosterone directly for the testes.

you are making your own testosterone and particularly someone in your area of life is very likely to need that and there are ways to tell by measuring those other hormone their pituitary hormones LH and FSH if you can raise LH which is what hCG is in effect it acts like LH it's a it's a natural peptide it's actually used in women to ovulate women because at that point in the cycle we use LH if you're undergoing IVF or you need to be you you've been stimulated that will release the eggs from the ovaries.

And so is hCG in some way a more optimal way of way of way of to me it is testosterone. Yes. To me it is because there is data that has shown when men are when their testosterone is optimal and their testes are functioning well. They live longer. Women who get pregnant later in life, same thing. So if you have the ability to procreate as you as you age into your 40s or 50s and in men it could be 60s7s 80s 90s um then you it is connected to biological aging slower slower biological aging.

So active hormones with active testes which is another reason to keep the testes performing as long as they can. at some point because men are different than women but at some point testes may not be as responsive. It's not because of treatment. It's not because of uh hCG. It's because naturally as we age cells do not as well. They do more poorly. LH and FSH from the brain aren't secreted as as regular a fashion as they need to be or go as high as they need to be.

It's a pulsatile system pulsatile system pulsatile system which requires when something goes down the brain should recognize it and push it up. That starts to fail in men in their 30s and certainly every decade beyond that. But it might fail in one man in his 40s and another man in his 80s. 80s. 80s. How does someone take hCG? What sort of form does it come in? It is a tiny shot. It's a small needle. So if somebody needs reading glasses, you can't see the needle. Um [snorts] so it doesn't really hurt.

You take it twice a week. Twice a week. If you take it once a week, it's insufficient and you're flattening the curve. If you take it every day, you're not pulsatile. you're not enough pulsing. And I've seen all variations on this because sometimes a man will say, "Well, I think I feel well. I'm going to cut back without checking with us and he cuts back and his testosterone falls." So if a man is becoming resistant to hcg, we increase it to three times a week. And in some people, we use testosterone because at some point we're not going to respond.

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Just scan the QR code on screen or visit hellolingo.com/livemore for more information. terms and conditions do apply. From your experience, experience, experience, and we'll cut to females and testosterone in just a moment, but from your experience with your male patients over multiple decades, if you have a man who is, you know, by all accounts optimizing their lifestyle, you know, their nutrition is pretty good, their sleep's pretty good, their exercise is pretty good, they're able to manage stress pretty well. pretty well. pretty well. and then despite that they have what you would call suboptimal free testosterone.

When you then get their testosterone, their free testosterone levels into the optimal range, what are the range of things that you have seen improve? I know you've already covered a couple of them, but I think if we could just have that list, I think it would be very useful to hear what sorts of things a man could experience on the back of that. So that's a great question and since it predates GLP1s which did make a significant difference, I can tell you exactly that you'll see increased muscle.

So your body composition will change. You will lose visceral fat and you will lose fat in your liver. Your sugars will normalize. So you will have if you've not had optimal carbohydrate metabolism, if you're you become too high or too low, you're going to add muscle and that will help with sugar directly and indirectly. memory. I've seen memory. That was quite a surprise to me, but I was delighted. And there are studies that show both estrogen and testosterone have an effect on your brain, cognition and memory.

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

In men, it's a loss of stimulation. So, does that is that clear? Is that okay? Yeah. So, the goal would be to stimulate and to make sure you could maintain Yes. and libido and sexual function. But here's another thing, two things I'll add. One is that I thought I would hear from men that sexual function was at risk and libido in their 30s, in their 40s. And I have models of men, and this is genetic, that have early heart disease in the family, and they look at 30, they look like they're 50 from a biomarker point of view.

They have fathers, mothers, relatives who have died young, getting heart attacks beginning in their 30s and 40s and dying in their 60s. And stroke too is another outcome. So um so libido and sexual function was second to energy. Energy and the ability to function and feel good is one of the losses you have. And what most men come back and say after a few months is, I feel like myself again. I can act and be all who I am. This is it's so interesting hearing that because many women who have struggled with hormonal fluctuations and permenopause, one of the things people will say or those women will say when they do start having hormones if it's appropriate for them them them is I feel like myself again.

Yeah. Yeah. Yeah. Are there any risks that we should be aware of here? Because I guess again I'm always trying to think of the counter points. Some people may go, "Yeah, but but Florence, in nature or mother nature has designed this so that yes, after a period of time, the testes do stop responding and they do stop making testosterone, right? So should we as doctors be um playing with what mother nature has designed?" Well, father time takes over and actually declines what mother nature has done so well.

And we can talk about that with reference to women because there's an interesting way to think about it. And so it's really up to the individual and doctors should be comfortable keeping people healthy for life as opposed to watching them decline. And I think testosterone plays a major role that way. As far as side effects, if we're not managing people effectively, testosterone at two high doses, and again, there's variation in how much is absorbed, how much is stimulated, it's affected by the food you eat, the alcohol you drink because it's metabolized also in the liver.

And so, um, you want and it's metabolized at different rates. So, it can vary. It's not going to stay in one number the whole time. It's going to go up and down within a range that is in the sweet spot. spot. spot. um you can have a issue where you create um arythroytosis or increased polyythemeia polyythemeia polyythemeia specifically red cells but I'm going to use polyythemeia which means that your blood becomes a little uh uh increased blood amounts which can cause sluggishness and blockage and deep vein thrombosis.

So you have to see where people come from, what they're doing with it, the doses they maintain based on the outcomes. And for example, if you've grown up in the mountains, I had a case of a of a man who we treated. He was about 40 and he came in one day and it was clear that his hematocrit and hemoglobin, red blood cells and the amount and how we look at it were higher than they should be. And I have a very strict limit actually less than the endocrine society which says your hemoglobin should be 20.

I actually don't like it if it comes close to 18. I see where a person starts and we we take some we do what we call a therapeutic phabbotomy unless a man could donate blood. So that is the one side effect I've seen happen. That is a side effect of of of uh reaction because um men who grow up in mountainous areas are going to do the best they can with generating red blood cells. is why Lance Armstrong and others train in tents that have less oxygen because when you go to higher altitudes you want you know more red blood cells to release more oxygen right so polyythemeia or arythroythemia which is more specific is caused by too high testosterone for that human being yeah yeah yeah let's talk about women and testosterone why should we be thinking about that as a woman as well we women have brains muscles hearts, bones, um, and libido and sexual function in a slightly different way is manifested than in men.

And we start losing testosterone the same way in the in the 30s. Testosterone's produced in the adrenal glands and the ovaries. Some natural tests of it are young women in their 20s who actually start gaining weight on birth control pills. So, they're given birth control pills, which has estrogen and progesterone, but no testosterone. It's not even approved for use in the states. And they start gaining weight. They blame the birth control pill. But what's really happening is that they're reducing testosterone even at a younger age.

And they gain weight. They gain uh trunkal weight. Their bones are not as supportive. There's data that shows on birth control pills that you are more likely to become osteopenic if you're on it for 10, 20, 30 years. Even though they're also protective of cancers of the reproductive system because you're lowering hormones. So women really need this as an essential hormone. It's part of the reason we women put on weight around our trunk in our 30s quicker than men do because you have more testosterone as a male.

So testosterone also is vital. I set up a protocol when I was at Yale when I started women's health in the early 90s where I had a protocol for women who had breast cancer and were had undergone mastctomies tried to block all the estrogen in their body. They were miserable and really didn't want to live. They lost their jobs. They didn't feel well. They didn't think they looked well. They they didn't have any sexual function. So, I set up a protocol to use testosterone and block the conversion to estrogen, which turns out to be not that big a deal in women.

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

They kind of work against the risk of cancer. cancer. cancer. So there's data in the book that people can read and find. And so women, we women need it. Now, we women hit a wall when we go through menopause because we're used up all the eggs. Unlike men, we are very complex. Each one of us, I think all men would agree. And each one of us when I'm stopped at a meeting, at a convention, and somebody in the field is trying to learn what this is all about, and they'll say, "Can you just give me something about women?" And I'll say, "Yes." Unlike men, each woman is different.

You cannot judge each woman by the next woman. Some women go into menopause overnight in their late 30s. Other women, I've had sisters where one has gotten pregnant in their 50s and the other one's in menopause in her 30s. And so there's a variety of the way we express genes. It is not like set in stone from our DNA, but because of epigenetics, the way we live life, the choices we make and our genes, we may express them in different ways. So in women, they need to take estrogen, progesterone, and testosterone.

And in fact, in the pmenopause, more women than not have irregular menes. You have to be careful with that because sometimes it's only estrogen that they're seeing. They're not seeing progesterone. You want to protect the endometrium to avoid endometrial cancer. And I've had sad stories of women who aren't seen because the doctor says, "Well, it's it's perfectly fine having irregular cycles. You're not ovulating. Don't worry about it." But in fact, with unopposed estrogen for more than three months, there's data that shows that you can get more likely to get endometrial cancer, which is curable if you find it early enough, but then you need a hyerectomy.

So testosterone for women does exactly what we want it to do for men. We increase endurance, V2 uh increases, your heart performs better, you lose visceral fat, you lose trunkal fat. So all of that leads to chronic diseases of aging. And so why wouldn't women be on testosterone? And yet even in the states, it's not approved formally. A doctor can use it if they have a reason, a category, and they justify it. And as an endocrinologist and a reproductive endocrinologist, I've been lucky enough to be exposed to all of that.

So I think slightly differently than most physicians. What's actually taught is sad because sad because sad because the group of people who really know about women, gynecologists, some of them even go on and train as infertility, fertility experts, but they don't really train in menopause and change of hormones. That's just beginning in the last maybe decade. And so I'm thrilled to see that. I'd like to see the same happen for men because I think men are underserved in terms of all their hormones. It's not just testosterone for men either.

I mean in the last 10 years there has been a woman's health revolution. Uh more awareness. Yes, with that awareness comes controversy. You know, different people disagreeing, but there's no doubt that female hormonal health is much more on the radar today than it was 10 years ago, which I think is is definitely a good thing. And it's kind of interesting to hear you with all your knowledge and expertise and experience saying that it's time for men to have one as well. Yes, that's going to happen.

I'm predicting it. That do men have hormones or not? or not? or not? Well, I guess it's because maybe for men it's less obvious in the sense that yes, with women there's a set point where the you know you stop ovulating, right? It's more like a cliff. There can be a leadup to the cliff. Well, go on. How would you put it? Yeah, I think it's having menstrual cycles. I think we women are programmed to see a physician. In the States, it's every year. Here it's every four years, which I'm kind of shocked about.

And maybe that came about because of the HPV vaccine. vaccine. vaccine. Um, but we women are trained to have pelvic exams and papsmears and be vis and visit at least your gynecologist once a year. And if you're having babies, it's even more often, right? Men finish college or school where there might be requirements to see and get certain treatments and then they stop seeing physicians. So men don't have that awareness of what is going on and why. And they're also not as open. They're not going to chat with their male friends necessarily and say, "Hey, I notice my energy is is dragging.

Uh, you know, I my libido isn't what it used to be. I just don't feel like myself. My memory is slightly on the fringe." And so I think sharing of information and that knowledge, those relationships really help women. Well, well, it sort of goes back to what you're saying before. We we we know that, you know, it's it's a bit of a cliche, I guess, within medicine, but it it's certainly been true in my experience that a lot of men just don't want to go and see the doctor.

Absolutely. Absolutely. Absolutely. And it is it has not been uncommon over the years to have uh men coming in with a heart attack. Well, yeah, but also the first thing they'll often say is, "Hey doc, sorry to waste your time. My wife made me make the appointment. Exactly. Right. That is it's it is a cliche, but it happens to be true as well. But I think if we rewind a little bit to the start of this conversation, conversation, conversation, this idea that we're trained that certainly in this country and I I think very much so in America, although I think it's a bit different as you say then with the gyne checks, right?

Yeah. Because we're a publicly funded system. What I've learned as I become, you know, more experienced in my career is that sometimes decisions are made to do with finances. finances. finances. Absolutely. Absolutely. Absolutely. It's like, well, how many can we actually afford to see, right? It's not always done with what is the best for individual health. That's not always top. And I think people may be surprised to hear that. And and look, a publicly funded system does have to make certain choices, right? It cannot. Let's be clear.

Even in the states where it's not publicly funded, there's population studies. It's applied to the individual. We don't think about the human being and proactively keeping them healthy. You started the whole podcast talking about it's not a health system. It's a diseasecentric model of healthcare. You get sick whether acutely or chronically. That's when you see a doctor. Yeah. And what I'm I guess what I'm what I'm trying to sort of bring in here is this idea that if we understood that modern medicine is primarily a disease management system then we go okay great let it do that okay but we need to also make sure that we are um part of a health creation system right a proactive aging system aging system aging system I love that that term health creation because I think we want to create health in people who as we age are bound to decline based on our genetic makeup which drives a lot more than we actually thought.

We actually put way too much emphasis on lifestyle and habits and we've kind of ignored for lack of knowledge what is going on in our genes and what our genes which is translated by family history because family history is expression of genes. If you have dementia in your family, if you have osteoporosis like I knew I had, if you have heart attack and stroke, um, you are at risk if your genes express themselves. So, what can we do as both an individual and a society to change that paradigm to have people own their future health by understanding they are at risk?

at risk? at risk? Let's get to genetics. Let me just close off what I think is an important point which is if we got in the habit of checking these biomarkers early regularly reviewing them seeing trends and patterns then those men who at the moment are perhaps not going in too embarrassed to go in don't think they should be in this country we have a thing about wasting the doctor's time right right right well if you owned your own health data and you could See? Hey, wait a minute.

Why was it that 2 years ago my HBA1C was 5.1 was 5.1 was 5.1 and now it's 5.6? Well, if you can see that and you have a nice graph or something showing you suddenly, I think that will land in people's head a bit differently that oh, I might need to do something or you know your your fifth bioarker is the free testosterone. If you suddenly if you saw that year on year starting to plummet and drop, you might be triggered earlier to say actually I need to see someone.

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

And when I looked, I did I made it a point unlike the center where people come in and it was part like more of the old-fashioned family medicine meets futuristic medicine because I see the patients. Um, and I made it a point of not getting a story, but rather just asking a series of limited questions, which was limited from the usual questionnaire, but what I thought was critical. His biioarkers were terrible. His testosterone was 52, not even 90 as you mentioned, and he was only 30.

He had recently married and his libido was decreased, not because he married, but because he saw that it was decreasing from his 20s. He was putting on a little weight, even though he was really active, but he was putting weight around the middle. And he didn't feel great. When I looked at the history, his family history, his father had had multiple heart attacks and strokes beginning in the 40s. I didn't ask if his father was alive or not. I didn't know. He didn't put anything in about his mother, which was kind of interesting because he actually lived with his mother.

He had a sister from another mother who was only five months difference in age. And he had a certain makeup where his father was Ashkanazi Jewish. His mother was Puerto Rican. And I looked at the pattern. I went to see him. I asked to see him and I said, "How's your father doing?" Well, his father died of a massive heart attack at 60. This man in his biomarkers was showing changes that you typically see in a man 10 or 20 years older. His numbers and his combin his hemoglobin A1C was perfect.

It was 4.9. But his fasting sugar ranged from like 75 to 95. And his testosterone was 52. His cholesterol risk ratio was 5.8 as opposed to being ideal at 102. And so you put that all together and you saw a man who was actually aging exactly as his father was, which is a syndrome we learned about, I learned about in medical school. When you have early heart disease in a family, it's hereditary. We just didn't understand the factors around it. And so we completely reversed that.

This this gentleman is like in amazing shape. We increased his testosterone with hCG. he was able to come off of it because by triggering in a younger man, and I have a set of those um for other reasons, for lots of other reasons, we can actually get function back and they can take off on their own. You can actually once you hit the 40s, it's much harder. I've had a handful of men in their 40s where I could stop using um hCG. Yeah. So, if that makes sense to you, I totally agree that getting biomarkers in front of you, it's hard to ignore.

When I started Women's Health, I would show women their bone density and I would say, "Do you see that your bones are very thin and that if they continue in this direction, you're going to have osteoporosis? You're going to fracture a hip. You're going to shrink." It's the trends that, you know, as humans, we only we only know hot because of cold, right? We we only know black because of white. We see changes. We observe and experience changes in things. Right? That's how we operate. Um, why would your health biomarkers be any different?

You know, a one-off reading, yes, has value, but it's so much more powerful to see how this is changing over time. over time. over time. You can't assume anything because numbers can vary naturally. So, and but it lands with you when you see that something in you has chang. It's like you can't unsee what you've just seen in a CGM. When I eat that meal, this is what happens to my blood sugar. you you may still choose to do it, but you can't unknow what you can't unknown.

But I will tell you that there are groups of men and women who are basically in denial. They they may see it, but it's like, well, I'm don't believe that's real and I'm going to age gracefully as father time dictates, which means getting weaker and getting chronic disease because I really don't want to intervene. Which is fine. You know, people are entitled to live the life they want to live. Exactly. But what what I what I really do like about your approach or one of the things there's many things I like about it is it's very empowering and hopeful for people.

You're you're sort of presenting this vision. I mean you say in the subtitle, right? Well, the book's called Invincible. The subtitle is defy your genetic destiny to live better longer. Okay. Who doesn't want to live better for longer generally speaking? Or they they're happy to live longer if they can live better whilst they're doing it, right? So I think it is a hopeful message and of course I'm sure some people may have a different view on hormones perhaps and hopefully we've tried to tackle you know your perspective on this and and why you think this is an important part of aging but but I want to go back to genetics.

Well I want to come to genetics. I also want to just discuss what you said about virtual and I've heard you in a previous conversation I heard you talk about this idea that health can be seen off in a similar way to banking which I thought was quite interesting and to to to sort of set this up I think there's no question that the ideal scenario for most people would be to have a clinician like yourself who they could see get their biomarkers done and then sit down for an hour with to discuss them all in detail.

Okay, sure. That would be best. And given the rates of chronic disease that we're seeing in your country and in my country and most countries around the world, the world basically, basically, basically, we simply do not have enough doctors and resources resources resources to to do that, right? Totally agree. Totally agree. Totally agree. And so I also do like this simplistic. I mean, you're trying to do it with your app in America. I'm trying to do it with my Do health app here in the UK is really try and get it out to the masses.

Say the you don't need to test everything, but these, you know, I really focus on metabolic health with do health. Okay. Um I go if we can help you take ownership of your metabolic health early in your 20s, your 30s, your 40s, your 50s, two things are going to happen. Number one, you're going to feel better in the short term, right? because that's it's not just about reducing risk of disease in the future. You're going to have more energy, focus, vitality, and you're also going to reduce your risk of pretty much every chronic disease you've got.

Right? So I want to acknowledge that in person with a really well-qualified and well- knowledgeable physician with time may be the best but as you've discovered and you talk about which is what I've learned here as well is that virtual like this appbased approach to it can also help. So talk a little bit about that and also this comparison of health to banking which I found very interesting. So I'll start at the beginning briefly. I had three epiphies. I was able to look at numbers and connect people through through their system, their entire system, a system-based approach to health.

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

It started in uterero just like Siamese twins who stay attached. They're not completely identical. Just like in your own body, your right side of your face does not look like your left side of your face. There's a mismatch because genes can express differently. It's very vividly seen when someone has a blue eye and a green eye. Why? They inherited the same genes. It goes to their eyes. Why does one expresses green and one blue? So, epigenetics has the power. That's why defy your genetics to change the direction and the choices.

That's why I strongly believe in the lifestyle changes, the little baby steps or as I think of it, atomic habits for longevity where you compound changes, small changes over time. Ultimately, I think the way we want to go is to be able to offer these kinds of insights, not just by influencers who do it for themselves and don't really take care of human beings and don't see the outcomes. do it in a way that's legitimately medical that as you mentioned credentialed. My Yale background, my NIH, my sc being a scientist as well as a physician allowed me to devise and see things that I was confident though nervous about because no one else believed me.

I'd wake up with a cold sweat when I started women's health and I was too young to be in menopause thinking this is so obvious. Why isn't everybody doing it? And so my belief and why I compare it to banking is how many of us have to go into a bank nowadays, at least in the US, you can do everything through your app. You get information. So I banks anymore. They're all closing down anyway. anyway. anyway. Exactly. Exactly. It's like phone booths. You know, you have nice phone booths in London, but no one's really using them.

They're all on their cell phone. phone. phone. They're taking photos for Instagram on them. them. them. Let's bring medicine to a point. Let's bring health creation where we can give true basic knowledge, credentialed knowledge, scientifically based, not necessarily in a millions of people where you then get uh regression to the mean and you get averages and a one-sizefits-all, but specific to that human being virtually. And that was always my dream. The book was part of it. The app is part of it because we I can't I even if I want to, I can't see millions of people, right?

And it's not realistic from a resource point of view. This is expensive. But if you can own a part of it, if you can share it in partnership and you can get guidance and AI will make a huge difference in that based on proprietary database. That's what I have. I have a proprietary database that I've developed over the years because of my What does that mean proprietary database? database? database? It means the work I've done. I've collected every bit of data. It was done as a protocol prospectively billions of data points in individual people.

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

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

But do you want to live in a healthy body in a body that can enjoy life to the best of your ability? Or do you want to be on a porch in a rocking chair or with a stroke where you can't really or your neurons are not popping the way they should and so your brain isn't working as clearly, you can't read a book that you used to love to do or you can't ride a bike. I'm not saying that all of us should run marathons at 100 or 120.

I'm not saying that all of us have that capacity. But the longer we can invest in oursel, the better off we'll be as the future unfolds. And I think that's what I'm hoping for for everyone. It's a very empowering message as the entire book is. Uh the new book is called Invincible: Defy Your Genetic Destiny to Live Better, Longer. Florence, it's been a joy talking to you. It's been a joy reading your book. Thank you so much for coming on the show. If you enjoyed that conversation, then I think you are really going to enjoy this one that I picked out especially.

especially. especially. We need to realize whatever we put into our body is either going to take our health down or build our health back up. And it all works at the level of the defense systems.