#520: Healthspan Medicine, A Practical Approach

It's a lot of fun, so check us out at patreon.com slash curbsiders, or you can click the link in the episode description to sign up. So Paul, we were eating dinner tonight and my daughter said to me, Your glass is empty, would you like another one? Exactly, Paul. What am I gonna do with two empty glasses? It was a dumb it was a dumb question. I sent her to her room.

Pretty much we aren't responsible if you screw up.

What do we do on the Curbsiders? Why are we here? And uh then you can introduce our co-host.

In his current role as founder and CEO of Velocity Health, Dr. Palicadetti focuses on advancing personalized preventative care models that help high-achieving interven individuals sustain long-term health and performance. Tonight on the show he teaches us all about how to manage health span in primary care, including diet, exercise, sleep, and other core metrics.

I would also like to shout out his new book, The Ultimate Asset. He also runs a podcast that goes by the same name. You can check out both of those to hear him talk more in depth on some of the topics that we mentioned today. So without further ado, let's get to it.

which has scared him into a high saturated fat carnivore diet because it keeps his glucose line flat. So to set s to set the stage, Tony is seeing these post meal spikes to one eighty on his C Gm. So in a non diabetic patient, what actually counts as an actionable signal versus just normal physiologic variation and how do you use that to guide an early insulin resistance plan?

Fear perhaps or or misunderstanding of how to interpret these numbers. I think the challenge in primary care is always comes back to time. It's how much time do you really have to explain these concepts? to patience and get into the depth of it. When you do have that time, you know, I think it's important to show people that

before you get this CGM, you're educating them on what are the things that you're likely to see. First of all, why are we getting it? Is it just out of curiosity? Is it because we really are worried about you know, uh, some sort of consumption that is is causing these real postprandial sustained spikes where our lifestyle change might impact that. Um, you know, there's all sorts of reasons people might do family history of it, just curiosity.

Uh but regardless, people are gonna come in, they have the information and the data. I think the first question is how long are you spiking that high to one hundred eighty? You know, postprandially, especially with Simple carbohydrates like fruits. it is normal to spike. You should spike. You should be at one sixty or one eighty. That's not uncommon. One forty or so is really what the American Association of Clinical Endocrinology suggests post preendually. In two to three hours

the sustained hyperglycemia is really where you start to worry that, okay, this is maybe an impaired glucose metabolism, right? Not just a real spike. I think the other thing I often see patients come to me with is a a big log of CGM where it's not even food related, right? They said, I exercised and I spiked or I was really stressed and I spiked and I had a terrible night of sleep and I spiked and Great. Okay, these are really important

teaching points for us to help understand normal physiology. Why would your blood sugar spike when you're exercising? Isn't that what we're supposed to do? Wouldn't your muscles and skeletal tissue need more fuel to to power what your your activity? Of course, right? And I think when the interesting conversations come to me are when people start to see connect the dots of things like poor sleep or stress leading to chronic cortisolemia, leading to chronic hyperglycemia, and seeing that, oh

not only is it my food, it's all these other things in my lifestyle that may lead to impaired metabolism. So All of that to say, you need to talk to Tony about what is normal and what is acceptable in these kinds of things. So the direct answer is no, a spike to one eighty is not something to worry about as long as you're sort of coming back down. 180 is a little bit high. I do think that

It is perhaps a canary in the coal mine and invites a deeper conversation on what else might be happening here. And so I'm happy to go into what that might sound like as well.

You know, we're we're coming at this from a framework as a patient shows up, they already have the CGM and now they're asking us to sort of interpret the data they provided for us. I would like to hear And I and not and Deep and and even actually from you wanted to are there certain patients for whom you actually suggest they get A C G M who do not have

A diagnosis of diabetes, like I guess, is that for everyone who comes to your practice when you're using this information to kind of gauge someone's metabolic health, like who gets one, who doesn't? Is it all comers? What is your initial approach rather than Me in primary care just reacting to someone showing up with a CGM log and trying to figure things out.

is important. And I think people need to understand what does actually drive different um, you know, spikes or or physiology in their body. And so we Suggest it for people who have a strong family history of diabetes and who are are displaying other sort of metabolic syndrome um, you know, uh features. We suggested for people who are actually diabetic and, you know, obviously anyone who's on insulin.

Um, we we believe that it's important. But, you know, ultimately it's an experiment for most people, in our practice at least, that folks are using it for sixty to ninety days, understanding as much as they can about their body, about their diets, about what's driving some of these spikes in numbers. and having detailed conversations with us and their team about how to impact their lifestyle from that. I realize that's not the luxury that many primary care docs have, but

You know, we get ninety minutes with our patients and we have dietitians on staff and and all these different things. But that's how we see it specifically.

their fasting blood sugar is a little high and you wan or or maybe their fasting blood sugar is normal and their A1C is higher than you'd expect from the way they tell you they think they're eating. uh it can be helpful just to see what's going on the rest of the day with their blood sugar. So that's a that's a time where I might prescribe it to somebody that doesn't necessarily have diabetes, but they

They either have impaired fasting glucose or an A one C that just doesn't quite fit the story. I think that can be helpful. And then you do have just like the the the interested hobbyist that's like very healthy and they just wanna see what their blood sugar does. Like there's that guy that's like uh famous on TikTok or whatever that just eats things and Like that's a pretty

So I I think that's that's a viable reason. But if you think about it, like we get the A one C that's a ninety day average, right, uh roughly of the glucose, and we can get a spot check, which is like a fasting glucose, and if maybe you get a fasting insulin with it. But we don't know what's really happening throughout the day. I think Colburn made that point, right? Like your if your A one C is like six percent, we don't know if it's like

your sugar's really high some of the day and really low the rest of the day. So so that's kind of why why I think they're there. And then the last thing I just wanted to say, Deep, you mentioned like people n notice they exercise and it spikes up in my experience'cause I've worn'em for, you know, a month or two in in the course of the past few years. And if you do a high intensity workout

it tends to spike'cause like your body thinks you're dying or you're like running away from like, you know, a tiger or something. And then if you do like a low or moderate intensity workout or just go for like a long walk, like brisk walk, your sugar tends to plummet. Because you know, you you just

you're you're kind of just using you're using the blood sugar at a steady rate and your body doesn't you know like your your cortisol, your adrenaline, all that stuff is not activated is the way that I think of it. So I do tell people to know to watch out for that because they're gonna be like Oh my gosh, I sh I gotta stop exercising. My sugar spiked up to like one sixty

For but it it comes right back down i if it if it's from exercise. So it's it's kinda neat and I mean for physicians, if you're gonna be prescribing for patients, I would wear one yourself for a week or two and and just see what happens.

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correlating that with what the imperfect tracker does. So, you know, people can certainly get in their heads about this stuff. I I have I have a patient who's a ex MLS player uh player, soccer player, and and his hemoglobin A1C is

Consistently five point six. And I think it's Matt like what you were saying before. Like he goes really hard on these workouts three times a day. He's doing high intensity stuff. So I think he's spiking very often and then You know, he's he's eating well and and doing well overall, but he's watching this this CGM constantly and he's texting and calling and saying, look, what's I ate this thing and now I'm spiking and that's

you start to realize that he's gotten in his head a little bit too much with this thing. Like he's completely metabolically well and and he's thin and healthy, doesn't have high blood pressure, his lipids are controlled. And and so now you're in a place where, okay your stress and your cortisol are probably causing just as much hyperglycemia as as you know, any dietary stuff would here. So you have to have the conversation and I think it's

It's right to trial people on it and have the experiment with them for a few weeks or you know, we we suggest two to three months. This is the experiment. If at any time we feel like it is it is becoming something that we're persever perseverating on. Let's just take a week off. Let's see how we feel and journal and log things, just how we feel, rather than looking at the device.

You know, I think you started to allude to Paul, something that that people do and I sometimes see and you know, maybe is happening with with our friend Tony here where he see the he sees these spikes with the with, you know, uh fruit or something like that. And so he cuts that out completely. And he's like, I'm now gonna eat carnivore only because I don't want to uh see these blood sugar spikes and I don't want to get diabetes. Okay, fair point. You don't want diabetes. There's a

high hazards ratio with diabetes and downstream incident cardiovascular disease as well. So yeah, you don't want diabetes. But are you trading that for an Apo B of what did you say, one fifteen or something, right? And and laying down atherogenic particles now because you're overdoing it on on a dietary lifestyle change in swing. I mean my general guidance and you know we may get into this later is is

Any diet that is either canonizing or demonizing one macro is probably not taking the full picture into account and is going to be hard to broadly apply to the entire population. And so Can it work for some people some that some of the time? Absolutely. And have I seen a carnivore diet pull people back from all sorts of other types of risk? Sure, but is there

a then sort of uh re analysis of sort of where are we now, right? Like, okay, Tony, maybe you've lost some good weight, you've gotten in a good spot, but you now have this other risk that we have to mitigate. Maybe it's not so much carnivore red meat kind of stuff. Maybe there's a modified Mediterranean type diet here that can still focus on the lean, healthy meats and fish and fats and start to incorporate some of these other things.

And you you start to experiment with that and start to push people with that. And as long as you've given them the guidance and said, Don't worry about the hundred and eighty spike, that's not the thing. We're gonna monitor all these other things. Here's the real risk.

It's a conversation that happens, right? And that's why it's hard to do this in a twelve or fifteen minute primary care appointment. And that's why you need these sort of long format discussions. But I'll pause there. That's how I I would sort of see it with the the trade offs there.

some experts w even want lower levels. But a level of one fifteen is kind of moderately high um by by a lot of the the big national labs. Um and of like over one thirty or so is considered very high and Um it's just another way to gauge how many atherogenic particles you have rather than just looking at L DL which can sometimes be discordant with APO B. So

Deep, are you seeing with with patients made and maybe I don't know if you've had a lot of experience with this, we've asked a a bunch of our experts about this. The patient that goes on either a keto or like a carnivore diet and they're their Ape O B or their LDL kinda just shoots way up high and kind of trying to figure out what to do there because I I think that's that's a common situation that we're seeing and I

I think maybe that's what the the case is getting at a little bit. Like we have these people that they think because th blood sugar has been so demonized, which I think is appropriate, like we we do need to make sure our blood sugar is regulated, but they're kind of sacrificing like, all right, I'm just gonna eat stuff that just keeps a flat blood sugar, even if it might have other risks, so That's kind of the issue.

Most experts would say in RCTs and Mendelianine uh you know trials would all show that time under the curve for APO B is very likely causal for cardiovascular disease. So always a little trickier than the black and white because people will say, Well, I don't want to see the the spikes and sure my APO B is elevated, but I'm pretty healthy otherwise.

you know, there's maybe one isolated archetype that I think is being studied more and more, which is you have low blood pressure, you are lean, you have no diabetes, you have no inflammation, you have no smoking history, you have You're eating a keto diet and you have an isolated LDLC, you're isolated elevated APOB.

What is the cardiovascular risk in a profile of that kind of patient? I think it's tricky. You know, there's all sorts of other imaging and things that you could backstop that with, but I would argue that in real clinical practice.

We see that almost never, right? Like how many times has someone come in and fits that profile, but then has this APOB of 130 and you're stuck with that, right? Like I see that maybe once every few years, like maybe, right? So Yeah, that exists, but for most of us you really need to focus on the big rocks that we that we know are gonna cause disease and

And I do think diabetes is a huge one. I'm not saying don't don't don't, you know, focus on that, but the CGM spikes themselves don't necessarily play in one to one to your diabetes risk.

Um and so we we're we're in and we have, you know, wearable devices and we're just like massing all this data. How do you parse through like what are the big ticket items for someone to kind of really hone in on if you're just sort of starting broad and certainly You know, we you might want to get into the nuance of those later on, but like what uh if there's like two or three things that you just have to focus on that are take real priority, what what are those for the other thing?

Apo B and lipoprotein A, I think, are very important ones. And measuring those in patients helps us quantify their risk. Lipoprotein A is a is actually family I think under APOB and it is s by some measures six times more atherogenic than LDL particles. Uh many times when we have these patients who have a quote unquote normal LDL and they still have a big heart attack, you're wondering why.

you know, you should check the LPA and sort of see it's it's thought to be a genetic marker, can't be sort of modified. There are phase three trials going on right now for meds uh about this. So I think we'll see s all sorts of interesting things. So from a Cardiometabolic standpoint, I mean understanding your your risk for whether the biggest cause of death is going to kill you or not, and on what time frame is important. And so, you know, I think the APO B and L P uh Lil A

Potentially, you know, and I think there's probably a whole other conversation here around imaging like cardio uh uh coronary artery calcium scans and uh C T angiographies. Um but putting that aside, you know, the things that most people could have access to. We also believe that testing someone's true sort of uh body composition and their cardiorespiratory status helps us

push the plan forward in really important ways. So one being a DEXA scan and most people, most of us think about that for bone mineral density, but we get these on all patients for looking at subcutaneous fat. visceral fat and uh something called appendicular lean mass index looking at at muscle max and I'll explain why.

And we also like to get something called a VO two max on patients, um, which we can go into a as well. But it's, you know, for the audience, if you've ever seen these athletes kind of running on a treadmill with a uh a mask on their face, uh They're measuring actually the milliliters per kilogram

uh per minute of oxygen used by the mitochondria to produce ATP. And there's all sorts of things that go into that calculation and why it's a good predictor of all cause mortality. But you know, when we work up patients, we we do a pretty broad and in-depth analysis. And I'd say these kinds of things, while ubiquitous and available in every community, typically for a hundred bucks or less and

You know, all these labs I just said are are lab core and quest and pretty cheap. Um and in guidelines, we tend not to focus on these kind of of data points and and just say to people, You gotta exercise more, you gotta, you know, eat better and while that's fine. Like a lot of my advice is going to circle back to that.

I do think the conversations I have when informed with this level of personal understanding of you as a patient helps make it really real all of a sudden. Instead of saying, Hey, your LDL is high, your A1C is high. It's like, hey, Your L your AP B, your L D L, your lipoprotein A, your insulin resistance score, your coronary C T angiography, your genetics, all of these things are pointing to

really high risk. Like this isn't just one thing. Let's take real action here. That tends to move the needle more than anything.

a false precision thing, right? It whether you're sixteen percent or seventeen percent body fat doesn't matter. Whether you're thirty five or eighteen matters. And what matters even more is where did you start and where are you going? six months from now, right? Did using the same machine, did your fat go down and your muscle go up? Yes or no? I think if you can answer that question, then you're probably making positive

movement in the right way. So, you know, as long as you can get something reliable, you can only manage what you measure. And I think too many of us put our head in the ground and and just hope that the numbers are going to be okay when there's real pathology happen.

you're gonna get some sense of are things moving in the right direction or not if you get enough if you get enough readings. Um and then the VO two Max, similar line of questioning. I've done VO two Max tests uh when I was in college. Uh they are very unpleasant. But uh all the wearable devices now, if you if you kinda tell it you're going on a run or if you tell it you're rowing, there are some tests like there's the Cooper test for running, there's like a 2K row test.

Um the Apple Watch will give you a estimated VO two max. So I I do go buy some of that stuff just because A true VO two max is test is so unpleasant and and again, like we're saying here, it's like the pr it's not if if if your Apple Watch is telling you your VO two max is going up, you know, I would tend to believe that uh

There are other ways to test that and push that. You mentioned the Cooper's test. I think that's probably the the the the easiest one. I think you just basically run as f far as you can in twelve minutes and plug it into this formula and it gets sex and age adjusted. There's another one where it's like you run a mile as fast as you can and you can plug that into the formula as well. Um the

Wearable and stuff are fine. The Apple Watch specifically I looked into at one point and the algorithm they used was based on a study of like twelve college age like white man at some point. And so how generalizable is it? I I've seen a lot of discordance with with Apple, but again, same thing. Like is your cardiorespiratory fitness generally trending up or down on these wearables? That's the thing you care about more than anything.

get a good sense of where people are. Stroke volume is the biggest driver of that. Um, but it's also measuring your Yeah, your capillary bed in your pulmonary vasculature. It's measuring the strength and and integrity of your endothelial health in your arterial walls. And again, it's really that mitochondrial use of oxygen per minute and

You know, it's interesting to think about VO two max because it's not something that changes quickly. You're not doing this once every few months. This is maybe a test you would do once every year, every few years. Um an interesting thing way to think about is you know, developing mitochondria mitochondrial biogenesis and tuning our cells to be as efficient as possible is a years long and decades long activity. That's why many hypothesize that you rarely see like a nineteen year old um marathon

winner or or world champion, right? They are all in their late twenties, early thirties or forties, even people who have spent years and years and decades honing and building this. cardiorrespiratory capacity. So it will take time. Um one last thing I'll uh a comment I'll make on VO2 Max. It's not just this stupid vanity metric. Like I actually use it to work backwards and I ask people, okay, you're 50 right now.

Let's talk about your eightieth birthday. What do you want to be doing when you're eighty? Well, I want to dance at my granddaughter's wedding. Okay. Well dancing, let's look at this chart. That requires a VO2 max of somewhere around twenty-five to thirty at minimum. you're gonna lose about ten percent of your VO two max per decade, even if you're staying pretty well trained.

So where are you right now? You know, if you're at a thirty or forty right now, you're not gonna make it that there in in thirty years. You will be winded walking up one flight of stairs. You'll be winded walking around a flat block of of city uh of city. Um so, you know, think backwards on what you want to be doing and it makes it a little bit more concrete for people on why you need to actually push this. And we can get into how you might train for, you know, increasing that, but

Those metrics are things that we rarely get time for in primary care, right? Rarely have the opportunity to have these kind of conversations with patients, but will moving that will by far change their outcomes on their chronic diseases much more than whether we're initiating metformin or cliposide.

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Eating a banana by itself will have a spike to one eighty, but eating a banana with almond butter with some fat and protein as well tends to blunt that response. And and so consuming even small amounts of protein and fats with carbohydrates can prevent that. Um, moving right after you eat, I think that's one of the most amazing things I see patients tell me about when they wear the C GMs is Wow, I spiked to one hundred.

And then I sat there and I sat on the couch and I felt terrible and I watched my blood sugar just slowly, you know, l like linger down to one forty and one thirty hours later. But then The next day I took a ten minute walk with my family afterwards and it went from one sixty to like a hundred right afterwards. And I felt great, you know, and those kind of reinforcing things I I think.

are helpful. So the postprandial five or ten minutes of movement can absolutely crush those glucose spikes if that's what you're sort of really worried about. I think overall for for Tony outside of nutrition, you know, in the next ninety days, the biggest things are really

probably getting his visceral fat down. You know, we talked about like focus on the cardiovascular risk here. Um he has an elevated BMI, has an elevated APOB. I would suspect there's probably an elevated inflammatory component of visceral fat, high subcutaneous fat. Get his insulin sensitivity.

you know, to a good place by uh instituting resistance training. Muscle acts as a glucose sink as well. And so to combat any of those spikes and to to, you know, ensure that he's has the strength he needs long into life, then we would we would put that into place. And really focusing on that VO two Max, like we said. Um, there's a couple of ways to really drive that by focusing on zone two and doing some high intensity work as well. So we can get into that later perhaps. But

Um, that's, you know, probably the biggest focus for him i over the next ninety days are those lifestyle things. One other thing I'd maybe throw in there that most people don't focus on is is sleep. I mean, i i it all starts with sleep for me and especially with busy professionals and and parents and people juggling a lot, uh that can wreak havoc on our metabolic health. So I spend a fair amount of time talking about sleep first before we get into anything else.

How do you introduce a framework to someone like Anita to address her kind of drifting in kind of in the oncoming traffic of uh poor metabolic health? How how can we sort of frame her overall health picture before we kind of dive into her sleep metrics specifically?

deal with long term preventive care in a way that allows us to unpack all of these things before disease really sets in. But you mentioned all these data points on her, which to me would suggest like you said, she is drifting into oncoming traffic, right? Like ten more years of this and you have Frank diabetes, you have Frank cardiovascular disease, you have, you know, sleep issues that have wrecked your metabolism and in and and inflammation. So

you know, she's here, she's asking the question. She doesn't feel great, obviously. I think starting with sleep is an important place to to recenter people on on, you know, the entire day. I mean they they they when I see executives, when I see busy, stressed people like her sacrificing sleep for kind of everything else and then seeing them burnt out on all these other things.

it's it's the other way around, right? They need to be focused on sleep so that they can give themselves the energy, the the wherewithal, the um, you know, even physiologic capacity to to move through the days and And unfortunately I think I our our modern life just doesn't allow for that. So these conversations with with people like Anita are all about You are at your absolute prime right now. You are being asked to

to do incredible things, to be a parent, to be a leader, to take care of yourself. And while we also you know, we're all in this phase of Of maximum contribution to society, the phase she's in in her 40s and 50s, these are the same kind of patients I see every day that are kind of facing down the barrel of gun where final you know the the uh chronic disease is starting to finally catch up. And so having these long format discussions with people that it's not

in my opinion, okay to just follow lagging indicators and throw medication at you once you have a disease. It's our responsibility to promote wellness and salutogenesis and part of that means understanding these these leading indicators ahead of time and taking real action before we have a diagnosis. So with all that context, you start having a conversation with Anita. So happy to get into that.

wellness influencer type world as well. And and it's a weird spot for clinicians to be in because there's a lot of wisdom in focusing on wellness and prevention and lifestyle. Like obviously we should be talking about that. But the That paired with the quick hit and the desire for, you know, the easy fix in our society, I think has made it a little bit challenging to just focus on the big rocks that matter.

having functional strength to actually hold the railing or catch yourself or the balance for that is is important. And so grip strength is important in that way. But I do think that we've kind of blown up grip strength to be a proxy of what we actually care about, which is overall muscle mass in one's body. You know, and I I give an example of of a patient I had who i who was exceptionally high grip strength. extremely low appendicular lean mass index, which is a measure of overall

Muscle mass, like fifth percentile. How could that be? Well, he was a uh a mechanic, and like the specific action he did was like. doing this for thirty years where he's using a screwdriver and like has incredible forearm and grip strength but His BMI was like forty and he didn't have muscle anywhere else. So is that person strong in the ways that we want them to be? Not necessarily, right? So you have to separate those two things. I think it's hard to Study strength.

and have a my mom go in and do a squats or deadlifts in the gym, right? And so figuring out what the right exercise is is challenging. I do think that there are these good objective measures. I mention mentioned the ALMI, some people use the free fat mass index and it's What a a normalized measure of how much muscle mass do you have on your skeletal frame? That's w that's what we use is the ALMI. And we like to see our patients at the seventy fifth percentile or higher for their

age and sex matched um uh cohort. And again, it's for functional independence, right? We work backwards. Do you wanna be able to stand up by yourself from a chair, from seated position in thirty years? Do you wanna be able to put a 30 pound suitcase in the overhead in the plane as you're as you're traveling in 30 years? If so, what muscle mass would you require in order to do that activity? Now let's work backwards thirty years. Where are you right now?

Are you there? Are you are you way under and we need to muscle you up? Are you way over and you've given yourself reserves? So you start with the baseline, right? And so we want our patients. on strength that as one of the vectors to have a seventy fifth percentile A L M I or more. And again, that is for functional strength more than anything. We have all sorts of patients who are

athletes or Ironman competitors or whatever and they wanna do all this stuff and we'll we'll help them get there. But for most of us, we just wanna do the things I kinda mentioned, right? Like be functional for for our our later years. So So how do you start to build that then if if someone has finite time? Um, you know, you mentioned the the VO two max and the the muscle uh mass or kind of the

two vectors of of exercise that we're they're we're sort of watching. And so how do you build those things? I mean the DEXA we mentioned has the subcutaneous fat and visceral fat, I'd say that's all part of the body composition stuff. For most people, in order to move the needle on VO2 max, again, you need to put time in on that cardiorespiratory side. The The best data that I've seen at least is is at least a hundred and fifty minutes of zone two cardiorespiratory work per week.

Uh meaning 60 to 70 percent of max heart rate. And a lot of people give sort of the singing test. You can talk but not sing at that voice. You're kind of out of breath, and kind of have a conversation with someone, but you're not like Sprinting. You're not you're not gas. You can maintain that. To my knowledge, there is no data to suggest that it needs to be broken up by every single day.

You know, in fact, um last year I believe in Annals of Internal Medicine there was a good uh weekend warrior kind of um you know, so like you can bunch your your time and probably still get a lot of the benefits of this. But Hundred and fifty minutes, how are you gonna do that? Is that gonna be a two hour long bike ride and, you know, thirty minute walk sometime else? Is it gonna be thirty minutes of rucking every day? You know, you can kind of

figure out how you need to build that into your life. But Some of these things have to be non negotiables for patients, right? And and we have to be able to give them and paint them the picture for why and how to build that in and the capacity and resources for that. So That's from the cardiorespiratory standpoint, from a um a muscle standpoint, um it We have to start with balance and posture first. And you know, I write about that in the book too, in that that's really step one is we can't have

you injuring yourself, especially as patients get into middle life and older, that's gonna take them out for many more weeks and months potentially than anything else. And so Um, you know, really walk working on balance, proprioception, stability first before you start working with things like weights. And it does not need to be um like going to the gym and pushing iron and pushing dumbbells. It's really resistance training, uh anything that puts tension against your muscles and you move towards

progressive failure, meaning you do more and more in order to build that muscle group. So it can be body weight activities, pushups and squats and sit ups and dips and whatever. It can be resistance bands. Uh i there's a lot of ways you can build muscle without going to the gym, but it is a core component of everyone's fitness regimen in our practice.

You can you could use like the analogy I've heard of of like saving for retirement. Like, you know, if you're living paycheck to paycheck right now, if if something happens to your body Like you're in a hospital bed for a week, you have no reserves there. So you're just trying to build up reserves for the future or if anything bad happens, both with your cardiopulmonary fitness and your physical fitness.

Now that I know what it feels like to get like seven hours of sleep when I don't get it, I realize how awful I've been feeling most of the time. So um but anyway, uh this is this is not about me. Um I I could do therapy elsewhere.

But I did want to ask about like this this heart rate variability and sort of the role of wearables in in sort of optimizing sleep. I'd love to hear your approach about that because this is completely alien to me. I don't even think I would know what to ask about this. So what what do you do with that number? How do you help patients? use their wearable devices to kind of help optimize their sleep, if at all.

are chronically fatigued and and they tell me they sleep seven and eight hours. They don't remember waking up at night but you start looking through some of their wearable stuff and you see that they're getting twenty minutes of deep sleep per night, you know, and they're in this kind of chronic cortisol state and low level just alpha waves all night long and and and barely barely even really asleep, just resting in a lot of ways. And so there's data there, but

I have also found, I think I mentioned, you know, the orthosomnia, like people definitely get a little bit over the top with the the wearables. I think some of the the the numbers are interesting

sort of canaries there. Heart rate variability. I know Aura Ring does this symptom tracker thing where they basically predict three or four days before you're gonna get sick and In my experience with my patients, it's actually quite accurate to see someone's from baseline to see their heart rate variability go down and their resting heart rate go up.

tells you there's some sort of sympathetic overdrive going on. And, you know, for for those that don't know even the the heart rate variability, it's an interesting thing. The way I've sort of heard it described is if you're in chronic sympathetic state. your your pacemakers are like metronomes and you're just constantly on this beat whether it's

eighty or a hundred or whatever if you're if you're needing to be at a hundred and twenty heart rate, then you're you're at a hundred and twenty and there's not much variability there. When you have activation of your parasympathetic nervous system as well. And there's a healthy balance between your inhibitory and excitatory nervous systems.

then there is a lot more variability there. You might be at sixty five beats per minute and then forty beats per minute and then eighty five beats per minute and that tells you that there is a healthy balance of of nervous system there. So uh or so I'm told. And so the HRV is sort of the only metric we have to understand that. And It is there is a genetic component to it as well. So one of our clinicians are in practice, um she's very keen on this and I don't know that we can measure it but

Some people just live higher and lower and so it is again a directional thing more than anything. And I think that's what those symptom trackers are are really looking at is a deviation from the baseline more than anything.

your average from month to month, th that can kinda tell you if it's tracking in a way that's that's different. But you have to wear it for a while, just one reading. And then like you said, there's that Some people it you can't really compare like my HR V to yours deep because we have our own sort of genetic set point maybe and we're gonna fluctuate around that. So

Um make sure you're not just like comparing it to your your friends at the gym and then you think yours is terrible. For you, you might be at your personal best. You don't know. Um, even if it's different if lower than your friends, so Uh yeah, HR V is one of those ones where I I never even heard about it until the past couple of years and I never really even looked into it until the past year or so and I find that

Um, I still think that like how you feel when you wake up in the morning, if you decide like, hey, I feel good, I'm ready to exercise. I don't really care what your HRV is. If it if it says it's bad, but you feel good, then we're gonna go with how you feel more so than what your your HRV is.

you know, you see the Brian Johnsons and people out there in the world, that's fine. I I appreciate what he's doing to help push human biology forward, but I think there's a different type of neuroses there that sets in that starts to become counterproductive to the conversations and the lifestyle discussions you're actually trying to have with people.

Uh we we focus on the core four, you know, she's she's sleeping a little better, her fitness and nutrition have improved. She's kind of following the prescription that you gave her, doing some resistance training and some kind of zone two and hit training. And then uh S that stuff's looking better, but she still just feels like she could feel better. Maybe she's got a little bit of brain fog once in a while and she just feels her energy could be better. She wants to know about peptides.

She feels a little sore when she's working out. She heard B P. C. one five seven is great. What's your framework for this when people coming in asking like I want NAD infusions because I have brain fog? I want BPC one five seven or some other peptides because I think it'll help me, you know, age slow more slowly and recover better. How do you handle that?

incumbent on us to not sort of to do our best to to meet people where they are and have these conversations and and educate them on that. There's a structured way to do it. I'd say I think about this in two different ways. One is what is the evidence for the thing that we're actually talking about? Like what are what is BPC one five seven? Why are we saying this in you? And two, there's like the sourcing and administration of it, which is separate. So

On the first one, which I think is maybe the bigger question, when someone's asking you as a PC P. like how do you think about B P C one five seven? First of all, you gotta sort of know what that is and be able to, you know,

If you don't, like dance around it and talk about finding out more and let's schedule some another appointment to have that conversation, et cetera. Right. But What we did is we got so many of these questions overall where we said we need to have a much more organized framework for thinking about each of these uh compounds. And so the ones that we keep getting questions on, BPC is a huge one for us. Uh a lot of people come to us asking us uh about this for musculoskeletal complaints

Um so we created this a couple of different frameworks. One is the easy framework and then what we call the BHB matrix. So the Easy Framework is EASI. So it's the evidence strength. The alignment, the safety, and the impact. We score that from zero to three on each vector. And we give it an overall score and we say, Okay, if it's like above nine, this is pretty reasonable to try. I think we've we've given ourselves the um the you know, gut sense and and done the work to say that this

one or two, no, we're not doing this. There's there's nothing to say that this is gonna be beneficial, it's gonna harm you. If it's something in between, let's have this shared sort of discussion together. We also on the other side then create essentially like a rest risks benefit

alternatives matrix, right? Like what are we gonna do? If you start this thing that we don't have a long term RCT on, how are we actually gonna monitor it? So let's talk about BPC because I think that's a a good one, right? So let's just do the framework. So on the evidence base, There's no

The theory is it's really just allowing your body to deliver more of your own natural anti inflammatory and healing NK cells, whatever are there to repair the tissue, but you need to have the actual blood flow to get there. So Do we have evidence that this thing actually works? Well, we have a ton of rat studies, we have a ton of animal studies on it, and

it seems to work for those kinds of things like tendon repair that I said. The alignment. Is there an alignment with this person wanting to take this sort of uh compound? I mean Yeah, I think so. She's saying she's got the musculoskeletal complaints. We know we've got the evidence for this. Um, there seems to be a a match here. So You know, on the evidence, let's give her a one on the app alignment, let's give her a two on the safety.

Same thing, we don't have an RCT, but there's a lot of human observational data on safety, and there don't seem to be major safety signals on that. So we'll we'll give it to you on that. Uh on the impact. I don't know. Anecdotally, a lot of patients have had a lot of impact from it. I cannot point to the study that shows you that at this dose for this duration at this protocol of BPC 157, we had a 30% higher. injury reversal rate or or healing rate than placebo. We don't have that. But

I can tell you these other things. So generally for her, you know, we're somewhere in that gray zone, right? We're at a six or so. And so this wouldn't be a slam dunk. I wouldn't say Anita You can't take this. Like if if she had a contraindication, for example, she has an active malignancy, that is a contraindication to BP C one five seven. It is angiogenic, right? You don't want a new tumor to So

We would score that as a zero and she'd kinda get kicked out of that. But that's not her. And I think a lot of patients kinda fall into this but it

w it is on our uh it is incumbent on us to kind of do the work and understand, okay, what is this compound? And so You know, we talked about the benefits, the harms, what burden is there? Are you gonna take it orally? Are you gonna inject it? Um, what are the uncertainties that we have? where are you gonna get it? How are you gonna ensure that it's safe and not contaminated? Those are separate conversations that we have once we've made the decision to move forward. But

You know, that easy framework is really the conversation that we're having with patients and we try to document that as well. And for those evidence based sets, we've uh employed a l research team of a physician, pharmacist and researcher to scour the data as patients are asking us these questions about NAD, about BPC, about whatever, we can go create this data set for ourselves and and at least inform our patients and and ourselves on where our level of comfort is.

Um, but it's at it's at least you have a framework and you're coming at it from an organized manner, which I which I really appreciated. And then you mentioned the benefit harm burden uh the BHB matrix. Anything you wanted to say about that with regard to this one?

in Y days, like a true smart goal around that. We try to set and we also set the harms. Like if you know, we know that generally speaking, somewhere in the five percent range will have kind of an anhedonia or depressive kind of affect with BPC five one five seven. If that's not acceptable to you, we need to understand that and that needs to be one of our sort of stop rules. Um you know the burden is Anita, where are you gonna are you gonna actually inject this stuff?

five times a week or whatever the protocol says for thirty days and then take a a month off and where are you gonna get it? We we guide people, you know, again, these are not FDA approved compounds that people are putting their bodies in. We we almost take a harm reduction approach to it in a lot of ways. Like if if you're gonna do this, we're trying to inform you to do it in the safest possible way. Here's where we would get it because

They provide a certificate of analysis where they do mass spectrometry on this and tell you exactly what's in it. They pull random samples from different lots and test it for LPS and contaminants. So you have relative assurity that they're doing pharma grade uh security there, but you don't know, right? Um I one thing I would offer is Even in FDA approved Manufacturing labs. There have been all sorts of

lawsuits and adverse events that have come from contaminants in kind of run in the mill medications. I'm not saying, you know, at least there's some liability there. I totally get that. With the peptides you have no idea. But I do think there's sometimes a false sense of safety that something you're getting from the pharmacy is like absolutely not going to be contaminated and something you get online is absolutely going to be where I'm not sure it's just that black and white.

But maybe maybe I'm uh Paul, maybe I'm projecting on them, but I do think it's an interesting area and people people are coming in asking me about it. So I w we will keep exploring this. Paul Williams, anything else you wanted to get into before we get to take home points?

Notice that every single person presents differently. Every medication is differently. Even when we have things like goal directed medical therapy where we know exactly what kind of meds we should get people on there's a million factors that go into their lives, the context of who they are, their culture, their access, all sorts of things that may or may not allow them to

follow your exact prescription. So as clinicians, as we're out there giving people this guidance, having the humility based on the reps to have said, you know what, I think that this is the right answer, but I've seen this play out a hundred times and it could go a lot of different ways and here's how we're going to prepare for those various outcomes. I think in especially in the kind of medicine that I do where where there's a lot of unknowns and you're dealing in sort of the gray zone a lot.

most of the conversation is before the test and the test's result is confirming or denying something that you've already had a conversation about. So, you know I wish we all had more time in primary care to have that depth of conversation with our clinicians, but where with our patients I mean, but where you can at least, you know, do your best to to lean in and and give people that guidance and advice they need.

Really appreciate this conversation, Matt and the Pauls. I I know this is a growing space and there's a lot of questions, so I welcome the opportunity for another discussion and and and welcome any of the listeners. Please reach out and we'd love to have a conversation.

A special thanks to our writer and producer for this episode, Dr. Paul Wirtz. And to our whole Curbsiders team, our technical production is done by Podpaste. Elizabeth Proto does our social media. Jen Wato runs our Patreon. Chris the Chu Man Chu moderates our Discord. Stuart Brigham composed our theme music, and with all that, until next time, I've been Dr. Matthew Frank Watto.