A look at how to accurately quantify your cardiovascular fitness in order to optimize endurance sports or your cardiovascular health. Is VO2Max the gold standard? Are the metrics in the current “fitness trackers” useful for this goal?

In this episode we look at different ways to track fitness. Previously we have talked about VO2 max and Heart Rate Variability (HRV), along with the trackers (ex. Fitbits) which are used to quantify such physical activity markers.

This episode highlights difficulties and advances in translating physical activity data into meaningful information. We seek to understand what tracking fitness actually tells you about how fit you are? How is your fitness evolving due to training and other changes you are possibly making to your lifestyle? Ultimately, can we usefully quantify cardiovascular fitness yet?

Aiming to accurately capture this, our guest has developed his own approach to analyzing fitness and this is the main topic of this episode.

There is an opportunity.. to quantify what the fitness levels [are] that you can have. You can have feedback… from a health point of view, to see if exercise is having any impact.
– Marco Altini

Our guest is Marco Altini, a PhD Data scientist and entrepreneur working in the middle of the quantified self area. He has spent a lot of time working on heart rate, HRV, fitness, and physical activity analysis via wearable sensors.

Marco has published over 25 papers on the topic. He has a popular HRV4Training app, which is available on the iTunes store. I have used this app myself for over-training monitoring. So he has really done a lot of work in just this specific space.

If you’re in the quantified self community you probably know Marco already because a lot of his posts are widely circulated as these are normally rigorous and interesting. Today he heads up Data Science Activities at Bloom Technologies, where he is using technology and data to help women have healthier pregnancies. We also touch on that.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. Enjoy the show and let me know what you think in the comments!

itunes quantified body

What You’ll Learn

  • Marco’s research interests and the science behind personalized fitness (3:49).
  • Interpreting accelerometer, heart rate, or calorie meter device data (8:31).
  • Modeling physical activities and normalizing body data to accurately determine energy expenditure (9:54).
  • Using the VO2 max test as a marker for quantifying cardiorespiratory fitness (15:49).
  • The VO2 max test in tracking for performance or health benefits of exercise (19:24).
  • Interpreting VO2 max test results and the drawbacks of normalizing (25:13).
  • Using technology for normalizing results and improving accuracy of quantified fitness (25:54).
  • How to track individual fitness changes (30:23).
  • How Marco’s StayFit app works and distinguishing features from other similar apps (30:38).
  • Key points of analyzing energy expenditure as a fitness marker (33:44).
  • Because fitness improves over long periods, accurate tracking should aim at long – term benchmarks (37:14).
  • The complexity of the relationship between HRV and quantifying fitness levels (38:45).
  • How Marco tweaked his app to adapt measuring heart rate in overall fitness equations (42:28).
  • Normalizing fitness metrics and allowing for un-biased comparison between people (43:26).
  • The importance of context when considering what normalized fitness metrics actually mean for an individual’s results (44:12).
  • Comparing the advantages and limitations of tracking HRV vs. heart rate as fitness biomarkers (46:37).
  • Tracking HRV and fitness parameters in order to prevent pregnancy complications – a Bloom Technologies project (48:22) .
  • Discussing near-future market products and collaborations with major clinical research centers (51:54).
  • How to obtain more information on the topics of this episode (52:50).
  • How best to connect with our guest (53:36).
  • Marco’s recommendations for learning about cardio fitness (53:52).
  • Marco’s approach to tracking his body data on routine basis (54:34).
  • Caveats and useful insight into tracking HRV as a cardiovascular fitness parameter (55:45).
  • Marco’s number one recommendation for improving health, performance, and longevity (57:41).

Thank Marco Altini on Twitter for this interview.
Click Here to let him know you enjoyed the show!

Marco Altini (PhD), Bloom Technologies

Fitness Apps developed by Marco

  • HRV4Training: This app is useful for preventing over-training by measuring HRV and providing personalized feedback on your physical condition. Learn more on their website.
  • StayFit: This app from Marco is based on a novel method for quantifying cardio fitness, known as the Fitness Index developed by Marco Altini. Some of the research backing this up was just recently (after this interview took place) published in the Artificial Intelligence Journal here.
    Note: StayFit is not available on the Apple Store any longer. Marco has integrated the Fitness Index into his main app HRV4Training.

Tools & Tactics


  • Lypo-Spheric Vitamin CLiposome Encapsulated Vitamin C for Maximum Bioavailability; 0.2 fl oz. – 30 Packets | 1,000 mg Vitamin C Per Packet. Damien suggests taking this supplement in response to particularly low HRV test scores. As such, it can be used to prevent potential colds in a timely manner.



  • Maximal Oxygen Consumption (VO2 max): This marker reflects the ability of your circulatory-respiratory system to provide oxygen to your muscles for sustaining exercise. Research has confirmed that low cardiovascular fitness is associated with higher disease risk, including heart disease. A running VO2 max test is more indicative of cardiovascular fitness compared to a biking test which does not require you to carry your entire weight forward. We have previously discussed this marker in the context of wearable devices which estimate VO2 max with Troy Angrignon in Episode 24.
  • Heart Rate Variability (HRV): HRV is the measure of the change in the heart’s rhythm, measured as variations in para/sympathetic stimulation to the heart muscles. HRV is not an ideal marker for tracking fitness improvements because of day to day variability in results. Previously we covered HRV in the context of optimizing training in Episode 1 with Andrew Flatt, longevity in Episode 20 with Dr. Joon Yun. and using HRV to reduce stress in Episode 35 with Richard Gevirtz.
  • Heart Rate: The speed of the heartbeat – measured in beats per minute (bpm). Lower heart rate is associated with stronger cardiovascular ability. Marco recommends tracking resting or active heart rate for tracking overall cardiovascular fitness. Heart rate increases by 10-20 bpm during pregnancy – an important factor to consider when quantifying fitness or risk for pregnancy complications.

Lab Tests, Devices and Apps

  • Basis Peak: A watch functioning as a fitness and sleep tracker.
  • Moves: An exercise tracking app which can detect the type of exercise being performed.
  • FitBit: This company offers wearable devices which include cardiovascular fitness tracking. The FitBit Surge is a fitness watch that offers GPS tracking, heart rate monitor, all-day tracking, and sleep tracking. The FitBit Charge monitors physical activity and sleep quality.
  • Runkeeper: An app which tracks running, walking, cycling, workout, pace and weight and which also lets you manually enter the activity you are performing.
  • MyHeart Counts: A personalized tool that can help you measure daily activity, fitness, and cardiovascular risk developed at Stanford University.
  • Steps: A pedometer and activity tracker app with measures how far you walk and how many steps you take.

Other People, Books & Resources


Full Interview Transcript

Click Here to Read Transcript
[03:49][Damien Blenkinsopp]: Now Marco, thanks so much for joining us on the show today.

[Marco Altini]: Thank you, my pleasure.

[Damien Blenkinsopp]: So I wanted to get first into a story about where you are at, and how you got into measuring fitness and looking at that specifically. What’s your background, and what’s your interest in this area?

[Marco Altini]: So basically I’ve been doing a PhD all around using wearable sensors to monitor energy expenditure. Well, let’s more say on their machine [04:12 check ‘machine landing’] aspects, so integrating multiple data streams [04:16 unclear] to accurate measurements of physical activity. Which is normally what we focus on is energy expenditure. So basically the intensity of the activity.

And taking a step back, let’s say most of the research in the field focused on the component of energy expenditure, which is due to physical activity, right? So body movement, because energy expenditure is actually composed of three elements. So we have diet induced thermogenesis, which is the energy expenditure we expend due to digestion, for example. And that’s something we consider as a sort of standard component, about 10 percent.

Then we have our basal metabolic rate, which is basically the calories we burn at rest. So if we take a bit of a simplistic view, this is what we would consume if we were not doing any activity. We lie in bed all day, and we still consume actually most of our energy which is due to this component. And then the third component is physical activity energy expenditure, which is the calories we burn when we move or exercise.

So by working a lot around this component and trying to estimate this more accurately using accelerometer and heart rate data, then I started focusing on aspects like personalization. Because when you use physiological data like heart rate to estimate energy expenditure you basically rely on parameters which are very well correlated with energy expenditure at the individual level. So for a single person, because of course heart rate is directly connected to oxygen uptake, which is also what we measure when we want to get the reference for energy expenditure.

At the same time there are individual differences between people so you need to try to understand how to model this difference between people in a way that your energy expenditure estimate coming from heart rate is accurate. And while working around this, basically you’ll get the work on what is the problem of basically normalizing heart rate between individuals, which is directly connected to fitness.

Because everyone tends to know that lower heart rate means better fitness. This is true at rest but even during exercise, which is, as a matter of fact, the principle behind, for example, sub-maximal fitness tests.

So, people are brought to the gym and they do an exercise to a certain intensity, and then based on what their heart rate you get, basically a surrogate of their fitness level. And all of that came back as something that you need to account for also when you measure energy expenditure because the whole reason behind normalization is that our metabolic response to exercise is not affected by fitness.

So just as an example to clear this up, if we think about, let’s say two individuals which are the same in terms of age, body weight, body mass, pretty much the same anthropometric characteristics. Then when they do a certain activity, they consume the same energy. So it’s the same kilocalories per minute because that’s mainly driven by the type of activity and the body mass.

However, these two individuals could be having a very different fitness level. So let’s say that one is very fit and while doing this activity their heart rate is very low, and the other one is very unfit and the heart rate is much higher. Then if you use heart rate to estimate the energy expenditure, you would be over or under estimating for one of these people.

[Damien Blenkinsopp]: So the one with the fast heart rate is over estimating?

[Marco Altini]: Yes. If you have a higher heart rate and then you don’t take into account that there is a difference in fitness, then you will assume this person is consuming more energy because the heart rate is higher with respect to the average, let’s say.

But that’s not the case because actually metabolism is not affected by fitness and there have been quite a few studies looking both at rest and during exercise, and given basal metabolic rate the component of energy expenditure.

[08:31] [Damien Blenkinsopp]: So what we’re saying is there are a lot of devices out there right now which are attempting to assess how many calories you’re burning in addition to the steps. So when you’re looking at that, actually, it’s a bit more complicated than the standards currently use, right?

[Marco Altini]: Yeah, exactly. Especially manufactures which are using, providing sensors with heart rate. They like to claim that just because there is heart rate they will be more accurate. And let’s say that using heart rate certainly is already a step forward compared to accelerometers because you can, with minimal effort already take into account energy expenditure for many activities which don’t involve body movement. Right?

For example with accelerometers we have limitations even just biking, because you might have the accelerometer in a place where it doesn’t move when you do these activities. So by using heart rate you can solve, partially, these issues. Because of course your heart rate will increase.

It doesn’t matter if you don’t move if you are doing exercise which is intense and of course requires your heart to pump more oxygen to your muscles. At the same time, due to the fact that the relation with heart rate is very personal, then you need to be able to make an extra step and model that if you want your system to be accurate during intense physical exercise.

[09:54][Damien Blenkinsopp]: Great. So in terms of the tech out there currently, would it be safe to say that a lot of it’s either overestimating or underestimating based on these restrictions or are there devices or apps out there which have tackled this problem?

[Marco Altini]: So I think what we are starting to see a bit more is, for example in the context of even just monitors using, for example movement or steps, some of them are introducing something more around context. Which is important because when you use accelerometers this first instance were probably already in the late 70s, for sure in the early 80s.

The researchers started to develop the first equations to link accelerometer output and movement to energy expenditure. however some of the imitations there are that, for example, the relation between the accelerometer output and energy expenditure changes depending on the activity. So if you are walking or running there’s a different relation. If you are at rest, of course, there is no movement, and all of that.

Recently we started seeing even commercial devices which are able to detect activities. For example, I think the Basis watch is detecting a couple of activities. Even apps like the Moves app can detect activities.

So in general I would assume even though they don’t disclose the methods they use to estimate energy expenditure, I would assume the ones that are able to detect the activity, then what they do they use this table, it’s called the compendium of physical activities. Basically it’s a table where you have almost all possible activities you can think of, and for each of them there is a value of energy expenditure normalized by body weight that people are supposed to be expending while doing that activity.

So these devices are probably mapping the activity they recognize to this level of energy expenditure. This method [11:53 unclear] like four or five years ago, to be much better than using accelerometers without context. But it’s even better than combining heart rate and accelerometers, if you don’t take extra measures like modeling context or normalizing heart rate.

So just putting together accelerometers and heart rate is not able to outperform methods where you use only accelerometer data. But with a bit more of machine learning to be able to recognize what activity is being performed, and then map that to an energy expenditure level.

[Damien Blenkinsopp]: Right. It sounds like if you have the heart rate, and you have the anthropometric data ñ what’s your weight and age and so on — and if you have the accelerometer data showing the movement, and you have an algorithm which categorizes what kind of activity it is based on the accelerometer, what’s that showing.

Which, I know isn’t always correct, based on my experience. So sometimes, for instance, I was wearing the Basis and it would say I’m on a bike where I never got on a bike. So it isn’t quite perfect yet, but we’ll assume that’s getting better. And maybe it’s already better.

Then what they’re doing is they’re looking at the activity and they’re saying, ìWell for this type of activity this heart rate is standard for this kind of fitness, and this heart rate is standard for this kind of fitness.î Is that how it works? Or is it a more basic thing right now?

[Marco Altini]: I think step zero would be simply to map it to known values, regardless of your heart rate. Let’s say, an app without heart rate, like the Moves app. So you just have the activity type, and you map that energy expenditure. Yes, like the average energy expenditure for that activity for a person.

So you are walking, and of course you can walk at many different speeds, so maybe that’s not known by the app. But still you would assume that for the average walking speed for the average person, you would consume this many calories. And when you detect walking you just map it to that and then based on other characteristics you input, like your body weight, you scale that by your body size, basically.

And then if you do a bit of more advanced work, let’s say, and you want to develop your own model for a specific activity. Let’s say you have the Basis, and at Basis they have a couple more physiological parameters together with movement, then it could develop there on regression models by collecting reference data.

So normally we do that with indirect calorie measure. So that’s a device which is a physical mouthpiece, where you breathe and it’s measuring O2 and CO2 counts. So, you compare the O2 and CO2 in body sheets, and that’s basically energy expenditure. So by having people performing different activities wearing the Basis watch, while you measure these reference calorie meter data, then you can see how all these valuables change depending on the activity.

And then you can map, let’s say heart rate changes and movement changes, the energy expenditure for a specific activity. I don’t know if they are doing that, because that would require to do all the tests with a calorie meter. I would assume, considering that they have all that physiological data that they did also this kind of development. While maybe all the other devices which are simply accelerometers, they might have simply used the values from the compendium of physical activity.

Basically the compendium of physical activity is what you use also when you, let’s say you use an app for tracking your workout, like Runkeeper, that let’s you also manually enter the activity. So maybe one day you didn’t have your phone and you want to enter it manually, then it will also estimate your energy expenditure. And that’s basically just a lookup from this table. And then it’s just scaled by your body size and for the amount of time you did the exercise.

[15:49][Damien Blenkinsopp]: Okay great. So what we’re talking about here is physical activity level, right? These are different version of it. There’s energy expenditure, and there’s Steps, which is currently what’s on the market. All these devices are looking at quantifying our physical activity level.

I guess the question is is that what people really want in terms of the end game? Because you’ve got this app out which is trying to get at something which you feel is a bit closer to the end goal of what you want to measure.

[Marco Altini]: Yes, so while I was doing research here on energy expenditure and the more I looked close to the whole personalization story, basically I was thinking what is a way to quantify not only what activity you do, right, the amount of exercise, the Steps, but also what the impact of this activity on your health, if there is any.

So this is a process in which we try to move from quantifying physical behavior to quantifying physical activity related health markers. And one of these markers, which is probably the most important one, is cardiorespiratory fitness.

[Damien Blenkinsopp]: That’s kind of well-known. That’s been the standard for a long time, in terms of quantifying fitness. But it’s only been done in laboratory contexts, as I understand it.

[Marco Altini]: Exactly. So far, as you say, it’s been really, I think 20 or 30 years that we know for sure that all these studies show that low level of cardiorespiratory fitness is indicative of higher risk of getting different sort of diseases. And even in general of just what is called [17:24 check – all cause mortitus], so you’re just most likely to live less if you have a low level of fitness.

And what is interesting here is that it is true even when it’s basically controlled by physical activity or body size. So it means that it doesn’t matter even if you are obese or if you have less levels of activity, but as long as your cardiorespiratory fitness is higher, you tend to be protected with respect of these other issues.

And indeed we know that. The research community at least is well aware of the importance of cardiorespiratory fitness, but in the general population I think we still lack awareness of this. Mainly because, as you say, there are basically no tools. So the way this is measured is in laboratory conditions. The reference is called VO2 max test.

And while VO2 is the oxygen volume and this is called VO2 max basically because the way the test works is that you get people either to do a treadmill test or a biking test in which they bike around until exhaustion. So you increase the intensity of the exercise every 5 minutes or so. And basically there is a point in which an individual is still able to keep it going at that intensity, just a bit before you drop. And then your oxygen sort of plateaus, and that’s your VO2 max.

[Damien Blenkinsopp]: What does that signify? Is that the moment when you switch to anaerobic, or what does it signify physiologically?

[Marco Altini]: Well, there is really the moment in which you cannot take any oxygen anymore. You need to stop. You cannot take any more intense activity, so that’s the max oxygen you can take.

[Damien Blenkinsopp]: Right. So it’s like your maximum ability to metabolize…

[Marco Altini]: It’s the ability of your circulatory-respiratory system to provide oxygen to your muscles for sustaining exercise.

[Damien Blenkinsopp]: Great, great.

[19:24] So showing that efficiency and when people are looking at that list, let’s talk a little bit about the decisions.

Typically when you have these meters when people are using these activity tracking meters for, whether it’s biking and running and so on, typically they want to improve something. They either want to lose weight, sometimes, or they want to improve their fitness. Or they want to improve their health.

So you’ve talked a little just there about cardiorespiratory fitness, we say that that has a protective effect against heart disease, which is one of the biggest killers. And also, if our cardio fitness is better, is more efficient, then we’re probably going to be able to run further, and run faster.

We’re going to be able to perform better, which is also something that we want. Whereas the Steps and the energy expenditure is hard to understand how that reflects either of those two cases, kind of like the use cases: health or better performance.

And with Steps and energy expenditure, you can tell that you’ve done more in terms of quantity but you can’t really tell if it’s going to give you more performance or you’ve actually got health benefits.

[Marco Altini]: Yeah.

So I think there is an opportunity in trying to quantify what is the fitness levels that you can have. You can have feedback for the ones that are interested just from a health point of view, to see if exercise is having any impact. You can have, actually even for professionals it would be, they do the VO2 max test and they know their actual cardiorespiratory fitness level, but still you cannot do that that often and it takes time.

[Damien Blenkinsopp]: It’s expensive, I think it’s like 300 dollars or something. Because I looked up, when I was in the US recently I was going to do one in San Diego and they had a gym that was actually providing it. Sometimes you can go to laboratory health centers or sometimes some advanced gyms will have the equipment to do this.

[Marco Altini]: Yes. I think there are a few limitations around the VO2 max test, apart from the cost.

Certainly you need some medical supervision and you need, again, the calorie meter to measure the oxygen. It requires a level of infrastructure. And apart from that, I think sometimes it’s even tricky to interpret the result. Because VO2 max is normally reported normalized by body weight. So you need to provide people with an easier way to understand their fitness level.

So you have these tables where basically different levels are divided by gender and by age. So if you are a person of a certain age and you’re male, and then you have your VO2 max result and it would soon [21:53 unclear]. Okay?

But however, these tables are not organized by body weight. Only by gender and age, since the results are normalized. However, the exercise type you use to acquire the VO2 max data is not part of those tables. And that has a great influence on oxygen consumption.

Because even just when you normally measure energy expenditure, even if you’re doing an activity which is weight bearing, you literally carry your weight around, like when you walk around, then the link between oxygen consumption and body weight is much stronger compared to when you just bike. Especially for stationary biking in the gym your energy expenditure is much more similar to the one of a person which is of different body size compared to you. While if you would be walking or running there would be a much bigger difference, because it’s a different impact of body weight.

Even, like in one of my recent studies through my PhD I measured VO2 max on a group of 60-70 people, and for example there I had a subject which was unfit; so all the parameters that we measured seemed to show that his fitness level was quite poor. He had very high heart rate at rest, very high heart rate during all exercises, he couldn’t finished some of the protocols. During the free living part also, his physical activity level was very low.

And the VO2 max test [23:25 unclear audio] it turned a result that he was the most unfit person as well. However, if we go to normalize the VO2 max, so we divide by body weight, this guy became the second most fit of the entire data set just because he’s very thin.

And that’s actually the result normalized by body weight, is what you normally get. Because it’s common practice to report it that way. But at that point, how do you interpret it?

[Damien Blenkinsopp]: So it’s a bit tricky to make it. So VO2 max is the gold standard in terms of measuring this.

[Marco Altini]: Exactly, but it has its own limitations. Yeah.

[Damien Blenkinsopp]: If someone was to go and take that test, what would you suggest they make sure, like to check they get a result that’s useful for them. Is there anything they can look out for or ask for?

[Marco Altini]: So in my opinion at this point, I tend to think that maybe a running test would be a better way to do it, because the relation with body weight is a bit more clear than compared to the biking test. However, normally a biking test is done also because of safety reasons. It’s a bit easier to do a maximal test on a bike; it’s a bit more of a controlled situation.

However, when you then go to normalize by body weight, the fact that your body weight doesn’t have the same impact because you’re biking and you’re not carrying your weight around, then you’re [going] to have this weird results like we did where the normalized VO2 max basically makes an unfit person the most fit person. That’s one of the reasons why I prefer to use VO2 max data non-normalized. So I use the value of oxygen consumption they reach, and that’s it. I don’t normalize it by body weight.

[25:13][Damien Blenkinsopp]: Okay. So, are there benchmarks for that? If they get a specific score back they can assume they’re relatively fit?

[Marco Altini]: Yeah, but the problem with that [25:22 unclear] is then you don’t have this [25:23 unclear] they’re not aware of, that there are these tables for matching it to something like, [25:29 unclear], like fitness is poor or average or good. These tables are all normalized by body weight. So that’s sort of a problem.

[Damien Blenkinsopp]: So what you’re saying is if you were to do this twice, you could get your relative fitness without normalization, right? If I took a test today and I took another test in 6 months.

[Marco Altini]: Exactly. You could calculate longitudinally. That’s no problem, maybe it’s more difficult to compare with other people.

[25:54][Damien Blenkinsopp]: Right. So is there any way we can get around the issue of normalization so that it works for us?

[Marco Altini]: There are some maximal tests which are not all bad.

So basically, some maximal tests, the way they work is that of course they want to predict VO2 max, and they rely on the fact that we know, as I was saying before, that the heart rate changes based on fitness.

So instead of doing a maximal test and measuring oxygen consumption until exhaustion, you do tests at a predefined speed. For example you run at a certain speed, you bike at a certain intensity, and then you measure your heart rate. And that goes into an equation that was developed before using referenced to VO2 max, which basically predicts your VO2 max based on your sub-maximal heart rate, and a bunch of other parameters like it measures your age and body weight and all these other parameters.

And the simplest of this test I actually did on [26:57 unclear audio] to measure heart rate, for example. I think something interesting is that we’re seeing now is also to bring awareness to people with [27:09-27:12 unclear audio] and we got this out from Stanford which is called MyHeart Counts, I believe.

So they measure, they ask you a lot of things and get a lot of reference points and your lifestyle and what you do. And then they track, using the phone, your activity. But since the study is all about cardiovascular health, they ask you to do this fitness test, which is one of the most commonly used because of its simplicity, I would say, where you just have to walk for six minutes.

And you have to time it, and you have to check the distance basically. So the longer the distance you go in six minutes, the more fit you are. And again, here you don’t need physiological data, and this might be probably a better test for people which are not in optimal health conditions.

But I think it’s good because the app is also targeting healthy users. So it’s a good indication that fitness should be of interest for the general population. And there is an effort here to raise awareness.

This being said, I think the potential of current technology is much higher. So you can do much better than that. And you can overcome also the limitations you had, because until now you had to either do a VO2 max test, which is expensive and has all the limitations you discussed, or even if you want to do a sub-maximal test you need still to go to a gym, you need to do an exercise at an exact intensity and then do your math to get what your VO2 max would be.

But right now, since we have phones with all sorts of sensors, and then we have wearable sensors and we have heart rate monitors and all of that, and then we have other reasons that can really automatically understand if you’re walking or running or what is your speed. You don’t even need a treadmill anymore to understand the context around the activity you’re doing.

So, some of the work we’ve been doing recently as part of our research is indeed to give people just a phone and a wearable sensor and don’t ask them to do any specific activity. They just live their life for two weeks while wearing the sensor.

And then all the other reasons we automatically understand: which location they are and what kind of activity they’re doing; if they’re walking, then then what is their speed. And then, basically you put your heart rate in a specific heart rate continuously. And by knowing that, since your heart rate still will be affected by your activity and your fitness, and you also rate the activity because you know the context. And then you can estimate the fitness level basically without requiring any test anymore.

So I think that’s quite interesting because you can finally get to something that is useable by everyone and doesn’t require any specific tests. And again, if you want to monitor them longitudinally, you don’t need to do a test every month. Because you just wear the sensor and it’s sort of being continuously updated just by wearing it.

[30:23][Damien Blenkinsopp]: So when you say longitudinally, that means testing ourselves in time, and seeing if we’ve got an improvement or decline over time.

[Marco Altini]: Exactly.

[Damien Blenkinsopp]: See if what we’re doing is actually working or not.

[Marco Altini]: Yeah. To see if there is basically changes at the individual level.

[30:38][Damien Blenkinsopp]: So this is basically what your StayFit app does?

[Marco Altini]: So basically with this app, I tried to make something where you don’t even need the sensor anymore. So [30:48 unclear] yields a research prototypes. Basically it’s a necklace, you wear it and there is, essentially you get full SG. And then we [30:56 unclear] heart rate. Then there is an accelerometer which we use for activity recognition and walking speed. Then with the phone we use GPS to understand location of that.

However, even if now you have some trackers that do heart rate like the latest FitBit or the Basis, we don’t have access as developers to all of their raw data that you would need to develop algorithms on top of these devices. So what I was thinking is, well of course if you have heart rate data during all of these activities, your fitness estimate can be more accurate.

But, at the same time heart rate at rest has been shown to be linked to fitness. So the lower heart rate at rest the higher fitness. This was the case in many studies, even interventions about physical activity trying to increase physical activity, often show that they were also able to reduce heart rate at rest.

So what I did with this app was to combine the two aspects. So using just the phone you can get activity level based on the step count, which is on the phone, and this data is transformed in energy expenditure, and your physical activity level. And then you combine heart rate. And again since you need context, the way the app is used is by taking a short test in the morning, similar to what the HRV apps do.

[Damien Blenkinsopp]: So, just to clarify, that means when you wake up in the morning you take a reading before you do anything else.

[Marco Altini]: Yeah, exactly. So that’s the easiest way to isolate context without having to go through much trouble. You just, you wake up, you take your test, that’s at least the moment we are the least affected by all other parameters and stressors.

And then you get your heart rate at rest, which goes in the system together with a bunch of other parameters to get you an estimate of fitness. And what the app is actually estimating is basically your sub-maximal heart rate, which is then transformed to a number between zero and 100.

But the whole point here is that since sub-maximal tests basically measure your heart rate at a certain intensity, because that’s what then goes into the formula to estimate the VO2 max. But if you consider that your age, and gender, and body weight will stay pretty much the same if you do two tests in a short period of time, then the actual measure of fitness is just sub-maximal heart rate.

So your VO2 max will be different only if your sub-maximal heart rate is different. So, here I removed the VO2 max step and estimate directly their sub-maximal heart rate. Which is a proxy to fitness, basically.

[33:44][Damien Blenkinsopp]: Great. And how have you seen this work out? Because you’ve been using this app for a while, and I guess you’ve gathered some user data now as well?

[Marco Altini]: Yeah, I did. Not that much, I must say. So I cannot really make any analysis yet, especially because I don’t have a reference point either.

It’s more of an individual tool that you might want to use to track your fitness, but I don’t know the VO2 max of the people using it. So maybe it’s something for future versions would be to try to add some other reference points so that I can do some further analysis like I did with HRV apps.

[Damien Blenkinsopp]: Great. So in your own case, how long have you been using the app, and have you noticed any differences in your fitness? For example, your running time, because I know you’re a runner and you developed it primary because of that interest.

So have you noticed or seen differences in your fitness level, in terms of your efficiency and your performance, and seen those correlate within the app, or has it not?

[Marco Altini]: So I used it for about two months. Something interesting I think is around the metrics that I used. So for example, I used the physical activity level as a measure of activity. So the physical activity level is a normalized version of energy expenditure.

So if you’re telling me your energy expenditure today is 4000 kilocalories, I can’t really infer anything, because if you’re severely obese that may be just your energy expenditure at rest when you do an activity, right. At the other end, if you’re a thin person and a small person, then it means that you’re being very active.

So, the total energy expenditure is difficult to interpret without knowing who are we talking about. And the physical activity level is the energy expenditure divided by the basal metabolic rate, so the component result is your metabolism at rest.

In this case you would get a value which is representative of how much you move. So if you don’t move at all it’s one, and if you move a lot it really doesn’t get much beyond two. So that’s a good indication of physical activity.

And it’s based on energy expenditure, which I think is important because sometimes, for example, I could see in my data is that I went for a trip and I did a lot of hiking, which is a lot of activity but at the same time it’s not really cardio activity or activity that I believe would improve my fitness level. It’s not like when you go running you know the intervals on track.

It’s movement but I would assume my fitness stayed more or less constant those days, right? And if I look at Steps, I see that I’ve been much more active than my average, because you walk all day and it’s much more steps than when you go training. So if my fitness was just based on my activity, I would get theoretically more fit when walking on holiday.

However, since we use energy expenditure, the normalized energy expenditure, the physical activity level, that was pretty much the same as it was when I was here and I was training. Because the activity when I train here is much more intense and consumes much more energy than when you’re just walking. So I think that’s a valuable point of using physical activity level as energy expenditure to track fitness instead of just movement or steps.

[37:14][Damien Blenkinsopp]: Okay. So for your hiking and so on, did you see your fitness level change in the app? Because it gives an index of one to 100.

[Marco Altini]: Yeah, exactly. So it stayed pretty much the same.

[Damien Blenkinsopp]: Right. So you saw basically that that case was shown in the results. Did you do anything where you saw your performance improve in your app and you correlated it to basically better times, or other things that seemed to be improving?

[Marco Altini]: For now I just saw it dropping, which is not good. So, yeah. I guess my condition is not ideal.

But I think it is interesting to track over long time. I tracked for two months, and I don’t race that often. Maybe for a professional person it would be more interesting because their life is training. For me it’s more of a hobby.

But I think looking after a year or so, then you can track it. You can look at data with respect to maybe the half marathons you did and the times you did, and then you get all these reference points, then it could be interesting.

So, you know I’ve been doing some work around HRV for example, and there it’s very valuable on a daily basis. Because there were points that you measure basically those points of this test, which can be training, and you get basically daily advice on how to train, and if your body is ready for another intense training. On the other hand this one tracks a parameter which changes much more slowly. Fitness doesn’t change fast.

[38:45][Damien Blenkinsopp]: Right.

So this one strikes me as it would be more useful to understand the effectiveness of your program. Like, the protocols you’re using to increase your fitness, for the longer term? So a lot of people will follow a set program for a while, especially if you’re a professional athlete you’ll have a set workout and timing and everything.

So you can kind of evaluate the performance of that, and if it’s increasing in the fitness one. But as you said, because a lot of people are using the HRV today. We’ve looked at the HRV in the context of stress, of longevity, and also of course the training in terms of recovery, which you just mentioned.

So, I could imagine that some people might look a HRV and be thinking, “Oh, my HRV is higher so I’m fitter.” Right? Because we’re also looking over time rather than the day to day, looking at the trend. Would you say that’s the case? Or do you think that’s not an accurate way to look at HRV?

[Marco Altini]: I think HRV is great as a day to day tool for recording and a proxy to personal activity and it is true that even at the [39:47 unclear – professional] level, let’s say athletes tend to have higher HRV, and really sedentary people tend to have lower HRV.

But, the link between HRV and fitness is, let’s say far from being clear. Meaning that there have been many studies, and some of them found some link between HRV and fitness, meaning higher HRV higher fitness, but many many studies found no relation there. Especially when doing interventions.

So, you know, longitudinal studies where you take people through a training program and then you measure their HRV at the beginning and at the end. And many of these studies found that heart rate changed and it was lower, but they couldn’t find any change in HRV, so it might be that there is a stronger genetic component there.

And also physiologically speaking, with heart rate you train, so you train your heart which then would be basically able to pump more blood. The volume changes, increases per beat, and that’s why your heart rate also decreases. The more fit you get, you train your heart muscle, which is going to be able to pump more blood and oxygen to the muscles, and then your heart rate as a consequence also decreases.

However this link, in terms of HRV, I don’t think it’s clear. So in general, even in this study I was mentioning before where I had all these people doing VO2 max test and doing also all the free living recordings, that was not a longevity study, so we just got a snapshot of these people. But there we can see clearly there is a very strong relation between heart rate and their fitness level.

And this was true for heart rate at rest, heart rate while they were sleeping, heart rate during activities. So you always see this relation which becomes stronger, of course, for more intense activities, but is there already at rest. While with HRV we couldn’t see any link with VO2 max, even at rest or sleeping or anything. So, I think in general HRV might not be the ideal tool to monitor fitness level.

[Damien Blenkinsopp]: In terms of cardio fitness?

[Marco Altini]: Yes, in terms of cardiorespiratory fitness. And basically as a proxy to VO2 max, heart rate at rest seems to be a much better parameter.

[42:28][Damien Blenkinsopp]: Right. If someone is just looking at their resting heart rate, that’s also a standard in athletics and so on, people could watch that. And then you’ve basically built up a bit more on that, through your fitness index.

[Marco Altini]: Yeah. So I basically used that one and the energy expenditure normalized value together with some adaptation due to age, so that basically the value doesn’t depend on age.

So if your other fitness index tries to predict is just maximal heart rate, basically it tries to predict, for example, what would be your heart rate if you were running, even though you’re now resting and you do these activities in your life. And then that your sub-maximal heart rate and your maximal heart rate are basically depending on your age as well, right. So it will decrease over time.

And so I applied some corrections there to allow people of different ages to get values that they could compare.

[43:26][Damien Blenkinsopp]: Right, right.

So it’s all about normalization, right? Getting normalization right so that you can use it, which would mean that you can compare it against different people. Right?

So just before this call, I was saying hey my score is 60, what it is it like? Does that mean I’m fit or not, compared to you, you’re 70 and I’m like, damn I’m less fit than you. Right? So that kind of context, which is literally what people like to do, right?

[Marco Altini]: Yeah, I think so.

[Damien Blenkinsopp]: People want to be a bit competitive about this, and you know it’s part of team sports and so on. And people are into this stuff.

[Marco Altini]: Exactly. Because for every time if you look at VO2 max, for example, then it’s basically impossible to compare unless you have a person who is basically your age, your gender, and your body weight and possibly also your body fat. Then you can compare. Because otherwise there are too many parameters there.

[44:12][Damien Blenkinsopp]: So I wanted to use this as bit of a demonstration on what’s important in a biomarker if it’s going to be useful to us.

So one of the things you brought up, which is key here, is normalization so we can compare it to other people. There are different devices out there, but sometimes we can’t compare against other people effectively, because as you say it hasn’t been normalized. That’s one part.

What other things do you feel are important? Like if you just think of a biomarker, what would you be looking for to make it effective and useful to make decisions around?

[Marco Altini]: I think in general, it’s important that we always contextualize these things and this whole thing goes together with normalization. Normalizing parameters means also understanding in which context you were measured. So that’s something important.

Try to know everything around it and take care of taking measurements in isomeric conditions, because otherwise it’s easy to make the wrong conclusions just because some other factors are influencing what we are measuring.

[Damien Blenkinsopp]: It’s important to get some benchmarks.

[Marco Altini]: Yeah.

[Damien Blenkinsopp]: So we can understand the implications for our goals. So I’d like to see in the future if you have more data with your fitness app to see if you can compare the range of readings for different users, and things like that.

[Marco Altini]: I think in general, when we make these tools and we release them, for me it’s very interesting to look and take it step by step.

First you try to look at some relations that have been proven already in research, for example with heart rate variability apps, I let the people give me some reference points. So basically they can annotate not only when they train, what’s the intensity of their training and in the next lessons they will be able to add some more text around sleep, and all of that.

And that’s interesting because afterward because then, again, you can put the whole heart rate variability story in context with respect to how they trained and all of that. And then you know from some studies in literature, on maybe 100 people, that there is an important relation between HRV and training.

But then you can just scale that at the level of 1000 people and you start to find all of these relations. And then you can start exploring maybe a new one. So I think that’s quite powerful.

[46:37][Damien Blenkinsopp]: So another thing about this measure and measures that tend to be more useful is its stability. We’ve often come back to this in our podcast in different episodes, with different markers, whether it’s laboratory testing or whatever.

If a marker is moving around a lot ñ HRV is kind of moving around a lot, which can make it more difficult to use sometimes.

So, often you’ll see a pattern where one day it’s up and a little bit down the next day. It’s always kind of a jagged reading, so you have to kind of take an average of the last three days and things like that to get a stable reading on where your recovery is. Of course where there are the extremes and it really drops, then you’re like, “Okay this is a recovery day.”

But the thing about these biomarkers in general is it does help if they’re more stable and they’re moving along more steadily over time so you can make decisions on a more even basis. Because we’re not making decisions hour by hour in these cases where it’s fitness and health. It’s more like what am I doing this week versus next week, and so on.

[Marco Altini]: Yeah, the two cases also something with HRV, I think it’s very powerful because of that, because it can react that way to some stressors. But at the same time, it makes it very difficult to interpret sometimes. Because even consecutive tests can have very different values.

So that makes it quite difficult sometimes. But yeah. With heart rate, that’s a bit less the case. So indeed that’s one other reason why heart rate at rest is better for the cardiorespiratory fitness estimate, because it’s more of a stable parameter like cardiorespiratory fitness is. While HRV is very good as a parameter which you can use to understand how you’re reacting to certain stressors.

[48:22][Damien Blenkinsopp]: Yeah, that’s great. So different contexts. So I also know that you’re now working with data to help mothers with pregnancy.

[Marco Altini]: True.

[Damien Blenkinsopp]: So I wanted to touch on that and see what you’re doing there, because it’s an interesting area.

[Marco Altini]: Yeah. Well basically I’m working at the start-up at Bloom Technologies, where we are working on different aspects and the goal is to better understand pregnancy complications, by monitoring longitudinally different physiological parameters.

Since many of these complications, like for example pre-term birth, or gestational hypertension or gestational diabetes, are poorly understand, let’s say. And even in the developed world, even in the US, the percentage of pre-term birth is more than 11 percent and the whole medical community is, let’s say a bit struggling around how to try to bring this epidemic down.

So what we are doing there is to try to add some parameters to what we are measuring today. For example, uterine activity or even heart rate variability over time. And all we discuss now basically becomes important again because during pregnancy there are even more challenges because all these parameters change also because of pregnancy.

For example, heart rate increases by, let’s say, 10-20 beats during pregnancy because of course their heart needs to work harder because it needs to provide also for the fetus while it’s growing. So you have the additional context of knowing at which stage you are of the pregnancy, and trying to understand how all these parameters change.

So what we hope there is to be able to use this physiological data contextualized longitudinally over time, and try to get a better understanding of what is the impact, for example, of uterine activity and physiological stress, physical activity in all of these complications together with the variables which are already known to be affecting pregnancy.

[Damien Blenkinsopp]: So it strikes me this could be pretty interesting, because you might be able to alert someone to an issue over pregnancy. What kind of outcomes do you expect once this work is completed? What kind of goals would you have?

[Marco Altini]: So I think the first part would be to try to understand better what parameters are influencing some of these complications. And then for some of them there are interventions.

If you consider hypertension or diabetes, you can reduce activity or [51:02 unclear] and you need to know to be a bit more under control. Others are more complicated, for example pre-term birth; there is really no intervention there.

So still by understanding better what are the pathways there, and what is causing the issue, you could then after the second step try to see what is possible to do in terms of, for example, behavioral changes.

It is, for example, known that high stress has an influence on some pre-term birth rate, and on pregnancy outcomes in general. So if you can measure physiological stress, you could also have an intervention around some mediation practice or whatever it is that could lower stress, and then try to reduce complications around pregnancy with these kind of feedback loops.

[51:54][Damien Blenkinsopp]: Great, great, thank you.

I’m guessing it’s quite a ways off in terms of bringing something to market or things like that.

[Marco Altini]: Yeah we hope to have a product by the end of the year, around contractions. But again, let’s say more limited but at the same time that would allow us to collect data and work with hospitals and doctors to start to explore a bit more around this using also the power of having consumers with the device.

And consumer inserted data and data sets can grow much faster than with regular clinical studies while still providing clinically accurate data. So, we’ll be looking into that with some collaborations also here, for example with UCSF in San Francisco where they have a pre-term birth initiative that we are collaborating with.

[Damien Blenkinsopp]: Great, great thanks.

[52:50] So, where should someone look first to learn more about the topics we’ve talked about, VO2 max, or are there any presentations on cardio fitness or anything like that you know of, or maybe a book, that if someone was interested in this to get a better idea of this they could look up?

[Marco Altini]: There are some good resources, maybe I’ll just provide you some links. More on the physiological aspects. I think in general I’m happy to see the whole thing moving forward with this Stanford study.

So even just the website of this study, the MyHeart Counts study would be a good starting point to understand better these things. Because indeed we target as well healthy people. So giving a look at this up, it would be a good starting point for your cardiovascular health.

[Damien Blenkinsopp]: Great, we’ll put those in the show notes then.

[53:36] What are the best ways for people to connect with you, and to learn more about what you’re up to?

[Marco Altini]: I would say through my website. I try to keep it updated. Normally I’m very active. So if they just drop me a line or an email or something, I’ll get back to them for sure.

[53:52][Damien Blenkinsopp]: Is there anyone besides yourself you’d recommend to learn about cardio fitness and these area we’ve been talking about today?

[Marco Altini]: From the HRV stories, for sure all the people you had already on your show are great experts. For the fitness, I would need to think about it, because the research I’m doing, being a researcher now it means it’s going to take some time before it’s out. So I’m sure there are a couple of other groups that are doing great work there, but I haven’t seen much yet.

[Damien Blenkinsopp]: Okay. Well we’ll be linking to your stuff in the show notes of course, so people can check that out.

[Marco Altini]: Maybe I’ll think of something and I’ll get back to you on that.

[Damien Blenkinsopp]: Great, thanks.

[54:34] I’d also like to learn a bit more about your personal approach to body data. Do you track any metrics or biomarkers for your body on a routine basis, whether they be labs, and so on.

I know currently you’re using your own fitness index, correct? What are you doing in your life, or what have you been doing over the last year?

[Marco Altini]: So basically I’ve much of a maker approach. I use this stuff all the time when I make it because I want to try things first and it helps me understand the limitations a lot and where things can improve. So I’ve been using HRV for a long [time] because I have these apps around HRV and now I’m using also these ones about fitness.

In general, the only things I really track are my trainings. So I like to track that and see improvements there. And that’s why I also work around these variables which are connected to activity and fitness, and try to basically close the feedback loop, like with HRV, that gives you advice, and fitness that tries to quantify what your basically current level, what performance can you achieve.

[Damien Blenkinsopp]: Great, great thanks.

[55:45] Have you got any insights, like from the data you’ve collected, have you got an insights about your biology? Have you made any changes to behavior, or taken some kind of actions?

[Marco Altini]: No. I haven’t yet. It’s not that I didn’t get any insights, but I think it’s important to track first for very long periods. Meaning a year at least before you can start making changes.

Because so many other parameters affect our physiology and performance, especially if I consider training there are months where everything looks the same. Like maybe I haven’t traveled much, and I kept my diet the same, and my stress at work is pretty much the same. And I think I haven’t over-trained, but still there are some weeks where you don’t perform very well.

So it would be sometimes easy to make the wrong conclusions if you tend to make too many changes. So I think it’s good to track for very long periods, even HRV, to get all the values you see. And then you look afterward how your training had an impact and all of that. And then you try to make adjustments.

Maybe around HRV I am making adjustments, like I tend to follow now what I see there. You find something very interesting things, like sometimes you can spot you are sick before you actually realize you are sick. You do your test in bed because your HRV is like…hugely affected by that, for example like even just a fever or something.

Maybe in the morning you don’t just feel particularly well, but it seems just a regular day. And then your HRV is terribly low, and then the day after you’re sick. And that’s quite interesting to see.

[Damien Blenkinsopp]: I definitely rely on it. I’ve seen that a number of times. If it really drops, then I’m like, “Uh oh.î I’m going to get some vitamins, liposomal vitamin C and stuff like that to try and void the crash the next day. Or minimize it a bit. So I think it is pretty useful like that.

[Marco Altini]: Yeah, it’s quite interesting.

[57:41][Damien Blenkinsopp]: Okay, so what would you number one recommendation for someone trying to use data to make better decisions about their health or performance or longevity?

[Marco Altini]: Be consistent. Don’t expect short term miracles but keep doing it, keep tracking. Try to understand at your personal individual level what is affecting these variables and then slowly start to make changes and bring to mind how these changes affect the rest. Let it be, I don’t know, performance or whatever variable that matters to you.

[Damien Blenkinsopp]: Yeah, I think you make a great point because as you were saying, there are so many different variables which we can’t keep track of. Especially in our busy lifestyles today. Whether it’s travel, a different location, different food, different sleep conditions, or maybe just different supplements and other things if we’re experimenting things. There are a lot of different variables that can influence it. So that makes a lot of sense.

So Marco thank you so much for your time today. It’s been a great chat.

[Marco Altini]: Thank you Damien.

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Heart disease affects 50% of the U.S. population in their lifetime. Learn how to accurately quantify your personal heart disease status and risk, and if necessary, take clear actions to reduce that risk by eliminating plaque in the arteries.

This episode presents an in depth look at heart disease because this is one of the most likely things to shorten our lifespan. We focus on the key topic of quantifying your real heart disease risk.

One in three deaths in the United States are caused by cardiovascular disease. Even worse, one of out two Americans will suffer some form of heart issues, meaning that one half of the population is at risk. The total costs for dealing with heart disease are larger than any other disease by far, estimated at 650 billion dollars in the US.

While heart disease is a big risk which is worthwhile taking a look at, it is not a big risk for everyone. For some people there are other health risks they should look at and assess. Thus it is important to know if heart disease is something you personally need to act on – in a proactive way which reduces the risk for it. Are there specific factors you need to be concerned about?

The way to approach this issue is by quantifying our risk for cardiovascular disease. Naturally, understanding of risk goes beyond the typical cholesterol numbers. We discussed some of the problems with cholesterol biomarkers in Episode Seven with Jimmy Moore which is a useful preamble to this episode. In this show we go deeper into details, looking at metrics which give you a real accurate view of your heart disease status and risk.

There is a way to be very accurate, both [by] blood work and by imaging. To really nail down your personal risk of experiencing the number one killer in the Western world, heart disease.

– Dr. Joel Kahn

Dr. Joel Kahn
University Professor & Heart Prevention Doctor

Joel Kahn has focused his career on preempting cardiovascular and heart disease. His goal is to reduce risks as well as to avoid surgery and cholesterol – lowering drugs. He takes a proactive approach by using information and interventions to ensure that heart disease does not become a problem in patients.

He is a clinical professor of medicine at Wayne State University School of Medicine, and Director of Cardiac Wellness, Michigan Healthcare Professionals P.C. He is a Summa Cum Laude graduate of the University of Michigan School of Medicine and author of two books, The Whole Heart Solution and Dead Execs Don’t Get Bonuses: The Ultimate Guide to Survive Your Career With a Healthy Heart.

Joel has also recently set up the Kahn Center for Cardiac Longevity. In their institution they emphasize early imaging of arteries and extensive laboratory evaluation for the correctable root causes of heart disease. So Joel and his clinic have a very quantified and longevity focused approach to this whole area, which is great to see.

I think this is an episode everyone should listen to, because absolutely everyone is going to have to deal with these issues in their life. Inevitably everyone comes into contact with heart disease, whether it be through themselves, their family, or their friends.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. I’d love to hear what you think of the episode – and if it has helped you – let me know in the comments!

itunes quantified body

What You’ll Learn

  • What led Dr. Kahn to choose a career in cardiology (4:30) .
  • A holistic view of the true causes behind developing heart disease (6:17) .
  • The causes behind heart attacks and strokes are tightly related and how both conditions are preventable (9:05).
  • How the condition of the endothelium (inner wall of blood vessels) and mitochondria affect cardiac health (10:26).
  • The biomarkers Dr. Kahn uses in his practice and ways to personalize medical and lifestyle advice (15:08).
  • Infrared Sauna treatment is proven to have positive effects on cardiovascular disease treatment (23:27).
  • Using chelation in treating disease to lower toxins levels – including heavy metals (26:03).
  • Early detection of coronary artery plaque using a CAT-scan for coronary artery calcium (30:47).
  • Because CAT scans are radioactive an ultrasound-based carotid IMT test is used for following disease progression (37:09).
  • How to get informed and decide whether to get a coronary calcium test (39:24).
  • Understanding genetic testing results in conjunction with imaging of arteries (41:04).
  • The Liposcience NMR technology platform offers the most accurate measurement of LDL cholesterol particle density (43:35).
  • Familial genetics and lifestyle when tracking lipoprotein levels as a biomarker for cardiovascular disease risk (44:07).
  • Using C- Reactive Protein (CRP) as a biomarker for cardiovascular disease risk (46:36).
  • Measuring blood vessels inflammation as part of a comprehensive heart health assessment (48:04).
  • Diet recommendations for preventing heart disease and examples of successful programs (50:00).
  • Replacing dairy products with healthy hydration is beneficial but strict ketogenic diets exhibit negative health effects by causing adrenal stress (54:19).
  • Why dark coffee is generally a health drink and the caveats to consider when consuming coffee (59:00).
  • Scientific and medical practice sources for discovering topics in this episode (1:01:32).
  • The biomarkers Dr. Joel Kahn tracks on a routine basis to monitor and improve his health, longevity and performance (1:03:50).

Thank Dr. Joel Kahn on Twitter for this interview.
Click Here to let him know you enjoyed the show!

 Dr. Joel Kahn & The Kahn Center for Cardiac Longevity

Books by Dr. Kahn

Tools & Tactics


  • Far Infrared Sauna: Sauna treatment improves heart health, especially in patients who have suffered heart attacks or have blocked arteries. As Dr. Kahn claims, repeated treatment consisting of 15 minutes infra-red sauna followed by 30 min rest helps the body sweat-out toxins and improves cardiovascular system function (See study looking at use of infrared sauna therapy for heart patients).
  • Chelation: Chelation therapy has been scientifically proven to rid the body of excess of toxic metals and is approved by the FDA for this purpose. This published study summarizes the findings of the US National Institute of Health clinical trial – specifically on using intravenous EDTA chelation therapy for coronary heart disease. We covered chelation and removing metals in greater depth in past episodes: episode 13 with Chris Shade (Mercury) and episode 19 with Garry Gordon.


  • EDTA: EthyleneDiamineTetraacetic Acid is the main chelating supplement discussed in this episode, and which is supported by the studies, in particular to chelate lead.
  • Niacin: Also known as vitamin B3 – is an essential human micronutrient. Supplemental niacin is primarily used to treat high cholesterol. Dr. Kahn claims that niacin is particularly good at lowering lipoprotein(a) levels – a proven risk factor for cardiovascular disease.
  • Proline / Lysine: Dr. Kahn claims that intake of these amino acids may prevent the damage that lipoprotein(a) otherwise imposes on the cardiovascular system.
  • Coenzyme Q10 (CoQ10): Helps support healthy mitochondria in cells. In turn, this maintains a robust cardiovascular system. Dr. Kahn encourages most of his patients to take this supplement.
  • Vitamin CLiposomal Vitamin C: Proponents of the Pauling Therapy from Linus Pauling argue that heart disease can be treated, and even cured, by substantially increasing Vitamin C intake.

Diet & Nutrition

  • Nitric Oxide (NO) Supporting Foods (Watermelon, Hemp Seeds, Pine Nuts etc.): Nitric Oxide (NO) is synthesized by the inner walls of blood vessels – known as the endothelium. It prevents arteries from constricting or spasming. NO prevents heart attacks in both an immediate and a long term time frame. Dr. Kahn suggests foods which support NO synthesis including watermelon, hemp seeds and pine nuts.
  • Coffee: As a drink, coffee is a rich source of beneficial antioxidants. However, it’s positive effects may depend in part on what type of caffeine metabolizer you are. If you metabolize caffeine slowly then you have a tendency to feel jittery or racing heart and there is some evidence that it may be less heart healthy than for fast metabolizers of caffeine. However, overall caffeine is considered a health food in most studies, and Dr. Kahn recommends 1 cup of black coffee per day to his heart patients.
  • Tea: The intake of tea is also an advisable health practice including green tea, herbal tea, hibiscus tea, or chamomile tea before bed – which is a source of sleep support.
  • Vegetarian / Vegan Diets: A vegetarian diet excludes meat by focusing on plants for food, but may include animal products such as milk and eggs. In addition to excluding all meat products, a vegan diet also excludes all animal products. Dr. Kahn argues that in world areas where people live the longest, and with the greatest freedom from heart disease, the populations are not completely vegan.
  • Paleo: This diet is based on the foods that paleolithic humans might likely have eaten. It includes meat, nuts, and berries, and excludes relatively – recently developed food products including animal products such as milk. Dr. Kahn described his view that there is a lack of scientific evidence to support this diet for cardiac health.
  • Ketogenic: A ketogenic diet is a diet that induces a state of ketosis in the body where the body uses ketones instead of glucose for fuel. Typically this involves a diet with low carb and low to moderate protein intake with high fat intake. Previously, we discussed measuring ketones and ketogenic dieting in Episode 7 with Jimmy Moore.



Cholesterol Based

  • High – Density Lipoprotein (HDL): The traditional measure of ‘good cholesterol’ used by doctors and healthcare. Levels above 60 mg/dL are considered protective of cardiovascular disease. Dr. Kahn stresses the importance of checking your cholesterol, even at around the age 18 or 20.
  • Low Density Lipoprotein (LDL): The traditional measure of ‘bad cholesterol’ – the type which causes heart disease. Less than 100 mg/dL is considered an optimal level, while levels between 160-189 mg/dL increase the risk for cardiovascular disease. Research has shown that LDL alone is not the best predictor for cardiovascular risk. Actually, LDL particles with the smallest sizes are most damaging to the cardiovascular system. Dr. Kahn puts more emphasis on using the LDL particle number and LDL particle size metrics.
  • Lipoprotein(a): Lipoprotein molecules carry cholesterol and similar substances through the blood. A test can be done to measure a specific type of lipoprotein called lipoprotein-a. Higher levels of this marker are associated with risk of artery damage. Dr. Kahn states that in most labs normal reference ranges for lipoprotein(a) should be under 30 mg/dL.

Blood Sugar Regulation Markers

  • Fasting Glucose Levels: A biomarker used to understand blood sugar regulation. Optimum levels are between 70 and 90 mg/dL. Higher levels indicate some level of blood sugar dysregulation, which increases risk for diabetes II.
  • Hemoglobin A1C: A form of hemoglobin which is measured to identify the average plasma glucose concentration over prolonged periods. Higher levels of hemoglobin (A1C) indicate poorer control of blood glucose levels. In turn, these are associated with diabetes and cardiovascular disease risk. Normal levels are less than 5.7%, pre-diabetes levels range between 5.7 to 6.4%, while higher than 6.4% is indicative of diabetes.

Inflammation Markers

  • High Sensitivity C-Reactive Protein (hs-CRP): Elevated hs-CRP levels indicate inflammation which is damaging to inner artery walls. If your level is below 1 mg/L then you do not have a cardiovascular disease risk. Because of the proven clinical use of this biomarker, Dr. Kahn claims it is high time for cardiovascular patients to start measuring hs-CRP.
  • Homocysteine: Elevated homocysteine blood levels indicate blood vessel inflammation and higher risk for coronary artery disease. This marker has previously been discussed in episode 5 with Ben Lynch and in episode 29 with Dr. Nicolson.
  • Lipoprotein-associated phospholipase A2 (Lp-PLA2): This biomarker gives insight into inflammation of blood vessel walls and is useful as part of a comprehensive assessment. The PLAC test measures the activity of ALp-PLA2 (an enzyme) in a patient’s blood. Individuals with test results showing Lp-PLA2 activity greater than 225 nmol/min/mL are at increased risk for cardiovascular disease.


  • Ferritin: Serum ferritin acts as a buffer against iron deficiency and iron overload. Levels are measured in medical laboratories as part of the workup for detecting iron-deficiency anemia. The ferritin levels measured usually have a direct correlation with the total amount of iron stored in the body. Female normal reference range is 12-150 ng/mL and for males it is 12-300 ng/mL.
  • Myeloperoxidase: A very sensitive biomarker for predicting myocardial infarction in patients with chest pain. It shows added predictive value compared to measuring hs-CRP alone.
  • Vitamin D: A vitamin which is essential for bone development and maturation and prevents osteoporosis. The Vitamin D Council suggests an optimum level of 50 ng/mL. The 25-hydroxy Vitamin D Blood Test is the most accurate way to measure how much vitamin D is bioavailable to be used by your body.
  • Free Testosterone: A steroid sex hormone. Physiological effects include muscle growth, increased bone density, and development of male sex characteristics. Free Testosterone is a small portion of this hormone which is bioavailable, because it remains unbound by carrier proteins in the bloodstream. Free testosterone reference ranges for females are 1.0-8.5 pg/mL and 50 – 210.3 pg/mL for males.
  • Estradiol: This is the primary female sex hormone. For females, the levels of this hormone vary greatly because of its key role in regulating menstrual cycles. In the normal reproductive cycle, estradiol levels measure typically <50 pg/ml at menstruation, rise with follicular development (peak: 200 pg/ml), drop briefly at ovulation, and rise again during the luteal phase for a second peak. At the end of the luteal phase, estradiol levels drop to menstrual levels unless there is a pregnancy. The reference range for healthy adult males is 14-55 pg/mL.

Lab Tests, Devices and Apps

  • Coronary Artery Calcium Score (CASC) Test: This test is a type of CAT scan which determines whether your arteries contain clotting plagues by quantifying calcium presence. By measuring calcium scores, the extent of blocking can be determined. This test lasts very short (under a minute), does not require injections, and is not claustrophobic. CASC tests have been shown to predict mortality.
  • Carotid Intima-Media Thickness (IMT) TestThis test measures the thickness of the walls of your arteries and helps determine whether you have a higher risk for cardiovascular disease. Individuals with unwanted CASC Test scores should undergo IMT ultrasound as a follow up for disease progression or risk. This is because the CASC test is based on a x-ray CAT scan, as opposed to the harmless ultrasound waves used in the IMT test.
  • WellnessFX Cardio Lipoprotein Profile: This test panel includes a number of lab tests, including the comprehensive analysis of lipoprotein particle numbers and sizes. It uses the accurate direct-measurement laboratory method (NMR (Nuclear Magentic Resonance) lipoprofile). Individuals with patterns of higher counts of smaller particles have a more concerning lipoprotein profile than those with less particles with greater size.
  • Life Extension Company Blood Testing: Joel mentioned LEF as one of the organizations that provides direct to consumer blood testing that he trusts.
  • Caffeine Metabolism Genetics: Whether you metabolize caffeine more rapidly or slowly depends on the presence of a Single Nucleotide Polymorphism (SNP) genetic variation in the liver enzyme responsible for metabolizing caffeine. The company 23andMe offers a genetic test for identifying slow metabolizes who may be at increased risk for cardiac attack due to coffee consumption.
  • Toxin Concentrations: These can be measured using blood or urine tests available in specialized labs. We’ve covered this subject extensively in previous episodes – see episode 13 with Chris Shade (Mercury), episode 19 with Garry Gordon (Lead) and episode 23 with Kara Fitzgerald (other metals and chemicals).

Other People, Books & Resources


  • Dr. David Katz: Founding director of Yale University’s Yale-Griffin Prevention Research Center and current President of the American College of Lifestyle Medicine.
  • Tim Russert and James Gandolfini: Both men were prominent individuals in American culture, whose lives were shortened by sudden unexpected cardiac attacks.
  • Linus Pauling: An American biochemist, author, and educator as well as one of only four individuals to have won the Nobel Prize twice. During the 1990s Pauling put forward a plan for the treatment of heart disease using vitamin C.
  • Stormie Jones: Was the world’s first recipient of a successful simultaneous heart and liver organ transplant at the age of sixShe suffered from an inherited genetic condition named Heterozygous Familial Hyperlipidemia which made her liver unable to remove cholesterol from her bloodstream. In turn, this was also causing her serious heart problems.
  • Nathan Pritikin: An American inventor, nutritionist and longevity researcher. His program features the Pritikin Diet which is focused on a variety of whole (unprocessed) or minimally processed foods.
  • Dr. Dean Ornish:  A cardiologist and the founder of the non-profit Preventive Medicine Research Institute. He coaches patients towards a vegetarian diet but not a strict vegan diet. His program is defined in four specific elements of lifestyle. It is the first scientifically proven program to “undo” (reverse) heart disease by optimizing stress, diet, physical activity, and social support.
  • Dr. Caldwell Esselstyn: His proposed diet for cardiac health is strictly vegan with under 10 percent of calories coming from fats. His program for patients includes walking, meditation, stress management, yoga, and other lifestyle choices to decrease cardiovascular disease burden.
  • Dr. Neal Barnard An associate professor of medicine at the George Washington University School of Medicine. He has led numerous research studies investigating the effects of diet on diabetes, body weight, and chronic pain.
  • Dr. Garth Davis: Among the leading researchers in the field of bariatric medicine – a branch which deals with the causes, prevention, and treatment of obesity.
  • Dr. William Davis: A cardiologist and author of the Wheat Belly blog.
  • Dr. David Perlmutter: A Board-Certified Neurologist and Fellow of the American College of Nutrition.
  • Dr. Alessio Fasano: An Italian researcher who sees pediatric and adult patients in the Center for Celiac Research and Treatment at the Massachusetts General Hospital. He is carrying out important research on the health impact of eating grains.


Books and Video

Full Interview Transcript

Click Here to Read Transcript

[04:30][Damien Blenkinsopp]: Joel, thank you so much for coming on the show.

[Joel Kahn]: My complete pleasure.

[Damien Blenkinsopp]: So, I’d like to start with a quick story about how you became a cardiologist; why did you get into, specifically, holistic cardiology?

[Joel Kahn]: Sure.

I knew really from a very young age that I wanted to be a cardiologist. I actually had a very small issue as a young child with a tiny hole in my heart. It healed, but I had the pleasure of seeing a very fine heart doctor until I was about 18 years old.

It had a very good impression on me; [there were] a few scary moments being in a big hospital as a little kid, but overall it was actually very positive. And kind of pursued a fast tract to making this my career. I’ve been doing it now for almost 26 years after training.

Holistic? I just always felt people are more than a pill. Doctors are wonderful people, nurses are wonderful people; I don’t have a chip on any shoulder. But I was exposed to some really good people. I got very involved in nutrition, nutrition lead to Mind Body, nutrition lead to Standard and Alternative Fitness, nutrition lead to supplements, Yoga, meditations.

So I just poured my heart and soul into studying and learning, and expanding my tool box for patients. And then I said, I’m going to start writing about it, because I don’t know if [they] are practicing it. So it’s all been a wonderful journey that’s far from over.

[Damien Blenkinsopp]: I didn’t realize you’d had that heart issue. Is it completely resolved now?

[Joel Kahn]: Yeah. Yeah. It’s very common, a little worrisome to the parents — god bless my mother and father. But it’s another example of if you don’t get in the way of things, the body can often heal itself. And this was a relatively minor thing, so good for that.

[Damien Blenkinsopp]: Great to hear. And it gave you the motivation to get started in all of this. It’s kind of funny who life always does that; it kind of steers us in the direction we end up going.

[06:17] I was wondering, because you’ve been looking at this holistically — and a lot of people focus on the heart, cholesterol, and things like this — could you explain what a formula to get heart disease would be, in terms of a holistic view? Because when you read through your book, it gives you a much more global view of how heart disease comes about than we’re typically used to.

[Joel Kahn]: Yes. And you know, we don’t want to throw away the basics. In essence, there’s two ways to approach this.

Our government, the United States government, has been publishing for a while, every 10 years, major causes of death. And unfortunately heart disease is at the top of that list, every list, every 10 years. But that’s not really the true causes, and starting in 1993 some very open-minded researchers said, “Let’s talk about the true causes.”

And the true causes for 80 to 85 percent of premature deaths were three activities: smoking, poor fitness, and poor diet. And those true causes dwarfed everything else. And it always dwarfed genetics. It’s a lifestyle world, baby, in terms of developing or preventing heart disease.

So, heart disease develops because we smoke too much; fortunately, under 20 percent of the population, and it used to be 40 to 50, so major inroads, it’s falling. Heart disease develops because we don’t move enough, and we’ve gone from farming and active community 150 years ago to everything being tech based, and we’re blessed with all of that. But we are paying a price.

And we now have to use, I have an app on my phone that reminds me to stand 5 minutes every hour. So we’ve come full circle, where technology was the problem and now technology will provide solutions. And desks that go up and down so you can stand at work and such.

And then heart disease develops because of the change in our diet since the Golden Arches hit California in the 50s, and all that’s followed with giant companies and processed food, and our crazy lifestyle where we don’t have time to make meals from whole foods anymore. Those are the big three by far.

A good friend at Yale, head of Preventative Medicine Dr. David Katz says, “Forks, fingers, feet.” Fork, what you do with it will determine your life; fingers what you do in terms of smoking, and feet whether you move and exercise that body. And really that accounts for the majority of it.

Sleep, stress, and love would be the other three. Adequate sleep, managing stress, and including yourself in a community to be surrounded by loving, like-minded people would round out the top six. And that’s a pretty holistic view, but it’s not very difficult, and it’s not very sophisticated.

[Damien Blenkinsopp]: Yeah, great, thank you very much for that.

[09:05] And I think when we think about heart diseases we often think about heart attacks, but is stroke related to heart disease as well? Is that one of the outcomes from the same kind of mechanism?

[Joel Kahn]: Yes. Stroke is a little bit more diffuse or widespread in terms of trying to nail down the cause. The number one listed cause of death in the United States is heart disease, such as heart attack. And number three is stroke, with cancer between the two. Therefore, if you lump heart disease and stroke, cardiovascular disease is the number one cause of death in every segment of the population over age 30, men and women.

But stroke has a shared cause to heart attacks; that is you can get clogged arteries from the lifestyle measures, and in part genetics that I just ran through. But there are other causes of stroke: bleeding disorders, heart rhythm disorders.

So the data is you can prevent about 80-90 percent of heart attacks through adopting a healthy lifestyle that’s neither expensive nor difficult, just rarely done. And you probably can prevent about 60 percent of strokes. It’s not as high because the cause is more commonly something other than atherosclerosis, or hardening of the arteries.

[Damien Blenkinsopp]: Great, thank you for that. Yeah, because I wasn’t really aware that they were so tightly related and preventable as well.

[10:26] In terms of stressors and some of the other mechanisms, could you talk a bit about the actual mechanisms behind heart disease? How this takes place? Without getting, obviously, into crazy detail, because it can get pretty detailed.

But in your book you talk about a variety of factors that we don’t often think about, such as mitochondria, and the gut, and other areas. And we don’t think about those leading to heart disease. So could you give us some kind of overview to show us how these mechanics are working to create a condition.

[Joel Kahn]: Well certainly, and one term that readers and listeners may not be familiar with but is important to grasp is something called your endothelium. And that is, essentially, inside every artery in your body — miles and miles of arteries carrying blood to your brain, your pelvis, your heart, your organs, your toes — is a one cell layer thin lining, like wallpaper on a wall.

And until about the 1980s we thought it was simply just a cell barrier between blood on the inside and the structure of the wall on the outside. But now we know that the endothelium makes many chemicals, the most important of which, or perhaps the most crucial, is nitric oxide, a little simple gas that in a healthy artery is created in abundance.

Arteries making nitric oxide because of a health endothelium will resist the clotting of blood; you want the clotting of blood when you cut your finger, you don’t want the clotting of blood when you’re on the verge of a heart attack. The nitric oxide will prevent; arteries from constricting, or spasming, which again can trigger a heart attack; the Raynaud’s blue-white-red fingers some people struggle with in the cold; leg pain on walking; and also the actual plaque, the actual build up of debris in arteries is resisted by a healthy endothelium with healthy production of nitric oxide.

So, that’s one physiology, and the good news is things that we would associate with a healthy lifestyle –eating a lot of produce, fresh fruits and vegetables, exercising your body, adequate sleep, good blood pressure, good blood sugar, good cholesterol numbers from a healthy lifestyle — are all associated with a healthy endothelium. And if you have a sick endothelium, you can make it healthier though a healthy lifestyle.

All of these things resoundingly shown scientifically. For example, eating watermelon, [it’s] very rich in chemicals that support nitric oxide. Hemp seed [is] very rich in chemicals that support nitric oxide. Other seeds and nuts similarly: pine nuts.

The other one [is] as you mentioned; inside every cell are little organelles, or little structures inside our cells. We have trillions of cells —- brain, heart, muscle, everywhere — and their powerhouse to generate function is called your mitochondria. We don’t think about them, we don’t give our mitochondria a kind of shout-out, we don’t wake up in the morning and say, “Thank you mitochondria for taking care of me while I slept seven and a half hours.”

But indeed, aging is a stress on our mitochondria where they won’t function to make energy so well. And unfortunately we now know not only bad lifestyle, which is way too common — sedentary lifestyle, food-based poor lifestyle, smoking poor lifestyle — but environmental toxins clearly affect our mitochondria: pesticides, herbicides. There’s data that genetically modified products and the herbicide roundup affects our mitochondria. Nutritional deficiency like low magnesium from not eating enough produce affects your mitochondria.

And our cells will age quicker and won’t function as well, and may produce fatigue, may produce congestive heart failure, shortness of breath. But again [it is] an area of science that is very hopeful, because lifestyle can cause our mitochondria to be much more efficient, and, probably most strongly, exercise. The actual number and health of your mitochondria in your muscles goes up when you exercise. You actually, you can be in your 40s and 50s and you can create more mitochondria by regularly exercising to a fairly vigorous degree for a while.

So yeah, those are concepts that I think are important to share. And there’s ways to boost the function of both our endothelium and our mitochondria, both by lifestyle, and not — I’m a fan of selected supplements. The supplement Co-enzymeQ10, CoQ10, which is more commonly used in Europe than the United States, helps support healthy mitochondria and [it’s] something I encourage most of my patients to be on.

[15:08][Damien Blenkinsopp]: Great. So, on this show we talk about a lot of biomarkers, and I know you have preferences for different biomarkers from the standard.

Could you, first of all, walk us through some of the very typical. I mean, when most people go to their doctor they are given the standard cholesterol markers. So could you talk through the LDL, the HDL, the total cholesterol, and if you use those, and how useful you find them.

[Joel Kahn]: First step, and I always like basics, is get your cholesterol checked, even at around age 18 or 20. Because one out of every 400 people may have an inherited disorder called Heterozygous Familial Hyperlipidemia, or FH, and you may be 18 years old with a cholesterol 450.

One out of every 400 is not all that rare. In a typical high school in this state that might be six kids. And it’s better to know it at age 18 or 17 than to find out in an emergency room at age 45 with a heart problem.

But in my practice, I do advanced cholesterol lab values. There’s a variety of different ways. For example I can see two people with a cholesterol of 220 and the LDL cholesterol of 120, and they may be at very different risk for artery damage because we can break down the size of their LDL, the number of particles in their LDL. Usually it’s a technology called NMR spectroscopy, but it’s become a very low cost lab that’s much more accurate.

So I can have two people and I can speak to them differently; that’s called personalized medicine. And say, “Nancy, your LDL is actually very favorable. You don’t have much. They’re large particles, and I think we can leave you alone and continue your good lifestyle. And Joe, your LDL of 120 is constructed largely of small, dense particles, and you’ve got way too many of them. And we’ve got to really kick that lifestyle in gear, and your nutrition in gear, and we’ve got to get that belly a little thinner.”

You know, it can help me define a more guided approach. But when we’re talking population, a standard finger prick or church-based or work-based cholesterol is a good starting point.

[Damien Blenkinsopp]: Right. It’s just a screen to see if it’s worth digging further. So basically, if LDL comes up high, you’d be like, okay I’ll look at the particle number and size to see if this is a problem.

[Joel Kahn]: It can. Yes, that’s one of the things we can do to refine if, everybody needs encouragement about lifestyle, but if they need beyond that consideration of medication or more intense lifestyle.

[Damien Blenkinsopp]: Great. So is it possible for someone to have a high LDL number, which is over the standard reference range, and it not be a problem because the size of their particles is large and small number of particles, basically?

[Joel Kahn]: Yeah. We broke up a little, but cholesterol is associated with developing heart disease. And it is causative, there’s no doubt. I mean, I reflect back when I was in cardiology training in Dallas, Texas.

I took care of a little girl, 11 years old, who was known around the world, Stormie Jones was her name, sweet girl. And she was born with a genetic disorder where she had both genes defective, that was called Homozygous FH. It’s very rare, it’s about one person in a million. But that little girl had had a heart attack, a bypass, a balloon, by the age of 12. And to argue that cholesterol doesn’t have a direct role in damaging arteries has many pieces of science behind it, animal and human, but I always reflect back on Stormie Jones.

So cholesterol is important, but there’s so much variability in human physiology. So when I’m dealing with one person, I try to find if their arteries are healthy or not. There are ways to determine if there’s any early plaque, if there’s any early endothelial damage.

And if I see somebody with a fairly high cholesterol at age 60, for example, but they have no evidence of plaque, no evidence of endothelial damage I’d have a very hard case to put them on a prescription drug, in my mind, because there must be other factors that are protecting them. And yes, they may have an additional 30 or 40 years to worry about, but I’m really going to stress to that person lifestyle — healthy diet, exercise, weight management, blood pressure management — and not necessarily write a prescription drug.

And, you know, there’s always the opposite too. There are people that have had a heart attack, or a bypass, and relatively moderate risk factors, and then we really have to go on a search. We have to go on a search for other biomarkers, like something called Homocystine, lipoprotien(a), Ferritin.

There’s a lot of people that are prediabetic that fall through the cracks, and are suffering artery damage from their prediabetes, but it’s really not been offered as a diagnosis, and that’s kind of a very common one, for example.

[Damien Blenkinsopp]: Right. With the Homocystine, for example, are you looking for the causes? Or are you trying to look a bit further back?

So if you get some high cholesterol numbers and some particle numbers that are indicative, is homocystine more indicative of a cause, so you can refine your prescription, the treatment you recommend? Or is that just a basic filter for your assessment?

[Joel Kahn]: No, I think the ultimate joy is trying to get back to the root cause. And the root cause, certainly the majority of it, is lifestyle. And we’ve talked about that, food choices, which I’ll go over carefully with patients: processed versus unprocessed, high in saturated fat versus low, high in added sugar versus low. [And also] body movement, body fitness, body exercise, adequate sleep, methods of managing stress.

For example, it’s been shown that meditation can have a significant effect on lowering your cholesterol. Kind of pieces of scientific data that are published that aren’t talked about much. When you’re stressed out your cortisol level goes up, your blood sugar goes up, your blood cholesterol goes up, your blood pressure goes up. And a practice of breathing or yoga or meditation can fairly dramatically lower blood cholesterol.

So then getting at the root cause, now the question is after those basics, which need to be addressed every visit, over and over — sleep, stress, nutrition, fitness — do we go further? We do know that there are environmental toxins, and we do know that heavy metals we’re exposed to through cosmetics, through industrial exposure, through dental fillings. We often carry a burden of mercury and lead and cadmium.

Smokers not only are ingesting all kinds of toxic carcinogens, but the ground in Virginia is said to be quite rich in cadmium, which is fine if you have it in the battery that’s powering your radio but you don’t really want cadmium in your blood stream in your body. So you can use blood analysis, hair analysis — take a little snip of hair — or urine analysis and determine if a person has greatly elevated levels of some of the pesticides, herbicides, pollutants like heavy metals.

And sometimes the course directed at identifying and removing those can really restore a person’s health to a much higher level. It’s a slow process because you accumulate those things slowly, and any plan to exit them by avoiding; if it’s an industrial exposure taking more care or changing jobs, don’t walk on your lawn the day that they spray the pesticides or look for more natural organic way to treat your lawn. Consider whether your mercury in your mouth might be a problem or not, you can get tested for that, for example. All those things.

But then there are strategies to remove some of these toxins. And of course considering eating organic versus non-organic to lower our input of pesticides. These are all strategies; and then there are more advanced strategies.

I’m a big fan based on some very fascinating and rich scientific data of the health benefits of sauna on our overall health, and specifically our heart health. And the amount of data that supports it is surprisingly rich, but very rarely taught in the annuls of medicine, of course.

[23:37][Damien Blenkinsopp]: Is that any type of sauna, or is that the infra-red version?

[Joel Kahn]: Well the infra-red is the hottest and most widely mentioned, because in Japan, starting about 20 years ago, heart patients have been treated, heart patients who’ve had a heart attack, heart patients who’ve had blocked arteries or even the very serious problem called congestive heart failure, have been treated with 15 minutes of infra-red sauna followed by 30 minutes of rest and it has been shown that they can enjoy dramatic improvements in health.

And these are all actually published studies; scientific journals, some of them involving up to about 200 patients, which is getting to be respectable size for a research project at all. So that’s infra-red sauna, which is a special kind of deeply penetrating heated dry sauna; not that common in this country at this point. People can consider buying one for their home for under $1000 up to a few thousand, or finding a spa that might have an infra-red sauna, which is growing interest in this country.

But recently, as you may be aware, out of thin [24:50 unclear] came a large research study with 2000 people that were asked how often do you get in a sauna, how long do you sit in a sauna, and all that tracked with actually survival and heart health. And the number of days a week that people used sauna, and the number of minutes per sessions were kind of linearly related to overall health, which was large, and shocking, and made the news. And that’s a slightly different form of sauna. It was dry sauna but not infra-red.

So I think there’s much hope in perusing that. And the theory is that it may have something to do with detoxification. There’s no doubt that the sweat that is generated in such a thing as infra-red sauna is rich in heavy metals, richer than your urine or richer than your blood. You’re actually exiting these toxins from your body in your sweat.

So I’m a big fan of that. Then you can get into other approaches, so called oral chelation, juicing, using green vegetables like broccoli, sprouts, oregano, parsley and other greens to accelerate the exit of some of these toxins from your body in a fairly easy and natural way.

[26:03][Damien Blenkinsopp]: So it sounds like heavy metals in particular sound like something that you think they are quite relevant and important to heart risk issues.

Did you see, I believe there’s some studies with EDTA and heart disease more specifically and the impacts on it with some of the plaque and things on it. Am I correct in that, have you seen those studies?

[Joel Kahn]: Yeah. I was not a fan of recommending chelation. And so let me just take a step back, because not everybody is going to be familiar with chelation.

But because of industrial exposures to heavy metals in the 40s and the 50s — for example a worker exposed to arsenic in an explosion, or lead — there was an interest in trying to treat those acute toxicities. And various medicines like EDTA have been shown in those kinds of exposures to be quite helpful. And they’re, in fact, approved by the FDA for use in these industrial exposures to heavy metals: heavy lead, cadmium, mercury and such.

But in the process of some of those treatments, there were reports that people with heart disease were describing that they were having less symptoms. And some sharp clinicians were observing this and started to specifically treat some people with clogged arteries of their heart and their legs with chelation. And that, to this day in the United States, is not an FDA approved treatment; you won’t get paid for it, and in your charting you could be subject to some exposure for saying that’s why you’re treating them. Using i.v. EDTA for the reversal of atherosclerosis as opposed to heavy metal toxicity.

So, all of that was kind of subject to derision from the standard medical community, including myself. If you would have asked me four years ago, can we talk about the science behind chelation — I know there’s people that say they feel better, but do we have much science? You would have been very hard put.

So again, very forward thinking people about 10 years ago approached the National Institute of Health and said we need to resolve this; is this witchcraft, is this good care, and let’s do a study. And surprisingly the United States government came up with about 30 million dollars and designed a trial using kind of standard i.v. chelation protocols in, ultimately, 700 people that had survived a heart attack — that’s what was required to be entered in — and they were supposed to show up for about 40 weeks.

Some of them got EDTA based intravenous infusions, some of them got some vitamins, but there was no EDTA in there. And at the end of that study, which took a little longer to complete than hoped, was a little bit more difficult to recruit patients, but the overall trend of the study favored an improvement in outcome, like the combination of being alive, freedom from a heart attack, freedom from needing a bypass and hospitalization in those that got the active chelation.

And specifically two groups, if any of those 1700 people were diabetic or any of those 1700 people had actually experienced a fairly large heart attack in the background in their history, they had a dramatic improvement. It was a 40 percent reduced chance of having a bad outcome. And if you had a pill that within about four to five years reduced those bad events by 40 percent, you’d have a blockbuster new pill.

So chelation looked good, actually, and the combination of i.v. chelation plus potent multivitamins — because that was another aspect of the trial, it’s called the TACT trial, Trial to Assess Chelation Therapy — that the combination of i.v. chelation once a week and potent twice a day multivitamins had the biggest impact. But that was announced, I think it was around November 2012, so more than two years ago.

And there’s really been no movement since to seek out reimbursement, or FDA approval. Most doctors clearly are not set about to offer intravenous therapy. There’s a very small chance of harm. You can lower blood calcium levels because it’s going to chelate minerals, and calcium is one of those so very often the mixture has to have some nutrients and mineral support in it. But I have referred patients to colleagues of mine in the area that are experienced and certified in chelation.

[Damien Blenkinsopp]: Great, great, thank you for that, because the connection is appreciated by a lot of us.

[30:47] So I wanted to look at some of the, because I know you recommend some more accurate tests. For someone who really wants to know for sure their heart disease risk and where it’s at, if the status of their plaques, what do you use to accurately and directly see what the picture is looking like?

[Joel Kahn]: Yeah, well thank you for asking that question, because that’s really my passion. My passion is to teach people that there is a way to be very accurate, both by their blood work — and we talked about that — and by imaging, which we’re going to talk about right now. To really nail down your personal risk of experiencing the number one killer in the Western world, heart disease which can come on suddenly, without warning, and the next day there’s a funeral tragically leaving spouses and children and parents wondering how did nobody pick up that there was a burden of disease.

I’ll just give you a quick example. Sadly a friend of mine lost her husband, who was a prominent businessman in my town, who was a very fit person [who] ate healthy, looked good, wasn’t overweight, enjoyed athletics, and a little over two years ago went out for a bike ride on vacation and never came back. And was found at the side of the road and shown by autopsy to have a 99 percent blocked Widow-maker artery. And that shouldn’t happen.

My passion is to say, that’s tragic and we need to circle around that family with a lot of love, but let’s not let the next family and the next family and the next family, you know the Tim Russerts and James Gandolfini from Sopranos and such. We just had a bank president in my town, about three or four weeks ago, who experienced the same tragic end to his life, a man I’m sure was getting good medical care, absolutely.

So, there is the most accurate way right now to [if] you’re 45, 50, 55 years old, you’re concerned that this this number one killer in America could be creeping up inside silently; And you should be concerned, particularly if you’re overweight or sedentary, or [have] blood pressure, cholesterol, blood sugar issues, smoked in the past, [have a] brother, sister, mom, dad with heart disease.

There’s a CAT scan that takes 10 seconds, 20 seconds. You lie down, you’re pushed into a tube, a CAT scanner. It’s not around your head, it’s not claustrophobic. No i.v., no injection of medication. The CAT scan is done, you go home, you get a report. It’s called a coronary artery calcium scan, or coronary artery calcium score, CACS.

You can see the three heart arteries on the CAT scan without any injection of contrast material. Your arteries should contain no calcium; calcium should be in your bones and your teeth. If your heart arteries have calcium, your heart arteries have plaque. And you’re going to have that way before you ever need to have your bypass, your stint, or your heart attack therapy. So you can find out.

And there’s a number associated with it. If your score comes back zero, you have youthful arteries that are free of calcium, and your 10 to 15 year risk of a heart event are extremely low. Keep living healthy, but you can take a sigh of relief.

And if your arteries are prematurely calcified, you’ve got plaque. You may not be 80 percent blocked, you’re probably not going to need a stint or a bypass, but you need to see somebody about it. So that number could be 20, or 100, or 200.

I get people that show up, I saw one yesterday, totally good looking guy 61 years decent lifestyle, his calcium score was 1,100, mainly in the one artery we call the widow-maker. That’s a ton of burden of abnormal artery that we need to deal with by identifying why, and we’ve talked about some of that search.

He had already had a stress test that was normal, so he doesn’t need an angiogram, stint, or bypass, but now he needs a cardiologist who cares about lifestyle and all of the things we’ve talked about. We talked about yesterday about sauna, and heavy metal assessment, and advanced lipid blood work, and a daily aspirin. He’s a heart patient now, so I plead with people now.

[Damien Blenkinsopp]: Right. Yeah, I guess in that situation you would kind of throw everything at it, because it does sound like you were pointing out the worst case scenario, the worst score you’re likely to see.

Would you kind of throw everything at that case? Should he be really worried, and say, “Whoa, I’ve got to really change my lifestyle. Heavy metal chelation, everything I can.”

[Joel Kahn]: Yeah, that person needs to become a good student of the disease, reading my book, reading a book by Dr. Dean Ornish, a book by Dr. Caldwell Esselstyn. Many many good resources: Dr. Neal Barnard, Dr. David Katz. There’s plenty of good resources online for free, or books, or watch the DVD Forks Over Knives. I mean, many good resources, and I encourage my patients to do all of that.

But we ordered up a pretty in-depth analysis, and we’ll sit down in a few weeks and design a personalized plan. Now on the other hand, I see people all the time, they’re carrying extra weight, their cholesterol is 250, their diet isn’t exactly what I’d called in-line with nutritional goals, and their calcium score is zero at age 65. They’ve gone through six decades of life and are identifying no calcified plaque in their arteries, and their risk is very low.

And I don’t want them going to fast food places and eating their french fries, but I can cut back a bit on their medical treatment and focus on lifestyle with a great sense of joy and relief. And I see that a lot; a brother died at age 44 and the sister is zero and is going to smile for the next few years that she isn’t also carrying a burden of life-threatening plaque.

The oddity about the test is in the United States it’s not covered by insurance in about 48 states; 10 years ago places were charging 700 or 800 dollars. It’s very easy now to find that test under 150 dollars, sometimes under 100 dollars, which makes it very reachable for most people.

[Damien Blenkinsopp]: Is it quite widely available, like a lot of hospitals have these machines?

[Joel Kahn]: It’s just a standard CAT scanner, you do have to have special software to calculate that score, but it’d be very surprising if [in] most medium or large towns at least one of the hospital systems, or all of them, don’t offer it.

[37:09][Damien Blenkinsopp]: Okay. As it’s a CAT scan, is this something you shouldn’t do to often because of the radiation? With your patients, if someone’s got a score of 1000 or above, I guess you’re tracking progress over time to make sure it’s not increasing and you’re reversing some of that damage. But are you concerned at all about radiation, and do you do anything about it?

[Joel Kahn]: Well it’s an excellent question. I am a bit hesitant to repeat the CAT scan to follow their disease for two reasons: every time you do it it is some additional radiation, and number two there is not much data that you can drive that calcium out of the artery.

For example, the TACT trial, the chelation trial didn’t, unfortunately, assess calcium score. It would have been nice if we actually knew. So I don’t know the natural history. I know the natural history tends to go up if you do nothing; there are some studies that your calcium score may go up 30 percent a year. So if your score is 100 this year, it may be 130 next year. That’s just an average; it’ll be less for some, more for some. But I’m not so sure what I’d do with a repeat calcium score, because I fear they all go up.

There is an alternative test, called a Carotid IMT, intima-media thickness. This is an ultrasound. So ultrasound, of course, is no radiation; ultrasound can be repeated. And there’s about 700 medical studies on the value of having a special ultrasound machine with special software, that measures the thickness of the wall of your carotid artery.

And that is something you can track every year, every six months, compared to databases that have thousands of people age matched and sex matched, to make sure your arteries aren’t rapidly getting thicker and more plaque ridden. And hopefully actually seeing some improvement. So, if I have somebody with a bad calcium score, I’m probably going to use an ultrasound technique to follow them so I don’t need to keep exposing them to radiation.

That’s kind of a high level approach, but we’ve got the disease that’s the number one killer in America. So we’re throwing all kinds of high pollutant, expensive technology at other issues, it’s about time and way overdue that we try and prevent a million heart attacks in the next couple of years in this country so families don’t get ripped apart.

[39:24][Damien Blenkinsopp]: Who would you recommend takes the calcium scoring test?

[Joel Kahn]: Thank you for asking that. Not people who know they have heart disease. So if you’ve had a stint, a bypass, if you’ve had a previous angiogram that showed you’ve got 40 percent blockages, you already know you have a problem and you need to be working on it with somebody that can direct you.

However, it would be somebody aged 40 to 45 and up who has risk factors; brother, sister, mom, dad with early heart disease; high blood sugar; high blood pressure; smoker. Or maybe around age 50 to 55 just because you’re halfway through life and you’ve got the number one killer in America lurking around.

The American College of Cardiology, a fairly conservative group, gave very high endorsement of this coronary artery calcium score for people with risk factors. So if you’re 50 years old and you’ve got high blood pressure, boom: American College of Cardiology endorsed, and unfortunately not covered by insurance. They would leave it in a gray zone.

If you’re perfectly healthy 50 year old, do you need it? Well, I think that’s a personal decision between you and your doctor. I tend to favor getting one because it’s a very low dose of radiation and we still are dealing with the biggest silent killer in America.

There’s a very interesting documentary that came out two months ago called The Widowmaker. And it’s available online, about 90 minutes. I’d encourage anybody to watch it. It’s all about this topic of coronary artery calcium scoring and why is it not more available to make inroads into the health of Americans and identify those at risk.

[Damien Blenkinsopp]: Great, great, thank you for that.

[41:04]There are actually a lot of other blood markers. If you look at WellnessFX — I don’t know if you know the WellnessFX lab for consumers?

[Joel Kahn]: Which blood test is that, sir?

[Damien Blenkinsopp]: It’s not a specific blood test, it’s a lab which is directed at consumers. So it’s a company called WellnessFX, and some people are using those for blood panels.

[Joel Kahn]: Right.

[Damien Blenkinsopp]: So they have a large array. There’s a few companies like this, but WellnessFX is the best known at the moment. So it’s direct to consumer. They have a cardiovascular panel, which is why I bring it up. And there’s quite a few things on it.

So I wonder if you could just comment on some of the values that they include in their panel, if you find them useful. Because it seems like to me that there are so many markers linking to cardiovascular disease it makes it more complicated.

Because we have all these markers, and I’m sure someone like you could maybe get more data and get a better picture, but for the majority of us, it builds up this kind of complex mass of data. And maybe some of them would be out of range, some of them aren’t out of range, and we’re like, “Okay, so where does this put me? I’m not really sure.”

[Joel Kahn]: Yeah, I agree. I am familiar with WellnessFX. There are some others — I have no financial ties to any of these. There’s an organization that I very much like called LifeExtension.org. They’ve been in Fort Lauderdale for 35 plus years, and you can directly get a kit and blood work — a male panel, a female panel — and they’ve got hundreds of thousands of data points built up over the decades.

So you’re right, I think it is worth [it]. I have not seen the advanced lab test we talk about, the particle number, particle size. I have not seen that available in a direct consumer way; I’m not absolutely certain if that’s at WellnessFX. But you’re going to get a good screen, and you can learn quite a bit.

But I do go back to the idea that imaging arteries remains the kind of litmus test. You can have a lot of abnormalities in your blood stream, but you really need to know if you’ve either got thickened carotid arteries by the ultrasound, or if you have calcified, hard arteries by the CAT scan. You need to know that at least once to make sense of the blood work.

These biomarkers are all associations, where the imaging studies are direct imaging. So I favor the coronary artery calcium scan. In some places [it] requires a prescription, but since it doesn’t involve insurance, not everywhere, you can often arrange it on your own.

I encourage people to pursue these direct blood tests, like you said.

[Damien Blenkinsopp]: Yeah.

[43:35] I just wanted to go through a couple of them. You mentioned the NMR, which is, as I understand it, the most advanced blood test if you really want to understand your heart disease risk. Is that kind of the best one you find, in terms of accuracy and getting the closest to the same bar as the calcium score, if you’re just looking at blood?

[Joel Kahn]: Yes, in terms of blood, that LDL particle number which is most commonly obtained through the Liposcience NMR technology, is at the present, I believe, still the most accurate particle in the blood you can measure.

[Damien Blenkinsopp]: Yeah, Great.

[44:07] So WellnessFX, they have something called LPa, or lipoprotein(a). Are you up to speed on that one? Do you find that one useful? Because it’s a little bit similar in that it’s looking specifically at low density lipoprotein, I understand.

[Joel Kahn]: Yeah. Lipoprotein(a) is a cholesterol particle that a smaller number of the public has heard about. A very large amount of science saying it’s a blood test, the higher your level, the higher your risk of artery damage. It seems to be a highly inherited abnormality.

So I get it basically in pretty much everybody once, but I’m particularly aggressive in people that have a family history of early heart disease in their relatives, because that may be the factor. Usually in most labs lipoprotein(a) should be under 30, and in some patients of mine it’s over 200; it’s seven, eight, or nine times elevated above normal.

What is still lacking a bit is an absolutely clear cut trial that shows that lowering it — we can talk about lowering it in a minute — but lowering it makes a long term difference, just because there hasn’t been such a trial designed and carried out long term. Lifestyle can lower lipoprotein(a), hormonal balance of female and male hormones can lower lipoprotein(a), Niacin is particularly good at lowering lipoprotein(a).

And there’s some work going back all the way to Linus Pauling that you can minimize the effects of an elevated lipoprotein(a) by taking Vitamin C, strengthening the wall of your artery, taking some amino acids called Lysine and Proline, and that they may prevent the damage that lipoprotein(a) may do otherwise.

So there is, finally, there actually is a very strange therapy where, much like dialysis, you can get your blood cleansed through a filter. And this is an FDA approved treatment of people like that little girl I mentioned, Stormie Jones, if she were still alive today. That’s a therapy that would be used for somebody with a familial super high cholesterol.

But that filter also takes out lipoprotein(a), so if somebody has a very high level and vascular disease, that’s an option. So, it’s important, I believe, for people to measure their lipoprotein(a). And again it’s genetic, but I mentioned some things you can do.

[Damien Blenkinsopp]: Great, great.

[46:36] So one that I’ve been using for a long time is high sensitive TCRP. Is that something you find useful?

[Joel Kahn]: I do. We’ve been measuring C-reactive protein for decades, because we were measuring it to assess rheumatic fever, so it has a history going back literally decades and decades. But then along came a patented test, the high sensitivity test, and that seems to be more reflective of artery wall inflammation.

And inflamed arteries are more prone to suffer heart attack, stroke, clot and the rest. So you do not want an elevated high sensitivity C-reactive protein. And you want to measure it. And it is highly correlated with increased risk.

So then I’d get on a search for why it might be elevated, and most common would be abdominal obesity, poor nutrition, a lack of exercise, poor sleep or sleep apnea. But you can also look for occult causes like gum disease, periodontal disease and such, unsuspected prostate disease, prostatitis, and probably a diseased gut. Our Western processed foods, high in salt, sugar, and fat causing gut disorders. Lack of adequate microbiome health probably causes inflammation.

So you’ve got to work on the entire patient in a holistic way.

[48:04][Damien Blenkinsopp]: And so I don’t think we’ve really covered this properly, but inflammation is directly related to heart disease as well? Or is it a bit more of a wavy line?

[Joel Kahn]: Yeah no it’s prime time to measure inflammation and high sensitivity C-reactive protein. There’s also a number of other markers out now, like myeloperoxidase, and a test called the plaque test that give insight into inflammation in vessel walls and can be quite useful in a comprehensive assessment.

[Damien Blenkinsopp]: Great, great.

So in terms of some of these indicators, like CRP, the lipoprotein(a) , they’ve got others like alpolic protein, the HDL, the LDL, none of these are binary, as I understand them.

So if someone has a high CRP score, say it’s four or something like that, is that a sure thing that they have some kind of heart disease risk as well? Or could it just be related to some inflammation, or something like that.

You’re really using these as indirect indicators and you can’t trust the picture from that, but it’s just kind of a notice [that] I should go see a physician and investigate maybe if it’s calcium score.

[Joel Kahn]: Yeah. If it’s elevated, it should prompt a search into lifestyle, it should prompt a search into, as I say, gut health, gum health, prostate health, any other. Even though it’s felt to be largely a vascular marker, it’s a marker of the disease and it participates in, actually, vessel damage. But sometimes it can be very frustrating and unclear. I’ve had people with very high C-reative proteins: 40, 50, 60, 70, 80.

There’s a very limited experience with using a shotgun approach, after searching for every possible cause, an antibiotics like minocycline in the tetracycline family. I have been taught that, and I’ve had rare experience to do that with patients after a very thorough evaluation for every other kind of cause of elevated C-reactive protein. And it came down dramatically and stayed down.

[Damien Blenkinsopp]: Great, great.

[50:00] I wanted to tackle one thing. Could you go over the diet you recommend? As background, I’m Paleo and we’ve often talked about ketogenic diets and high-fat diets on here with people like Jimmy Moore and so on.

So could you give your perspective, where you come from with respect to heart disease; what kind of diet and lifestyle are you recommending?

[Joel Kahn]: I like to stay, in every aspect where I can, grounded in the science that’s available. And in terms of artery health, heart disease, survival and heart disease, the weight of the data is not in the ketogenic or Paleo world, the weight of the data like by 100 to 1 in terms of science at least, is in the world of nearly or completely plant based diet.

[Damien Blenkinsopp]: Okay, so is that a vegan diet?

[Joel Kahn]: Yeah. Well vegan, I’ll distinguish those very briefly.

But you can look at epidemiological studies like the Blue Zones, five areas in the world where people live the longest with the greatest freedom from heart disease, none of them are completely vegan. Except actually Loma Linda, California is one of those five Blue Zones, the longest lived community in American, and ten percent of that community is strictly vegan, the other 40 percent are vegetarian, and the remainder are omnivores. They are the longest lived people in the United States and they have the highest percentage of vegans in the United States of any community, because of the Seventh-day Adventist Church there.

So you can look at epidemiological studies like that, or you can look at the data on heart disease reversal, which is a concept that is scientifically sound. Two centers started studying [that], actually three, Nathan Pritikin in what’s called the Pritikin Longevity Center in Florida. He was an engineer, not a physician.

But Dr. Dean Ornish, a cardiologist, began in the early 1980s a lifestyle that is a largely vegan diet. If you really read between the lines its a very low oil, no added oil diet; so less than 10 percent of calories are from fat. He does allow his patients to have some non-dairy fats and some egg whites. So by strict definition it’s vegetarian not vegan.

And he has now pursued that dietary research for more than 30 years. It’s actually approved by Medicare, because the data is so strong that for heart patients it can halt and reverse their symptoms and disease, and minimize their need for medical care.

Dr. Caldwell Esselstyn began the same research project at the Cleveland Clinic in the 1980s, and has similarly shown [with] follow up catheterizations [and] follow up on patients’ health, dramatic reversal of heart disease without stint, without bypass. And his diet is strictly vegan and again under 10 percent of calories are from fats. Kind of the opposite approach to many ketogenic diets.

And, very compelling, Dr. Ornish has taken his program, which is more than diet —- Dr. Ornish emphasizes 30 to 60 minutes of walking, an hour of stress management by meditation or yoga, and group support — and has shown that in prostate cancer you can halt and reverse prostate cancer with his program. And he’s embarking now on a program in breast cancer, which I suspect, but we’ll have to wait, the results will be positive.

So it’s dramatic research, it’s not out of date. I hear some of my colleagues say, “Oh, Dr. Ornish’s data is aged, it’s old.” Well, he’s working with Nobel Prize winning scientists and continuing to put out some of the most cutting edge data on nutrigenomics and epigenetics. And his diet is one that if all of America were to follow to a large part we’d have a tremendous drop in the burden of chronic diseases like dementia, diabetes, cancer and heart disease. Without question; it’s been scientifically proven.

So my recommendation, I lead in Detroit a patient’s support group for people striving to stick to Dr. Ornish, Dr. Esselstyn, the Pritikin program, the Dr. Neal Barnard, you know, reversing diabetes program. And we have about 1000 volunteer people in the area that get together for meetings and group sessions, and it’s been profoundly effective in improving their health at very low costs, very grass roots.

[54:19][Damien Blenkinsopp]: Yeah. So what do you think of the Paleo principles of dairy and grain avoidance? Would you include those in your recommendations, or are those not relevant?

[Joel Kahn]: Sorry, the question was about grains?

[Damien Blenkinsopp]: Yeah, grains and dairy, in general.

[Joel Kahn]: I’d love everybody to stop eating dairy. I don’t view it as a health food in any setting, and it’s a tremendous burden on animals and the environment. And if somebody is not willing to eliminate animal products from their diet but would be willing to eliminate dairy, it’s one of the most frequent food allergens that people react to. It may be involved in the pathogenesis of Type 1 diabetes in children and young adults.

I wish we could legislate a dairy free world. Even the Harvard School of Public Health has advised greatly minimizing your dairy intake and replacing it with healthy hydration, like water, teas, and coffee, unsweetened; even alcoholic drinks, to a limited degree.

But grains, I know it’s contentious. I have had the pleasure of spending time with Dr. Bill Davis of Wheat Belly, Dr. David Perlmutter of Grain Brain, and I think also a name that’s not as well known, Dr. Alessio Fasano, who’s an Italian scientist now at Harvard who’s really doing amazing research on what grains do to Celiac patients and what’s the actual molecular pathways.

And I tend to favor Dr. Fasano, who I think I’m fairly quoting that one percent of the population is showing signs of Celiac disease, six to seven percent of the population if tested shows signs of gluten sensitivity. And that leaves over 90 percent of the population that neither has Celiac nor documented gluten insensitivity and if they’re reacting to grains, they’re reacting very briefly in a way that’s not a big deal.

And they should be part of a healthy diet. If you look at the scientific data, which I just reviewed and published a blog on in the past six weeks, even just in the last two years the data on whole grains and health is an amazingly strong body of data for survival, for freedom from heart disease, freedom from diabetes, freedom from cancer.

And it’s always a question, what’s it substituting? If you’re eating whole wheat pasta, whole wheat bread or wheat germ you’re probably not eating donuts and fried food and vending machine food because you’re exhibiting an intelligence in a selection on the healthier part of the spectrum.

So, I always encourage my patients that are having problems, take a four week elimination diet from gluten. If you’re having runny noses, rashes, if you’re having unexplained headaches, maybe even for an unexplained cholesterol elevation it could be that it’s inflaming your gut, and four weeks would give us some input on how you’d feel and biological markers.

But I eat whole grains consistently and recommend to my patients they do the same if they’re not in that small percentage.

[Damien Blenkinsopp]: Great, thank you for that clarification.

So if someone is on a Paleo diet or ketogenic high-fat diet, is there a test they could take? Would it be the calcium score, would you recommend that they take that if they want to assess if it’s having some impacts?

[Joel Kahn]: Yeah, well my comment and advice for those that are following a ketogenic diet is if you’re doing it for 10 days to fit into a tuxedo for a wedding, it probably will work and you’re probably not going to do yourself any harm. Long term, again I have to go to science, which there were at least two or three major studies saying long term low-carb ketogenic diets are associated with increased risk of death.

These are studies involving tens, and tens, and tens of thousands of people; yes, they’re databases, yes they’re association studies, but they are strong because there is no data that you live longer with a ketogenic diet. And in the last nine months there’s been specifically a study that ketogenic diets after heart attack are associated with the increased risk of dying.

So I strongly advise my patients not to follow ketogenic diets, and if they choose to, yes I think they should have all the biomarkers. If they don’t know of atherosclerosis then they should be having calcium scoring and possibly the carotid ultrasound testing. But I would advise them against it.

I know it’s all the rage, but it is a stress on the body, it’s a stress on the adrenals. And the healthy carbs found in vegetables, even starchy vegetables and whole grains, are adrenal pleasing sources of nutrition.

[Damien Blenkinsopp]: Great, great. Thanks for the clarification.

[59:00] Winding up, this is kind of a thing that affected a lot of my friends in their 20s. People were working very hard and were taking a lot of caffeine and generally very stressed, [and] we were getting a lot of pains around the heart area.

One of my friends went to a doctor and he said it was just stress and caffeine. I don’t know if you’ve come across this before; is this an issue, or is it just a symptom which isn’t really that important? Maybe too much caffeine or something.

[Joel Kahn]: Yeah. Caffeine in general, I mean it’s interesting. There is some genetic variation, and there is even a blood test you can get that’s a SNP, single nucleotide polymorphism, it tells you if you metabolize caffeine rapidly or slowly. If you metabolize it slowly, it’s going to hang around longer and give you more tendency to feel jittery or racing heart. And if you metabolize it rapidly, otherwise.

But with that aside, if it doesn’t bother you, caffeine is, in most studies, a health food. Now of course, like everything, you dump in some manufactured whitener and sugars, and you don’t have coffee anymore you have some modified, processed, anti-health drink. And certainly a frappuccino isn’t a cup of coffee.

But black coffee, dark roasted coffee two or three cups a day is generally a good boost in the morning, a good brain support. I always would cut it off about two in the afternoon so it doesn’t interfere with sleep. It’s a rich source of antioxidants.

There’s a little concern that your readers may know about that some coffees may be contaminated with mycotoxins, fungal toxins. You don’t really know it because it’s not measured and reported on American coffee sources; it is in Europe, and in fact there’s limits in Europe where they can’t be sold. Coffee beans sit outside and they can get moldy, and the mold can get into the coffee beans.

So you can ask around where you buy your coffee; it’s not a topic that a lot of people know about, and it may be a source of some illness for some people that are sensitive or are drinking lower quality coffees that may have mycotoxins.

With those couple of comments aside, I am pro-coffee. My heart patients ask me, I tell them enjoy a cup of black coffee. I certainly also urge them to enjoy green tea, or any of the teas actually; herbal teas, hibiscus tea, chamomile tea before bed [is a] wonderful source of soothing and sleep support.

[Damien Blenkinsopp]: Right. So it doesn’t sound like there’s any specific mechanism there which would be giving people heart pain from just coffee. Maybe something more like stress?

[Joel Kahn]: Right. There should be no heart pain.

[Damien Blenkinsopp]: Okay, great.

[1:01:32] So, where should someone look first to learn more about your topic? Are there any good books, your books, or presentations on some of the subjects you referenced?

[Joel Kahn]: Sure. I [1:01:41 unclear] appreciated that, and I probably do need to get back to some hospital rounds here. But I do have an active website at www.drjoelkahn.com. And all the blogs and TV interviews and podcasts and things I’ve done over the last few years are there. I encourage anybody to take a peek.

I do have two books out. Last year The Whole Heart Solution, published by Reader’s Digest. And this year a self-published book — but they’re both on Amazon — it’s got the title, Dead Execs Don’t Get Bonuses: How to Survive Your Career With a Healthy Heart, which I think is an important topic and the title has caught a lot of people’s attentions. It’s a real plea to not be one of those dead execs, or dead anybodys, for as long as you can.

I would encourage anybody to read anything by Dr. Dean Ornish, Dr. Caldwell Esselstyn, Dr. Neal Barnard, Dr. Garth Davis in Houston. All active scientists, researchers, clinicians that I think are speaking from the heart about overall health and sort of bucking the trend that all fats are good and animal products are benign.

We just don’t speak about the environment enough. We just don’t speak about animal rights enough, and we have to have a holistic approach to our plate; our plate represents an impact on forests and impact on our waterways and impact on our grandchildren’s world. And our plates represent a process that is very often extremely cruel, extremely unfair to beings that feel and sense pain and terror. And it’s as if we can’t talk about that.

We have labels — Paleo, Mediterranean, Ketogenic — but that’s only partial descriptions. I like to eat a kind diet and my plate is filled with kindness. So I hope that spills into my life as much as possible.

[Damien Blenkinsopp]: Thanks so much for all of those references. That’s a lot of material for people to get through. We’ll put all this stuff up on the show notes, of course.

[1:03:50] One last question. In your own personal life, are there biomarkers that you track on a routine basis? What do you do in terms of collecting data for yourself, for optimizing health and performance, or whatever?

[Joel Kahn]: Yes. I mean, I’ll do inflammatory markers like C-reactive protein, advanced lipid tests like LDL particle number and size. I’ll look at my Vitamin D levels. I’ll look at my male sex hormone, estradiol, total and free testosterone; I try and keep those optimal through natural ways, exercise, weight loss, weight lifting and such, healthy diets, toxin free diets that don’t interfere with the process. Blood sugar and insulin sensitivity, fasting glucose, hemoglobin A1C, important markers. So those would round out the majority that I’m doing: homocysteine level

[Damien Blenkinsopp]: Great, thank you very much for that.

Well Joel, it’s been really great to have you on the show. You know, we’ve covered a lot of ground today and a lot of markers, and I’m sure it’s going to clarify a lot for the audience.

[Joel Kahn]: Well there’s so much people can do. They’re in control of their health. And it starts with realizing that, and realizing the power of food, the power of fitness, the power of abstaining from smoking, the power of sleep, the power of friendship, and then getting credible information. And your podcast has done a wonderful job [with that], and I’m very honored to be able to share with your audience.

[Damien Blenkinsopp]: Thank you.

[Joel Kahn]: Have a great day, sir.

[Damien Blenkinsopp]: You too.

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What is genetic testing able to do and not do with current services? We talk with one of the top genetic lab services to understand how technologies differ in accuracy and where it is working, where it is not yet ready and why.

In this episode we look at the impact that genetics has on our health and wellness. With rapid discoveries in epigenetics, the picture isn’t as clear as when we thought genetics was everything. Epigenetic factors regulate which parts of our genetic blueprints are actually active and working for us at a given time.

As previously covered throughout this show, the typical “cookie cutter” approach to genetic testing often doesn’t lead to results. We look at the potential for genetics to give us precision medicine and precision health, where people get targeted advice and care fit for individual needs. You are an individual; you are an n=1 experiment.

In which areas does modern day genetic testing give actionable information? For instance, what drugs should you use? What diet may best fit you? Which health complications are you most at risk for in the long term – so that you can strategically manage these and put the effort in where it’s really going to count for you?

We put a team together to really go after genetics as a solution for patients, and using genetics and genomics as a solution for patients, and also physicians, for risk assessment or to give them insight into personal issues and to try and take some action against it.
– Michael Nova

Today’s guest is Dr. Michael Nova. He is Chief Innovation Officer and Founding Executive at Pathway Genomics. The company is an accredited clinical laboratory that offers genetic testing services from screening for cancer and other disease predispositions – to precision health and medicine advice. These services differ and are broader than those of 23andMe, which you probably know about as you listen to this show – that’s the genetic testing company that most people have heard of and used.

Pathway Genomics is the first company to bridge artificial intelligence and genetics-based precision medicine or a health mobile app to consumers. It does this in partnership with IBM, and notably IBM Watson which is IBM’s artificial intelligence machine learning platform.

Dr. Nova is the inventor of many of Pathway Genomics’ solutions. He has over 30 patents and many studies published in peer-reviewed journals. He is also a winner of the World Economic Forum Technology Pioneer Award. Finally, he’s a serial entrepreneur and is on the board of advisors for IBM, which is a pretty big deal.

I hope you enjoy this interview with Dr. Michael Nova and it helps you to understand how genetics can be valuable to you personally.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. Enjoy the show and let me know what you think in the comments!

itunes quantified body

What You’ll Learn

  • Dr. Nova’s roots in genetics and how Pathway Genomics differs from 23andMe in structure, technology, staff, and interpreting testing results (06:12).
  • Why reporting on genetic tests varies between companies; why testing does not produce ‘black and white’ interpretations of tested parameters (15:22).
  • The meaning of personalized / precision medicine; current applicability and future prospects, as numerous testing technologies become cheaper (17:46).
  • How genetic test panels are researched and converted into actionable information for physicians and individuals (20:40).
  • The complexity of genetic and epigenetic tests and why professional guidance is required when making health decisions based on results (29:30).
  • Why epigenetics is more complex than genetics and how genes are switched on / off by interactions with the environment or due to behavior (33:50).
  • Pathway Genomics and IBM’s Watson collaboration – integrating extremely diverse and data-dense medical information into meaningful outputs (36:11).
  • How genetic testing improves pharmacological prescription decisions and why increasingly complex data is even more useful (39:20).
  • Optimizing exercise for individuals using genetic information (46:04).
  • How to access information about personalized medicine and genetic testing (47:33).
  • What information Dr. Nova tracks on himself and why it is crucial to be aware of your genetics (49:46).

Thank Michael Nova on Twitter for this interview.
Click Here to let him know you enjoyed the show!

Michael Nova, Pathway Genomics

Tools & Tactics

Diet & Nutrition

  • Mediterranean Diet: All diet recommendations at Pathway Genomics are generated based on a Mediterranean diet. Based on personal genetic information, diets can be modified towards a low-carbohydrate or low-fat diet.



  • BRCA genes: There are two BRCA genes, BRCA 1 and 2. Certain mutations in these genes are associated with a high risk for developing breast and/or ovarian cancer. Full gene sequencing and results interpretation is offered by the Pathway Genomics BRCATRUE test. Angelina Jolie underwent preventative breast surgery because of her positive BRCA 1&2 status and her family history with breast cancer.
  • Maximal Oxygen Consumption (VO2 max): The maximum rate of oxygen consumption as measured during exercise, usually on a motorized treadmill. VO2 max reflects the aerobic physical fitness of an individual. The Pathway Genomics PathwayFit test includes sequencing of genes which are relevant to VO2 max in individuals.

Lab Tests, Devices and Apps

  • Pathway Panorama (Not Yet Available): This will be a genetics-oriented mobile health application. It is intended to integrate personal genetics with publicly available scientific medical information from trusted sources. Using the IBM Watson engine, the app will compare this information to the standard of care and provide personalized feedback on health and well-being.
  • Fitbit Charge: Fitness watch with automatic monitoring.
  • Pathway Genomics: Genetic Testing Panels

  • BRCATrue: A genetic test that searches for mutations in BRCA1 and BRCA2 genes.
  • PathwayFit: Analyzes over 75 genetic markers known to impact metabolism, exercise, and energy use within the human body. Provides insight into how your body may process sugars, fats, nutrients, and vitamins. This is the most popular test of Pathway Genomics.
  • Healthy Weight DNA Insight: One of the most comprehensive weight-related genetic tests available. Unique combination of nutrigenetic, medication, and general health information.
  • Mental Health DNA Insight: Identifies genetic variants that affect the metabolism and efficacy of psychiatric medications. More than 30 common antidepressants, mood stabilizers and antipsychotic medications included.
  • Pain Medication DNA Insight: Identifies genetic variants that affect how an individual will respond to the analgesic effects of certain types of commonly prescribed pain medications.
  • Cardiac DNA Insight: Tests for the genetic risk of a variety of heart-related health conditions. Examines eight classes of drugs that affect the cardiovascular system.
  • Genetic Testing Technology Platforms

  • Fluidigm Assays: Pathway Genomics uses Fluidigm assays with high precision and whole gene sequencing to detect ALL Single Nucleotide Polymorphisms (SNPs). These are variations in DNA code which are usually associated with predispositions towards health-related conditions. In comparison, the company 23andMe does not use Fluidigm technology.
  • Illumina Chip Seq Assays: In addition to Fluidigm technology, Pathway Genomics uses this technological platform for genetic testing. The company 23andMe also uses this type of genetic testing technology.

Other People, Books & Resources


  • Prof. Roger Guillemin: Dr. Nova started his career in genetic at the laboratory of Prof. Guillemin – who was awarded the 1977 Nobel Prize for Physiology or Medicine for his work with hypothalamic hormones.
  • Jim Plante: Founder of Pathway Genomics.
  • Eric Topol: An American cardiologist, geneticist, and digital medicine researcher. Mr. Topol is a leading voice in the field of personalized medicine and putting the consumer in charge of his/her own healthcare.


  • IBM Watson Health: Overview of healthcare applicability of the IBM Watson’ artificial intelligence platform.
  • 23andMe genetic testing A popular and accessible genetics testing service company. The 23andMe model is focused on testing for subsets of SNPs (Single Nucleotide Polymorphisms) across various genes.
  • GeneMed: The company provides cancer and infectious disease diagnostic reagents for different instruments and technology platforms. This company also provides development and commercialization services to partners for improving In Vitro Diagnostic (IVD) products.
  • Lab Corp: Laboratory Corporation of America provides lab testing and services, with expertise in esoteric testing, genomics, and clinical and anatomic pathology.


Full Interview Transcript

Click Here to Read Transcript

(06:12)[DAMIEN BLENKINSOPP]: Michael, great to have you on the show.

[MICHAEL NOVA]: Thank you, it’s my pleasure.

[DAMIEN BLENKINSOPP]: How did you first get into the area of genomics, and now it’s personalized medicine, but was there an evolution towards that? When did this first start for you?

[MICHAEL NOVA]: I was a research associate at the Salk institute a while back in a Nobel Prize winner’s laboratory – his name was Roger Guillemin. It was a very large laboratory; it had a lot of different technologies and scientists that were involved with it, as you can imagine.

The overall function of the laboratory was to study growth factors, and so we were studying everything about growth factors. We were studying how the proteins worked, tissue culture, how they interacted with each other, the DNA and RNA genetics of these growth factors, everything you could think of.

[DAMIEN BLENKINSOPP]: When you say growth factors, what exactly would that be for?

[MICHAEL NOVA]: Things like human growth hormone and thyroid releasing hormone and corticotropin-releasing factor, every kind of growth factor.

[DAMIEN BLENKINSOPP]: Okay. Things that stimulate growth in the human body?

[MICHAEL NOVA]: Yeah, in one way or another. He got the Nobel Prize for the first person to isolate TRF, which was a growth factor that was released in the hypothalamus. A signal that is released in the hypothalamus goes to the pituitary and then turns on all these thyroid hormones. That’s what he got it for, and so we were just peeling back the onion on a lot of different growth factors using different technologies.

I got into genetics there and then I started a couple of companies and took one public in the biotech area. We’ve almost used genetics as part of the technology, but it’s only been recently when we started (with Jim Plante, the founder of Pathway Genomics), we put a team together to really go after genetics as a solution for patients, and using genetics and genomics, I guess, as a solution for patients, and also physicians, for risk assessment or to give them insight into personal issues and to try and take some action against it.

I think it’s really been within the last ten years that the technology has been inexpensive enough that we could even try to use it directly for patients.

[DAMIEN BLENKINSOPP]: Great. First of all, I think a lot of people have heard of 23andMe, but they haven’t necessarily heard of Pathway Genomics, so could you give us a comparison of how the technologies compare and how the service is different? I know Pathway Genomics kind of evolved over time, so potentially a bit of that back story would be helpful too.

[MICHAEL NOVA]: Sure. First of all, the major difference is we have our own laboratory; 23andMe doesn’t. We have a big laboratory staff and scientific staff and curators and all that. All the tests come back to our laboratory and we do the DNA isolation and we do the reading of the mutations on different types of machines and then develop a report that goes back to the physician, which is the second difference: we’re only a physician’s ordered test; we’re not direct to consumer. So there has to be a physician in the loop or some kind of health provider in the loop, certainly on the ordering side, but also on the interpretation of the test.

All our tests are covered by insurance in the United States – that’s a third differentiator. We sell our tests in 44 different countries…

[DAMIEN BLENKINSOPP]: So just on the insurance angle; I understand it that you’re targeting a much smaller range of genetics, and basically you’re targeting specific arrays of things that you want to look at, like pharmacogenetics and other areas of the human body, whereas 23andMe is very, very broad in terms of what they look for?

[MICHAEL NOVA]: Yeah that was going to be my fourth!


[MICHAEL NOVA]: You took the wind out of my sails with that one, that was going to be the fourth big differentiator. We offer, like you said, panels of genes. We have a test for fit, nutrition and exercise, which only covers those two elements and then some eating behaviors and some metabolism.

Then we have another test for pharmacogenetics, like you mentioned. And one which is specifically for psychiatric, and another one that’s specifically for pain medications. Then we have a cardiovascular test, a cardiovascular risk, which also has some diet and exercise components in it.

So we have about 12 different product lines, 12 different types of tests, including BRCA. We do whole genome sequencing or next generation sequencing for the entire BRCA gene, if you know that gene. It’s the one that is prominent in certain ethnic groups for hereditary breast cancer. It’s the same gene that Angelina Jolie had. So we test for that as well.

We’re the only comprehensive genetic testing company that has health and wellness products all the way to hardcore next generation sequencing products for risk assessment for things like breast cancer.

A new thing that’s coming is we have an alliance with IBM, who’s an equity partner, and we’re building a mobile application that will basically put an artificial intelligence super computer in a handset to help with managing patient information and giving recommendations back directly to the user. That will be a direct to consumer type of product, but at this point we don’t sell any of our genetic tests direct to consumer.

[DAMIEN BLENKINSOPP]: I’d like to take a little step back because 23andMe and you are really very different propositions. There’s also the technology and the accuracy of the tests, and you have a different price point as well. Whereas I think for 23andMe for the whole thing right now, it’s $99; per array, yours is roughly $199 per different panel. So why is that, what’s the difference in the technology and what you’re delivering?

[MICHAEL NOVA]: It depends on the genetic tests. We do Fluidigm assays for our smaller arrays of up to about 80 different genes; 23andMe doesn’t do that. They basically take an Illumina chip that’s got a certain number of markers on it and run that chip for their $99 test. We also have that chip-based technology and then we also have the sequencing technology, which 23andMe doesn’t have.

So we have, the sequencing technology is basically more expensive than the Fluidigm or TaqMan assays, which are probably the least expensive.

We run every different type of genetic testing in here, but some of our reports require more than one platform. Some of them require the Fluidigm platform plus either maybe a sequencing or plus an Illumina chip, so the cost varies on a particular report based number one, on the technology that we’re using – it could be more expensive to run that particular report.

Then the way we do the reports is also different. We have a physician that reviews the results, we have a dietician that reviews the results, we have all those people that are on staff that are patient and can access at any time, so there’s a little bit more cost that’s embedded into the test or tests, depending on which one the clinician orders from us.

[DAMIEN BLENKINSOPP]: Right. Are your tests 100% accurate, so we could run them one time and we’d know for sure which gene SNPs we have?

[MICHAEL NOVA]: Sure. We have our own laboratory and it’s CLIA certified, CAP certified, it’s New York State certified. We’re the only comprehensive genetic testing company that has a health and wellness panel that’s been certified by New York State, which is very difficult to get.

23andMe can’t sell in New York State; they can’t sell in certain countries because direct to consumers is illegal. It’s illegal in places like Brazil and Singapore.

Our accuracy, since we’re licensed by three or four different licensing bodies, they come in here and inspect us all the time, at least once a year on all of them. So, we have to be extremely accurate.

[DAMIEN BLENKINSOPP]: I guess what I’m getting at also is the chip set that 23andMe is using is pretty reliable but it’s not 100% accurate, as I understand it. So in the past when I’ve done tests – I’ve done the 23andMe and I’ve done some other more specific genetics tests – and the answers weren’t the same. As I understood it, it was related to the technology that 23andMe uses, which is very economical to get a lot of data – which is interesting, so look at a variety of risks – but if you want to actually get clinical based information where you’re going to make decisions, you should run with the sequencing technology that you’re using with your panels to be 100% certain. Or am I looking at the wrong things there?

[MICHAEL NOVA]: No, I think you’re right on one aspect or a couple of aspects of what you said. I think that for things like the BRCA test, which is a very serious type of genetic test, 23andMe only reports on a couple of variants on the BRCA mutations, whereas we run the entire sequence. So the doctors come to us for that particular test; they would not necessarily go to 23andMe, even though the mutations that they provide and the way they do it are probably accurate, but they, just by definition, miss stuff.

It doesn’t mean that their technology is bad, which it isn’t; it doesn’t mean that the way they run the Illumina chip is not sufficient. That’s not correct. For what they’re reporting on, it’s perfectly adequate.

[DAMIEN BLENKINSOPP]: So everything you get reported should be correct with their technology as well – the Illumina chip?

[MICHAEL NOVA]: Yeah and I think it’s a good company. 23andMe is a good company. There are good companies like us and 23andMe and some of the other ones – we’ve been at this for eight years or seven years; we know what we’re doing. We just happen to have our own laboratory and so we’re under a lot of different kinds of governance that 23andMe isn’t under.

(15:22)[DAMIEN BLENKINSOPP]: Do you use blood samples as well, or is it saliva samples?

[MICHAEL NOVA]: Sure, we can use blood, saliva…

[DAMIEN BLENKINSOPP]: Is there a difference in the quality, or is it exactly the same, it doesn’t really matter which one you use?

[MICHAEL NOVA]: Both samples have different pluses and minuses, but trying to get to the same endpoint you still have to conform to what the governing bodies and what the licensing groups want us to report on. So we don’t have any choice but to make them equal in the end – if you gave us a blood sample or a saliva sample. But the way we do each one… in some respects it’s harder to do saliva because there are more contaminants in it and whatever, but then it’s a much easier test. People don’t necessarily want to get needle stick all the time.

[DAMIEN BLENKINSOPP]: I guess I’m trying to understand like I had a blood test run through DNA sequencing and a couple of the SNPs were different compared to my 23andMe. What would be the cause of that or is it a mystery?

[MICHAEL NOVA]: We can’t do that necessarily. We would certainly have to report on the same SNPs in the report in the same way so I don’t know. It could be a number of different things.

23andMe, again, has been around for a long time and so I think the accuracy of their reports and what they’re reporting on is really good. It’s hard for me to make a kind of black or white decision on something like that.

[DAMIEN BLENKINSOPP]: No, no, I’m not talking black or white, I’m just curious if there was a technological basis or something like that.

[MICHAEL NOVA]: There might be.

[DAMIEN BLENKINSOPP]: Yeah, I just figured it was the slightly different configuration of the technology.

[MICHAEL NOVA]: I’ll give you a really good example here and I think people don’t realize it: If you went and got a SMAT panel or a CAM panel from one company, like LabCorp, or you went and got one and put in the same sample to Quest, there’s no question that there will be a little bit of difference in what each one of these things reported on, but just a tiny bit of difference. That doesn’t mean that they’re wrong – either of them.

People think that genetics is black and white and the laboratory results are exactly 100% supposed to be the same all the time; that’s not necessarily true. And then we don’t know a lot more about the genetics either: There are 25,000 different genes, and we probably know what about 10,000 of them actually really do, but then they have to work with each other and all this kind of stuff.

I think getting the information on the particular SNPs is not necessarily the hard part; the hard part is interpreting what it means and giving that information back to the patient.

[DAMIEN BLENKINSOPP]: So it may be just a different reporting basis, that’s what it sounds like.

[MICHAEL NOVA]: Yeah, it could be.

(17:46)[DAMIEN BLENKINSOPP]: Taking a little step back, because I know this is basically your area, what does a shift to personalized or precision medicine and health mean versus where we are currently in the world?

[MICHAEL NOVA]: As a physician, we’ve always kind of practiced personalized medicine. When somebody comes in and they’ve got some condition they’re worried about, we give them their medications or help based on them as a person. But now, we’ve got a lot more tools. There’s a lot more granularity in what we can actually see that might be affecting this individual or even preventing things from happening.

Genetics is just one of those tools. So there’s genetics, there’s epigenetics, there’s transcriptomics, there’s all these different types of technologies now that are becoming less and less expensive. They’re kind of getting weaved into the management, if you will, of patients, and that’s what doctors are doing, basically, with our reports.

Precision medicine is just another name for personalized medicine, but I think one of the reasons there’s a much bigger push for it now is that we’re really seeing some major advances in cancer-targeted therapies using genetics, we know cancer is a genetic disease, a molecular disease. We’re now starting to target individual mutations in these cancers to give better results.

We’re now getting a clearer understanding of things like obesity – there are 97 genes that are related to obesity – they’re all different metabolites. It’s not necessarily going to be one size fits all and now we just have technologies that are getting less and less expensive to weave in information for the physicians to make decisions on. That’s where it’s at right now.

This is going to be an ongoing process forever; there’s going to be some sort of genetics or -omics or precision medicine technology that we’ll be able to use to really personalize individual therapies or prevention regimes or whatever you want to call it.

b>[DAMIEN BLENKINSOPP]: I guess one of the things about personalized is, if we take a comparison: If you have a cough today, you’re given the same drug no matter who you are; but in the future – and you have a panel which is pharmacokinetics – you could look at the impact of the drug on you – depending on your genes, drugs have a different impact. So it’s taking it up to a much more personalized level than what is possible today by just looking at someone.

In some cases, maybe you’ll see they’re different and maybe have got some blood test that is slightly different, but the genetics adds another layer of personalization.

[MICHAEL NOVA]: This is standard knowledge in the industry that anywhere between 40 and 50% of all drugs that are prescribed fail for the user, and especially the first time around. That’s a huge number.
If we can add some way of tailoring those drugs – maybe you take this antidepressant instead of that antidepressant or you take this cough drug versus some other cough drug because your liver is metabolizing it different based on your genetics – you’re more likely to get a much better result.

Again, that is certainly where everything is headed in this whole precision medicine area.

(20:40)[DAMIEN BLENKINSOPP]: Great. So I also just wanted to talk to you – your tests are insured compared to the other ones, so I guess that the extent of research done on the specific panels is quite deep to get to that level where now tests can be insured.

[MICHAEL NOVA]: Yeah it depends. I’ll just take Medicare as an example because they’re kind of the gatekeeper for insurance coverage and our tests are covered by Medicare. The way that Medicare does it now in the United States, it looks at a panel on a gene by gene basis, and some genes have more clearly defined outcomes and predictability than others. So, on a panel of 80 genes, they might only cover three or four of them, but that’s enough to cover the entire cost of the panel.

There are three big levels of gene coverage in America. There’s a) genes that are covered automatically, like methylenetetrahydrofolate and some of the genes for warfarin metabolism. These are covered automatically, it’s an automatic payment, and since the technology on the panel is cheap enough, at least for us, to get over the cost of doing just that one gene, whatever Medicare decides to pay us, we make enough money to cover the panel. That goes for all the other insurance companies too, whether it’s United Healthcare pays on certain things, Aetna pays on certain things. Some insurance companies don’t pay at all on genetics, one way or another, so it really is not just based on whether the data is good enough, but it’s also based on whether a certain insurance company thinks it’s relevant enough to pay for it.

[DAMIEN BLENKINSOPP]: Right, right. As you’re saying, only part of your panel will necessarily be covered by that, and then there’s other things you’ve added, which you feel are relevant too. How’d you make those decisions? What kind of level of research has to be done?

[MICHAEL NOVA]: Yeah. We have a very strong curation. We have, I think, 15 PhD level geneticists and genetic counselors, and myself and a number of MDs, and we basically go and we grind through the literature. We look for human clinical studies and see if the data is relevant enough or there’s enough human clinical studies to put the gene into the panel and then report on it. We can only report on what the human clinical studies tell us.

There are plenty of genes and plenty of studies out there that we never would report on because we don’t think it’s relative; we don’t think that the data is strong enough. So to give you an example, in our healthy weight and fit test – which is our most popular test by far – we rate the science level in the test.

A really good clinical scientific study, let’s say on thousands of patients, and it has to be replicated in the same ethnic group, showed the same results and hopefully over multiple times, then that gets four stars.

Then there are other studies that aren’t quite as well validated but we think that there’s relevance because it might only have been done in two or three clinical studies of 500 patients each, which isn’t necessary a thousand patients but it’s 500 and it does show the same phenotype or it does show the same direction for what the genetics is reporting on. That’s a pretty good study so that gets put in the test too.

[DAMIEN BLENKINSOPP]: Great. I was going to actually ask you which was your most popular test but you’ve already brought it up.

So in terms of what that test gives people, who’s asking for the test and in what conditions are physicians looking for this kind of test? Is it someone who’s had a recurrent obesity problem for a very long time? What are the kinds of conditions and what’s actionable about that information for the physician once he gets it?

[MICHAEL NOVA]: For that particular test, we have a lot of different types of physicians that order it. Some are obviously looking for weight management, weight control in their population. But we also have people that are diabetics that are trying to use it to control their sugar levels or hemoglobin A1c levels, so we have a whole group of anti-diabetic groups that are using the test.

We have cardiovascular groups: many cardiologists think that most cardiovascular disease can be prevented by diet and exercise changing, so we have a lot of cardiologists that order the test and try to put people on more balanced types of diets, more personalized types of diets. Not necessarily to lose weight but to cut down lipid levels and other things that cardiologists worry about.

Then we have performance groups: we have performance athletes, we have gyms like Equinox health clubs that order our tests for a lot of their gym members to either increase performance or put on muscle mass, depending on what exercise.

So basically we have a lot of different types of groups, not just one type of clinician or group that orders the test.

[DAMIEN BLENKINSOPP]: Great. Is there an example you could walk us through of one of the most actionable genes in that area which people look at?

[MICHAEL NOVA]: Well, on that particular test… or do you mean all our tests?

[DAMIEN BLENKINSOPP]: The most popular one, because you said this was the most popular, if there’s one specific gene that people watch out for more than others.

[MICHAEL NOVA]: I don’t think it’s one particular gene. There are about 80 genes that we report on and we chop up the test into basically seven different sections. One section has to do with what is the best diet for you if you’re trying to lose weight and we have four different diets. That’s based on 50 different genes and how they interact with each other. Then we give you a diet recommendation, whether it’s low-carb, low-fat, standard Mediterranean or balanced diet. All of our diets are based on Mediterranean, but some have lower carbohydrates than others; some have lower fats.

Then we also give diet plans along with. So that’s a very popular part of the test, that section.

Another popular part of the test is we have a behavioral section, which looks at things like eating disinhibition – “I can’t stop eating.” Those genes around “When I start eating, I can’t stop eating.” Those genes in your dopamine pathway. We look at sugars – “Do I have a sweet tooth? Do I tend to like sugars more?” So this whole behavioral section is a very popular chunk of the test as well.

Then we have a standard metabolism section – we look at things like do you have a tendency to have increased insulin? Do you have a tendency to have increased lipid levels? Those types of genes, and there are multiple genes in that section – 20 or 30 genes in that section, so that’s also a popular part of the test.

[DAMIEN BLENKINSOPP]: Right. One of the interesting scenarios I think is the diet, the high fat versus the low-carb and the low-fat. Because a lot of the dietary recommendations today, it’s basically which crowd do you want to go with? I’m with the low-carb crowd; I’m with the high fat crowd, high protein…

Some of the genes can be pretty significant in that area, like the APOE gene. Could you talk a little bit about that and how that influences your diet and whether fats are going to be good for you or are basically going to be problematic.

[MICHAEL NOVA]: Let’s go back and look at diets in general. Most people, if they got on a diet and it was less calories than they usually intake and they stayed on that diet for years, they would probably lose weight. But it’s very difficult to get people to do that for a number of reasons.

So what we try to do is we try to look at particular genetics around fat metabolism – and APOE is one of them, and PPARgamma, and even FTO and some of these other genes – and not only how you process fats but also how you taste things. You have bitter taste receptors that we look at.

People don’t eat things that they don’t like, so we try to tailor the diet based on a number of these big subsets, whether it’s how you metabolize lipids – and people that have two copies of the FTO gene, there’s no question that they have trouble metabolizing fat in a low carbohydrate diet than somebody that doesn’t have those. That gene has been very well characterized and is a known obesogenic gene along with MCR4. If you put those two genes together, people that have those two genes tend to be about ten pounds overweight than people that don’t have them.

So we take that information, then we go back and we design a diet that’s based around not only what your metabolism is but also what you potentially would like to eat and make it a diet that isn’t too rigorous, that you’ll never stay on, and then try to give you direct diet plans – basically what to eat, literally, on a daily basis: Breakfast, lunch and dinner, this is what you should eat.

Then we have diet specialists and nutritionists and exercise physiologists and all that stuff, that if you really need help with that kind of stuff, we have ways to get you that as well.

I guess what I’m getting at is we don’t like to look at genetics in a vacuum. It’s one part of a big puzzle, and the more pieces of the puzzle we can put together, the more success we have for personalizing things for the user. That seems to really work.

We have other 20,000 physicians in the US that are ordering our tests and they keep ordering it over and over again, along with our diet plans and whatever information we give them, and the results speak for themselves – they’ve shown that what they get out for their patients is really working.

(29:30)[DAMIEN BLENKINSOPP]: Can we just go back to a distinction that you made was that you’re not doing genetics, you’re more doing genomics, right – the interaction of all of the genes together? Is that what you mean by you were saying?

[MICHAEL NOVA]: That’s a little bit of a slicing that onion really thin.

[DAMIEN BLENKINSOPP]: So what is the approach? You’re saying that it’s not a good idea to look at just one specific gene on its own?

[MICHAEL NOVA]: Yeah, very few things are one gene and then you have something bad happen. Even then, even for things like BRCA, it’s still only a relative statistic. Even if you have BRCA and you’re Ashkenazi Jewish and have the mutations that are relevant, there is still only a 80% probability that you’ll end up having breast cancer. So that means there’s 20% that you wouldn’t have breast cancer.

So very few things are one gene, one bad outcome, fortunately. It’s usually multiple genes. Again, we talked about obesity – there’s at least 80 or 90 different genes that have something to do with making somebody obese. And how they all work together? That’s the gold nugget in all this business is how to figure out how they all work together.

[DAMIEN BLENKINSOPP]: The BRCA gene is interesting because they’re pretty extreme decisions, or as you say, very rational decisions, but a lot of people see it as an extreme decision that Angelina Jolie has taken and it’s been in the press and everything.

One factor into that is that there’s genetics versus epigenetics and how we approach genetics in practice when there’s potential for some epigenetic influence and where the gene’s not actually turned on or off, right? You don’t know which one it is – is it turned on or is it turned off? Were Angelina Jolie’s BRCA genes – were they turned on and, therefore, they did represent the risk?

So, just based on what you said there, you said there was an 80% chance – I don’t know if that was a real statistic with a certain BRCA gene, but would it be in that kind of order that they were looking at BRCA?

If you took your BRCA panel, even not looking at the epigenetic influence, is there an 80% chance that that risk really exists, without taking into account the epigenetic influences?

[MICHAEL NOVA]: Correct. And remember, BRCA was first isolated in the Ashkenazi Jewish population – that’s where it’s most relevant. Angelina Jolie had family members who had breast cancer. So her decision to have surgery was based not only that she was BRCA1 and BRCA2 positive but also the fact that her mother, I think, died of breast cancer, and she’s half Ashkenazi Jewish.

So there were a number of factors that went into her decision to have surgery, not only to have her mammaries resected but also to have her ovaries taken out. I think she went down that path as well because there’s an increased risk, potentially, for ovarian cancer, which is still a very serious disease.

So you have to take all the information in total. If there was no breast cancer in her family and she wasn’t part Ashkenazi Jewish, then there might be a reason to not potentially go down that path. But that’s up to her and her clinician to work that out.

That’s why we don’t think a test like that, which is a very serious test, should ever be direct to consumer. That, for us, is something that really needs some guidance along with trying to make decisions about that.

[DAMIEN BLENKINSOPP]: Right. Excellent. I think the epigenetics area – how do you approach working with your physicians and advising them?

Do you ask them to look at factors like you were just talking about hereditary? – what’s the situation with your parents, your grandparents; other things you can look at in conjunction with some of your tests in order to capture the epigenetics? – whether something’s actually taking place or not: Do you say, “You should run these blood tests if you get these genes, and thus you could make a better decision based on that,” or do you tend to keep it to the genetics themselves?

[MICHAEL NOVA]: We tend to keep it to the genetics at this point because epigenetics is fairly new. There’s not enough data – although I do totally believe in it – in a lot of respects for us to weave that in to the process of, “You’ve got this gene but it’s not turned off.” We can do that from a technology stand point, but there’s not enough clinical data to make really informed decisions around that.

[DAMIEN BLENKINSOPP]: Right. I was talking more, at this point, as you say, epigenetics is relatively new and it’s probably quite expensive at this point for you to be integrating that type of service.

[MICHAEL NOVA]: Those kinds of expression assays – although Illumina has a methylone chip, but I don’t think it’s a clinical grade thing – it’s definitely more expensive than the genetics.

(33:50)[DAMIEN BLENKINSOPP]: I was thinking more about metabolites and lipids and things like that. So for example, we were talking about the APOE, so if your cholesterol markers are off, that would be an indicator that that gene is switched on – correct?

[MICHAEL NOVA]: Yeah, something is definitely not working correctly or you’ve got something in your diet, also, that’s not the correct diet. Maybe you’re eating too much of X, you should be eating more of Y. So there’s, again, a number of different factors – genetics, epigenetics, proteomics, metabolomics.

The metabolomics and the proteomics and looking at lipid panels, those give you a snapshot, an immediate time of day, this is what your lipid level showed. What genetics does is give you a tendency towards where potentially the lipid levels in the long run will go if you don’t take certain actions doing certain things.

[DAMIEN BLENKINSOPP]: Yeah it does. I think the area of epigenetics is potentially very confusing to people because there is this aspect of genes potentially staying switched off. Say, for instance, exercise is an important mechanism for turning off – I’m not saying this is true – but the APOE gene, right?

[MICHAEL NOVA]: There’s been data that’s shown that FTO gene for obesity can be mitigated with certain exercise and diet regimes; those are known facts. There are starting to be really hardcore data around using the environment, and epigenetics is all around using the environment – what you do in your environment to turn genes on and off – and there is data around that.

That would be one example of something that in the near future we might end up reporting on. You can change how genes are expressed by something in the environment.

[DAMIEN BLENKINSOPP]: I’m sure at this stage it’s just at a discussion level with you and colleagues and other people that you know, but how far out do you think these kinds of things are, like being able to take the next step and understanding the epigenetic aspect of it and making decisions based on that as well as just the genetics?

[MICHAEL NOVA]: Epigenetics in some respects is even more complicated than the genetics because there are so many different things that can turn genes on and off: there are methylation patterns, there are acetylation patterns, there are phosphorylation patterns, which means molecules that actually bind the DNA, or histones or whatever, and modify things and turn genes on and off.

And then there are all the microRNAs. There’s thousands of different microRNAs, the junk matter in DNA that will turn genes on and off if they’re expressed or not. So it’s extraordinarily complicated!

(36:11)[DAMIEN BLENKINSOPP]: IBM is an equity partner in Pathway Genomics?


[DAMIEN BLENKINSOPP]: Right. I wanted to talk about Pathway [unclear 36:16] but I think it’s also relevant to what we’re discussing right now, it being so complex and everything. Are you looking at bioinformatics and things like that potentially in the future?

[MICHAEL NOVA]: See that’s what computers are really good at. They’re good at taking noise, basically. Whereas we would look at it and not come up with any pattern; a computer’s really good at making patterns out of things. They’re not necessarily sentient, but they’re really good at taking databases and huge amounts of information and then telling you that these two things are linked together – that’s what the information is. That’s basically what we’re starting to build with IBM.

We have a very strong bioinformatics group and engineering group, and this is an artificial intelligence. Basically, it’s the Watson artificial intelligence that can play chess and was on “Jeopardy!” the show in the United States. So we have to train it.

We like to say it’s a little bit like a dog: you train the dog by lobbing it a question and seeing what answer you get back and seeing if it’s relevant. 99% of the time to start with it’s not relevant, then you have to tell it why it’s no, and go back “It should be this instead of that.”

It’s a huge process to train, especially around health care, because there’s nothing that’s more data dense than health care data. It’s not just genetic data we’re interested in; we’re interested in your electronic health record, your lab results, your wearables – your Fitbit data and all that other stuff. We want to take all that information and then compare it to the standard of care that’s what’s going to be in the Watson engine, and then give you back a recommendation that’s really personalized.

If you asked a question like, “I’ve got a nose bleed” – if you have our mobile app Panorama – “I’ve got a nose bleed, what should I do?” you would get a different answer potentially than what I would because I’ve scanned all this different information about you and compared it to what is the standard of care, and since you’re a little bit different in this gene and your latest lab result is a little bit different over there and maybe you went for a run and fell on your face, all of those bits of information are really important in order to give you a decision or some sort of recommendation about what to do.

[DAMIEN BLENKINSOPP]: Right. That sounds incredibly ambitious.


[DAMIEN BLENKINSOPP]: But you are going to release something relatively soon, aren’t you, so what will that be when it comes out?

[MICHAEL NOVA]: We will have public beta, sometime September to October time frame this year. We’re going through trials right now with the alpha version.

Like you said, it’s a very complicated problem because it deals with a lot of different types of data, and then getting that data so Watson can understand it, which is a whole engineering task on its own, and then getting the right information into Watson – or IBM, the super computer, the artificial intelligence – and then getting the right and curated information in there so it has the state of art in what people are thinking in terms of health care.

So you’re right, it’s extremely ambitious, and we’re really, really excited about it.

[DAMIEN BLENKINSOPP]: Yeah I can imagine. It will be fun to use it when it comes out. Is it going to be sold through iTunes or something, how’s it going to work?

[MICHAEL NOVA]: Yeah, we’ll go through the iStore and all that, and whatever Android is.

(39:20) [DAMIEN BLENKINSOPP]: Okay great. One of the other things we touched on that I wanted to get a bit deeper into because I think a lot of people don’t realize how varied this is, is pharmacogenomics.

You have several panels; it’s quite extensive the number of panels, it seems, under that area, because you have mental health areas and other areas. Is it extremely varied the impact a drug can have on each and every person? Is this very common that drugs have very different impacts per person?

[MICHAEL NOVA]: I’ll start with the panel. We have two or three different panels for pharmacogenomics. One is what you mentioned, it’s a mental health panel that has things like anti-depressants, antipsychotics, mood elevators, 30 or 40 different drugs and they each are metabolized in your liver a little bit differently.

One drug is metabolized differently to another drug, and we look at those mutations in your liver enzymes – they’re called cytochromes.

Then there are also transport proteins that have variance in how the drug is transported from the blood into the cells. There are a couple of drugs in there that have different transport kinetics. Then there are some of them also that get excreted by your kidneys, and they have a little bit different kinetics.

So we put that whole panel together on mental health based on a lot of this genetic information, or the best that we could find. Doctors use it to try and start somebody out on a drug rather than guessing what this person should have, or they’ll change a drug based on the genetics because they’ll understand why this potential drug isn’t necessarily working.

Then we have other panels. We have a pain panel, which does the same kind of thing but around pain medications – the codeines, oxycodone, morphine, tramadol, things like that – they get metabolized differently.

[DAMIEN BLENKINSOPP]: When you say metabolized, it means processed by the liver?

[MICHAEL NOVA]: Yeah, processed by the liver. There’s also transporters and uptake and excretion that are a little bit different for some of these drugs. Again, we use that information on a broad panel of different genes to tailor what potentially would be better for somebody than something else.

That kind of data is getting better. The good thing about genetics in general is that the data just gets better and better; it doesn’t get worse. It’s not like cold fusion – it’s not going to go away. It’s just going to be integrated more and more into the practice and pharmacogenetics and, obviously, drug metabolism is a huge deal.

To give you a good example: in the Asian population, there’s a drug called carbamazepine and it’s used as an anticonvulsant. There are genes involved around the metabolism of carbamazepine that if you have these particular genes, you will probably have a very high likelihood of going into Stevens-Johnson Syndrome if you take carbamazepine, and that’s a very serious disease.

[DAMIEN BLENKINSOPP]: Stevens-Johnson Syndrome; could you just describe the effects of that because I don’t think it’s very common but it’s pretty horrific, right?

[MICHAEL NOVA]: Yeah, it’s an allergic reaction basically, an immune reaction against this particular drug and you can basically end up dying from it – you go into anaphylactic shock and your skin starts to slough off. It’s a really nasty way to go if you want to call it that way. But again, it’s not very common.

But it is common more in Asians, and so screening for carbamazepine is 100% done in South-East Asia, Taiwan, places like that that are still using the drug as part of an anticonvulsant regime. They won’t put anybody on it if that person comes up with that particular variant.

That’s a really good example of how using a genetic test will really literally dial out a lot of drugs or dial in a drug based on your genetics.

[DAMIEN BLENKINSOPP]: Right. Currently though today, it’s a little bit of a trial and error process if you see a physician. Even with antibiotics sometimes, unless you’ve had tests done, it’s trial and error. We’re working hopefully towards a place where there won’t be any of that trial and error, it will be eliminated over time by these kinds of tests.

With the caveat that epigenetics sometimes will have some influence, so it’s not 100% fallible. In terms of the pharmacogenomics, there’s still some potential that basically says “This drugs better than this one for you”. It’s not 100% fallible, correct?

[MICHAEL NOVA]: No. Again, what we try to do in the genetics business is report on what the literature tells us – period; that’s the bottom line – and is that result valid.

We know, in pharmacogenetics, that across all drugs, 40 to 50% of them fail when they’re first given, so that’s a huge problem. So, dialing in the right drug, even though it might not be 100% correct… although the Stevens-Johnson issue, with this particular gene and carbamazepine, is almost 100%, so there’s nobody in their right mind if they knew that that patient had those particular genes would put somebody on carbamazepine because that’s one of those issues that is almost really one gene, one effect – you just don’t do it!

[DAMIEN BLENKINSOPP]: Yeah, right, when the risk is so high. What other high risk ones are there? Is warfarin a big one?

[MICHAEL NOVA]: Yeah warfarin potentially could be a big one for a couple of reasons. A dosing of warfarin to begin with is a little bit difficult, you have to have really strong expertise in doing that. The way it’s done is it’s done over a period of time to figure out what your INR is and how you’re metabolizing it and then getting the right dose.

Warfarin is a serious compound; you don’t want to mess around with it. It’s basically rat poison and it’s a very serious anticoagulant, as are some of the other ones like Plavix. But if you can figure out initially which dose of warfarin is better for that individual based on its genetics, that’s a good thing.

Warfarin tends to be used when a problem arises, like potentially a stent or you’ve got some sort of other issue that needs anticoagulation so you need to put them on warfarin immediately. I think that having a point of care warfarin test for pharmacogenetics is probably the way that that is going to go. Nobody wants to sit around and wait for a day for some sort of genetic test to come back before they put them on a drug like warfarin if they need it immediately, if they’ve got an embolic stroke or something like that; you’re just going to do it anyway.

[DAMIEN BLENKINSOPP]: Right. That kind of information is helpful to have it already pre-done. That is why – it’s pre-empting the need for genetic data on you. In some cases it’s worthwhile doing, right? Cancer…

[MICHAEL NOVA]: Yeah, and then the holy grail in a certain period of time it will be 500 dollars or a thousand dollars to get a whole genome sequence of all your genes, all your DNA. Then everybody gets it done, insurance will probably pay for it, and it just gets put in your record at birth. That’s probably where it’s going.

If you look at the long-term goal of getting everybody genetically tested, that’s probably where it’s going to end up. Then you’ll just pull down the information when you need it – it’s already in your file, it’s in your electronic health record. Does this patient respond to carbamazepine? Does he respond badly to warfarin? You’ll just know that because you’ll just drop down the information electronically.

(46:04)[DAMIEN BLENKINSOPP]: Great, thanks for that. One other thing you mentioned, which I’m sure is going to be interesting to some people, is the athletics aspect and the performance there. Have you got any specific examples of genes you’re looking at and reporting that are useful for training or changing/optimizing there?

[MICHAEL NOVA]: Yeah, there’s a lot of genetics on VO2 max. Some people tend to have a tendency to have a higher VO2 max than other people based on their genetics. How do you use that information in order to tailor your workouts? Maybe you’re one of these people that has a low VO2 max, maybe you need to do more X exercise than somebody that has a tendency to have a higher VO2 max. So there are genes around that.

There are genes around power and endurance: some people tend to be more power people, which means that they respond better to power athletics or power sports than people that are endurance runners. There are some pretty famous genes in that power area – actin is one of them and ACE and some other genes.

Then there are genes around exercise and insulin response, exercise and sugar response. Our panel covers a lot of these and gives you a broad snapshot of what potentially would be a better type of exercise for you than somebody else.

[DAMIEN BLENKINSOPP]: Right. so the type suggestions would be resistance training versus endurance aerobics, cardiovascular kind of work – these kinds of recommendations?

[MICHAEL NOVA]: Yeah, and then a sophisticated personal coach – we use an Equinox personal coach – uses that information to tailor what types of exercise regimes, along with their diet, potentially would be better, you’d get more response around than something else.

(47:43)[DAMIEN BLENKINSOPP]: Great, thank you. Where would you recommend someone look to learn more about personalized genomics? Are there specific books or presentations of the subject that you know are good resources to learn more about this?

[MICHAEL NOVA]: I think we have a couple of them on our website, pathway.com. There’s a lot of them out there. The University of Utah has a very comprehensive genetics database.

If you really want to get down to hardcore genetics, all the genes are listed in certain databases such as GeneMed and NIH has a database of all the genetics and all the genes, all the variants and what they mean.

You can Google in “Genetics textbook” and there’ll be 50 of them that come up. Hospital groups like the Mayo Clinic has a really good genetics site, Harvard’s got a good one, Stanford and UCSF, they’ve all got really good information on those websites about genetics.

[DAMIEN BLENKINSOPP]: Great, great, great, thanks. How could people best connect with you and learn more about you and your work? Are you on Twitter or are you active anywhere else?

[MICHAEL NOVA]: Yeah, people lob in stuff to me all the time. I figure my email is usually the best way to get hold of me, or Twitter – we have a Twitter account from Pathway Genomics. A lot of information gets disseminated through the usual media outlets.

[DAMIEN BLENKINSOPP]: Alright, great. Is there anyone besides yourself you would recommend to learn more about this, for personalized approaches, whether it be pharmacogenomics or anything else?

[MICHAEL NOVA]: There’s a lot of academic groups, every major university has somebody that’s doing it. I could certainly give you a list of…

[DAMIEN BLENKINSOPP]: It sounds pretty broad. I don’t know if there’s anyone more in the populous base, potentially working with big companies like IBM or doing some similar work, potentially different in some areas to you that would be of interest?

[MICHAEL NOVA]: One person that’s been pounding the genetics drum bag for a long time has been Eric Topol, you’re probably familiar with him. He’s one of the leaders in personalized and putting the consumer in charge of his own health care. That’s basically what we’re trying to do here from a number of different angles.

(49:46)[DAMIEN BLENKINSOPP]: Great, excellent. A couple of questions now just on your own personal approach and view of body data; what kind of things have you had tracked for yourself, whether it’s genes or other biomarkers or fitness activity trackers? What kind of things do you track on your own biology?

[MICHAEL NOVA]: I’ve had my genome completely sequenced, so I know as much about my own genome as probably is available. So in that respect, I know what’s good for me. Then I’ve certainly changed around my diet a little bit and the types of exercise that I do based on what my genetics have shown me.

I do wear one of these Fitbit tracking gadgets, and there’s a lot of them; there’s a lot of different types. Then I’m going to for sure use Panorama, this health care app that we’re going to come out with, because it will be integrated into your cell phone. You type in “What shall I do for my exercise today?” and it will tell you, “Based on your genetics or lab results X, Y, Z, you should do this. You’ve already done a thousand steps, you should do this now. You can eat this. There’s a store around the corner, you can buy it there.”

There’s a whole bunch of different parameters that I think will be very, very useful in terms of tracking where you won’t know what’s really happening. I think that’s another thing that users will like about Panorama is there’s not going to be a lot of input; you don’t have to do a food log.

Users don’t want to do that kind of thing. We live in 140 character world!

[DAMIEN BLENKINSOPP]: Yeah, there’s a burden to collecting information.

[MICHAEL NOVA]: There’s a total burden. That’s a very good word to use. There’s a total burden and we’re trying to make it very easy for it to be done automatically, so you feel as though you almost have a guardian angel on your shoulder, in some respects.

[DAMIEN BLENKINSOPP]: Are you integrating it with existing sources of information or are you just making the app very easy to integrate? A bit like Evernote, which you can upload all sorts of things into it.

[MICHAEL NOVA]: Yeah, it will be both. You’ll be able to take what you want, or we’ll go out and find it. We’ll go get your Fitbit data, we’ll go get your electronic health record, we’ll go get whatever lab result, provided we get permission from you to do it, obviously. There’s consent that’s going to be involved in this whole thing.

We’ll try and make that, as you said, that burden or that bar really low. We’ll make it very easy for you to get a very inexpensive genetic test through the application.

[DAMIEN BLENKINSOPP]: So you’ll be able to buy a Pathway genetic test through the app and it will get integrated automatically?

[MICHAEL NOVA]: Yeah, or anybody else’s genetic test. Whether you’ve got 23andMe’s; we’ll integrate that information in there.

[DAMIEN BLENKINSOPP]: Great, great. Okay last question – I always ask this of everyone – what would be your recommendation to someone trying to use some data, any kind of data, to make better decisions about their health?

[MICHAEL NOVA]: Knowledge when it comes to preventing things from happening and to changing your behavior when it’s based on real science is a very powerful thing. We hear that all the time – “Oh, that’s why I didn’t like X or Y. Now I know it’s not all my fault. Now I can change it and stick to some potential diet regime with a lot more confidence and I’m going to get a better outcome.”

So for us, knowledge is power in order to change behavior, and that’s the name of the game for a lot of us is trying to change your behavior. Because you have a lot of power to be able to do that. Giving the consumer more information about themselves is a very powerful thing.

[DAMIEN BLENKINSOPP]: Right. It’s like once someone understands something more clearly, it gives them more clarity, it gives them more confidence; it makes it a lot easier to keep that behavior on board.


[DAMIEN BLENKINSOPP]: Well Michael, thank you so much for your time today. I really enjoyed the chat.

[MICHAEL NOVA]: My pleasure.

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A look at a collection of high impact endurance tools and tactics – and the top biomarkers to watch for optimization. Vetted by an endurance athlete with years of experiments and competitions behind him.

Today’s episode is about endurance training and using high-impact tools to get the most out of it. We look at self-tracking in diet and exercise when aiming to optimize your body to perform at peak capacity.

We discuss factors playing a role in improving endurance through a healthy progression. What self-quantifying strategies are useful for tracking overall performance and health?

This episode features actionable takeaways on dealing with a variety of obstacles commonly experienced by endurance athletes.

How to make use of ketogenic dieting in maximizing fat-burning efficiency during physically demanding exercise? Which biomarkers are important for tracking individual organ-systems functionality in the body? How to maintain a healthy hormonal status?

Overall, we look to beneficial and practical tactics for athletes wishing to upgrade their performance and discuss common pitfalls to avoid in cultivating endurance.

On this full-on ketosis diet… the endurance payoff was huge. The amount of focus that I had for long periods of time. My ability to just hop on a bike and ride for hours with no fuel at all, with just water. It was pretty profound, because you produce all these ketones as a bi-product of fatty acid oxidation, and they’re used as the preferred fuel… while you’re out exercising. And that’s a huge boon to an endurance athlete.
– Ben Greenfield

Today’s guest is Ben Greenfield who is a professional competitor in endurance-demanding events, including triathlon and Ironman races. Ben has 11 years experience coaching athletes and fitness professionals.

Throughout his athletic career, he has researched physiology of upgrading endurance using a quantified approach. He has performed numerous self-experiments targeted towards understanding his performance parameters, and towards optimizing his diet and exercise.

Ben is the author of a New York Time’s best-selling book titled “Beyond Training: Mastering Endurance, Health, and Life”, which was published in 2014. His top-ranked iTunes podcast is called BenGreenFieldFitness.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. Enjoy the show and let me know what you think in the comments!

itunes quantified body

What You’ll Learn

  • Ben uses his biohacking experience to coach people on living healthy and attempting on-the-edge extreme exercise (4:46).
  • Ben’s interests in endurance training and research developed over time. No big eureka moments, just meaningful experiences (7:12).
  • Important biomarkers in endurance training specifically, and practical reasons for these picks in exercise self-tracking (11:24)
  • Why regulation of sex-hormones and cortisol (the stress hormone) are important to track in endurance training (15:50).
  • Why standard reference ranges for free testosterone are often not applicable to endurance athletes (16:48).
  • Liver enzymes, kidney parameters, Vitamin D, and digestive track inspections are also key biomarkers for healthy endurance training (18:20).
  • The digestive track plays an upstream role in multiple athlete pains and discomforts (21:18).
  • How to fight thyroid system dysfunction in endurance training (24:17).
  • The key lessons Ben learned from his 12 months ketosis dieting experiment (26:10).
  • The biomarkers for detecting adrenal fatigue symptoms (27:22).
  • Biomarkers and tests for autonomic nervous system functionality and distinguishing adrenal fatigue from thyroid system dysfunction (28:03).
  • Incorporating Heart Rate Variability (HRV) tracking in endurance training (31:39).
  • HRV is Ben’s ultimate marker for optimizing endurance training and quantifying overall health (33:23).
  • Success in endurance training requires optimization between high-volume achievements and short-duration precisely aimed tasks (34:29).
  • Dealing with negative effects of endurance exercise and ketogenic dieting (39:01).
  • Maximizing ketogenic dieting benefits and potentially useful supplements (44:34).
  • Breath ketones are an easy way to test for purposeful ketosis (46:20).
  • Tracking important biomarkers and avoiding excessive ketosis (47:20).
  • Why oxaloacetate can be used as a supplement with ketogenic dieting (48:25).
  • Why cold thermogenesis works for athletes’ bodies, for recovery and for overall performance (50:27).
  • The portal outlining Ben’s work and relevant people recommended by Ben (53:17).
  • Ben’s most-important advice on living healthy is being grateful several times per day (54:48).

Thank Ben Greenfield on Twitter for this interview.
Click Here to let him know you enjoyed the show!

Ben Greenfield, Greenfield Fitness Systems

Tools & Tactics


  • Cold Thermogenesis: Can be achieved through a variety of cold exposure methods such as cold showers or dipping into cold water streams . In cold thermogenesis hormesis is used to promote positive adaptations in the body as we saw in episode 8. Amongst other improvements it can help to burn fat more efficiently and improve blood vessel functionality in part by promoting development of your Brown Adipose Tissue (BAT). BAT is a type of fat which is active tissue and able to generate heat.


  • Heart Math Gratitude exercises: The Institute of Heart Math promotes using specific gratitude exercises to optimize the HeartMath Heart Rate Variability (HRV) score. We’ve discussed the HeartMath form of HRV previously in episode 6. This exercise can be done with one of either of their two HRV feedback devices: Inner Balance for iOS or emwave2.


  • Thyro-Gold: Thyroid glandular extract produced by the New Zealand company Natural Thyroid Solutions. This supplement is used as a biohack to correct thyroid-system dysfunction, sometimes caused by ketogenic dieting – especially with very low carbohydrate intake and endurance exercise.
  • AndroGel: Although the use of testosterone hormone-containing products is illegal in professionally-sanctioned sports events, this supplement is sometimes used because free-testosterone levels often drop in a ketosis state.
  • Ketosports KetoForce: KetoForce contains the endogenous ketone body beta-hydroxybutyrate (BHB) in sodium and potassium salt form. The compound BHB can be used as an energy source by the brain when blood glucose is low. Ingesting KetoForce raises the levels of blood ketones for 2.5-3.0 hours after ingestion. (Note: A similar product from same company is Ketosports KetoCaNa).
  • benaGene: This supplement, oxaloacetate, was previously covered in depth in episode 30 in an interview with its creator Alan Cash.
    Greenfield uses this specifically to increase the rate at which his liver synthesizes new glucose molecules, during a low-carbohydrate ketogenic diet including exercise. The goal is to take advantage of its ‘glycogen sparing’ effect, since glycogen is less available in ketogenic diets, and thus get more intensity out of workouts.

Diet & Nutrition

  • Ketogenic Diet: A ketogenic diet is low in carbohydrates intake and high in fat intake. As such, it induces a state of ketosis in the body – the condition in which the body burns fats and uses ketones instead of glucose for fuel. Previously, we discussed measuring ketones and ketogenic dieting in Episode 7 with Jimmy Moore.
    To provide scientific support in favor of ketogenic dieting for endurance, Ben suggests the research of a University of Connecticut team investigating athletic training and human performance. For more information, see this recent scientific review authored by them on using fat as fuel for endurance exercise.
  • Cyclic-Ketogenic Diet: In some people, full ketogenic diets can lead to hormonal or organ dysfunction (e.g. thyroid). The cyclic-ketogenic diet is the solution often used to avoid these downsides. This is a low-carbohydrate diet with intermittent periods of high or moderate carbohydrate consumption (e.g. a refeed with carbohydrates every weekend). It is used as a way to maximize fat loss while maintaining the ability to perform intense exercise during a ketosis state.
  • Based on his 12 month ketosis self-experiment, Ben has concluded that eating anti-inflammatory food, as well as increasing intake of food containing medium-chain triglycerides (MTCs) and resistant starches, are all beneficial in reducing the potential negative side effects of ketogenic dieting.


  • Polarized Training: Polarized Training is scientific terminology for the concept of easy-hard training. Researchers from the University of Stirling in Scotland have concluded that using an approach which excludes medium-intensity training is more beneficial for building endurance compared to an approach that includes medium-intensity training. The polarized training model (80% low-intensity; 0% medium-intensity; 20% high-intensity training) produces more positive results in endurance athletes, compared to the competitor threshold model (57% low-intensity; 43% medium-intensity; 0% high-intensity training).
  • Murph Workout: “Murph” is a CrossFit workout named after Navy Lieutenant Michael Murphy, who was killed in Afghanistan June 28th, 2005. He was awarded the Congressional Medal of Honor after his death. It first appeared on the CrossFit site 18 August 2005. This workout consists of (in order): 1 mile run, 100 pull-ups, 200 push-ups, 300 squats, and a 1 mile run at the end.



  • Heart Rate Variability (HRV): HRV is the measure of the change in the heart’s rhythm over time based on changes between sympathetic and parasympathetic activation. HRV was previously covered in the context of optimizing training workouts using HRV in Episode 1 with Andrew Flatt and using HRV as a biomarker for longevity in Episode 20 with Dr. Joon Yun.
  • Triglyceride to High Density Lipoprotein (HDL) ratio: Researchers have shown that using the triglyceride to HDL ratio is a better predictor of coronary disease risk factors, compared to tracking total cholesterol (which includes HDL and other lipoprotiens). A ratio of 2 : 1 or less is considered optimal.
  • High-Sensitivity C-reactive protein (hs-CRP): CRP is a protein that increases in the blood with inflammation and is used as a marker for cardiovascular health (high levels over 1 mg/l are indicative of higher cardiovascular risk). Both diet choices and overtraining can lead to high levels of hs-CRP (over 1).
  • Ketones: Ketone concentrations can be tested in blood, breath and urine samples to determine if you are in ketosis (burning ketones for fuel) and to what extent. We covered these markers extensively in episode 7 – how to measure ketones.
  • Creatinine and Blood Urea Nitrogen: These two biomarkers are often elevated above normal levels in endurance athletes, without being indicative of a health risk. In endurance training, creatinine levels lower than about 1.1 mg/dl do not pose a health risk. It is also relatively normal to have BUN levels over 20mg/dL.
  • Liver Function Tests: When excessive exercise is present, the blood levels of liver enzymes Alanine Transaminase (ALT), Aspartate Transaminase (AST), and Alkaline Phosphatase (ALP) are elevated above normal.
  • The 25-hydroxy Vitamin D Blood Test: The most accurate way to measure how much vitamin D is bioavailable to be used by your body is the 25-hydroxy vitamin D blood test. Optimum vitamin D levels range between 50-70 ng/ml.
  • Salivary cortisol to Dehydroepiandrosterone (DHEA) ratio: An increase in DHEA levels is highly suggestive of adrenal dysfunction because DHEA is produced exclusively by the adrenal glands. Excessive exercise stresses the body to produce very high levels of cortisol, which causes a depletion of endogenous DHEA. This results in an elevated cortisol to DHEA ratio. Testing for this ratio several times per day provides a more complete image of adrenal function, compared to a snapshot provided by simple monitoring of blood cortisol levels. A normal cortisol : DHEA ratio is approximately 5:1 to 6:1.
  • Thyroid Functional Test Panel: A TFT panel typically includes thyroid hormones such as Thyroid Stimulating Hormone as well as the thyroid hormones triiodothyronine (T3) and thyroxine (T4). Excessive exercise can stress the body to produce high-levels of cortisol (the stress hormone) which inhibits the conversion of thyroid hormone from inactive (T4) to biologically active (T3). This can result in lower levels of active thyroid hormone despite normal or up-regulated levels of TSH. Thus, testing for (active) T3 hormone concentrations is more relevant for endurance athletes self-tracking. Optimal reference ranges for TSH are 0.4 – 2.5 milliunits per liter (mU/L). Optimal reference ranges for free (bioavailable) T3 range between 350 – 780 pg/dL.
  • Sex Hormone Binding Globulin (SHBG) and free testosterone: The standard reference ranges for SHBG are 0.2-1.6 mg/dL for non-pregnant adult females and 0.1-0.6 mg/dL for adult males. Changes in SHBG levels affect the amount of free hormone that is available to be used by tissues, including the levels of free testosterone. In case SHBG levels are in abnormal ranges, then free (bioavailable) testosterone should be tested (reference ranges 1.0-8.5 pg/mL for females and 50.2-210.3 pg/mL for males).
  • Tests for detecting adrenal fatigue and thyroid system insufficiency

  • Iris Contraction Test: This test consists of you looking at the pupil of your eye in a mirror while shining a bright light at your eye. The light should cause the pupil (center black spot of your eye) to contract or become more narrow. The contraction should be sustained for longer than 20 seconds before the pupil starts to flicker or dilate. Otherwise, if the pupil starts to flicker immediately upon shining light, this is a good indication that you have adrenal fatigue – mainly because your adrenal gland is functioning properly in managing blood pressure.
  • Dizziness Test: If you lay down or you sit down and you stand up quickly and you get dizzy, then this is a sign of blood pressure mismanagement. Importantly, problems with blood pressure often accompany adrenal fatigue because one of the main functions of the kidneys is to regulate blood pressure via production of hormones in the adrenal gland.
  • Broda Barnes, MD Temperature Test: This test was developed by Dr. Broda Otto Barnes, who was best known for developing novel perspectives on hypothyroidism – a type of thyroid system disease. In essence, you do oral and armpit measurements every morning in bed upon waking up and keep a graph of the results. If your temperature is consistently low, then this is an indication that your thyroid system is dysfunctional even in the absence of a blood thyroid test.

Lab Tests, Devices and Apps

Other People, Books & Resources


  • Dr. Terry Wahls: Dr. Terry Wahls is a a clinical professor of medicine at the University of Iowa. Previously, Dr. Wahls was kind to participate in the third episode of our show, where we focused on linking mitochondrial health to autoimmune and chronic disease.
  • Alan Cash: Alan Cash is the CEO of Terra Biological. Previously, he has been a guest on our podcast in Episode 30, where we discussed the potential for using oxaloacetate as an anti-aging supplement.
  • Joe Friel: Joe Friel holds a masters degree in exercise science and is a USA Triathlon and USA Cycling certified elite-level coach. For Joe’s blog click here. For his Twitter click here.
  • Sami Inkinen: Sami Inkinen is a balanced person. He is a successful businessman and a top-age Ironman competitor. For his Twitter click here.
  • Dr. Peter Attia: Dr. Peter Attia is a scientist who is knowledgeable in healthy endurance exercise and self-quantification. For Dr. Attia’s Eating Academy Blog click here. For his Twitter click here.



Full Interview Transcript

Click Here to Read Transcript
[04:46] [Damien Blenkinsopp]: Ben, welcome to the podcast.

[Ben Greenfield]: Hey, thanks for having me on man. And I’ve got to ask you, is it Damien, or Damion? Or Dami-something else?

[Damien Blenkinsopp]: Or Damian? It depends where you come from, I guess.

[Ben Greenfield]: Okay. Just checking. I don’t want to stick my foot in my mouth.

[Damien Blenkinsopp]: Yeah. You can call me Dam. I tell people to call me Dam, just to avoid all those questions.

[Ben Greenfield]: There we go. I want to sound like I’m cursing the entire episode.

[Damien Blenkinsopp]: Yeah. But it even works in Asia, tried and tested.

[Ben Greenfield]: Nice.

[Damien Blenkinsopp]: I mean you’ve got a three letter name. That works well.

[Ben Greenfield]: Yeah, totally. Ben.

(05:12) [Damien Blenkinsopp]: So, Ben, you’re into triathletes, Ironman, and basically the way I look at you is you go around searching for tactics and tools to give you an edge in these areas that you’re interested in. Is that a fair kind of back story to who you are and what you’re doing?

[Ben Greenfield]: Yeah, I do a lot of that I guess n=1 guinea-piging myself. Going out and doing crazy things like training with the Navy SEALS or doing these Spartan Races or Ironman triathlons, things like that.

But then I also think I learn just as much via a lot of the coaching and consulting that I do, just because people typically come to me for one of two reasons.

They either want to do some crazy feat that’s completely unnatural for the human body to do, like they want to go run 100 miles in the wilderness or something like that, and figure out how to do it without destroying themselves. So my job is to figure out how to do that from a nutrition and a physiology and an exercise standpoint.

Or they come to me because they basically want to live as long as freaking humanly possible, and want me to manage how do you sleep when you want to do something like that, how do you exercise, what do you measure, what do you pay attention to in your blood and your gut. And so there’s that kind of biohackiness that I get into.

And I’ve got to admit, for me personally it’s a little bit of both, really. I certainly do want to live as long as possible. I also want to do as many crazy events as I can during the process, see as much of the world as I can at the fastest pace possible. And so for myself, personally, I’m doing a little bit of both.

But sometimes people come to me and want to do something that I know nothing about, so I’ve got to go and learn it. So part of it is that, too. That, or if it’s not coaching someone it’s writing about that. Because I’ve done a lot of writing recently. This morning [I] published a big article on my website about how to use marijuana to get performance enhancing gains.

And I never really would have delved into that if I hadn’t been asked by so many people, especially here in the US with the growing legality. It’s like, can I use this while I’m exercising? That type of thing. So it’s a little bit of everything.

[07:12] [Damien Blenkinsopp]:Yeah, great. So [what was] the event that started the whole Ben Greenfield fitness podcast, and the blog and everything? How’d you get involved in that? Because you’re obviously very passionate about it.

[Ben Greenfield]: Yeah. Well there’s, I mean I get that question a lot, and frankly – nothing against you – but it annoys me, because I hate when people go, “When did you decide to do this? When did you decide to do that?” I never make decisions. I don’t have a 10 year business plan. I don’t have some ‘Come to Jesus’ moment where I said, “Oh hey, I want to learn how to exercise.”

It’s just that I live my life. I do things that I’m passionate about, or that other people who I’m helping are passionate about and tend to fall into whatever I might fall into based on that. I’m getting into hunting right now – well specifically bow hunting and hunting competitions – before that obstacle racing, before that Ironman Triathlon, before that water polo, before that body-building, before that I was a collegiate tennis player.

It’s just like life is a series of chapters and moving targets. It’s never just like one commitment to do one thing. But I would say, to give you a rough answer to your question, the very first time I decided to something a little bit more endurance orientated – which I would define as something that has a nutrition rate.

You don’t see people dropping out of baseball or cricket games because of fatigue and heat stroke and lack of nutrition. That’s very rare, but you see it all the time in marathons and Ironman triathlons and things like that. So I would say the first time I started to get into that side of sports would have been my first Ironman Triathlon that I did back in the city of Portalane, Idaho in 2007.

And up until that point I’d been primarily an explosive power athlete. Like body-building and tennis and stuff like that. But my girlfriend, who is now my wife, was a runner. She ran cross-country for University of Idaho. So I kind of had to take up running, to a certain extent, just to be able to woo her.

And she dragged me to a triathlon one day and she actually had me run the running leg of the triathlon, which hurt like hell. I was a body builder; my boobs were bouncing up and down and my lower back was locking up and it was horrible. But it kind of got me interested in this high that you can get from endurance sports.

And so I wound up doing a few triathlons and doing, what I would say, is the biggest mistake for anyone who wants to avoid getting into endurance, that is I went and watched an Ironman Triathlon. And after watching Ironman and watching these intense feats of physical performance and the huge feeling of satisfaction and self-completion that these people were experiencing as they threw up their arms when they crossed the finish line I was like, I want that. I want to experience that.

And so I signed up for an Ironman and began taking everything I had been studying. At that point I had a Master’s Degree in Exercise Physiology and Nutrition and I was able to start applying that stuff to my training, and experimenting with a lot of what I was finding in research and sports science and seeing what worked and what doesn’t.

For example, all laboratory studies, or most of them, done by the white coats in their little labs will tell you that the body can take on about 200 to 250 calories of fuel during exercise. You can oxidize 200, 250 calories of carbohydrates while you are exercising. But for anyone, especially anyone who’s above about 150 pounds who has tried to go out and do an Ironman Triathlon, you completely bonk after about five hours on that number of calories, and you technically need about twice that in order to be able to get by in an Ironman race in most cases.

So, it’s a situation where what they’re saying in the lab and textbooks actually doesn’t work once you get out in real life and you try this stuff in the streets, in the trenches. So, that’s been kind of fun too, figuring out from research what works, and what doesn’t.

[Damien Blenkinsopp]: Right. Yeah, we often talk on here about n=1 experiments are often going to be different to the research, for a variety of reasons like the ones you brought up, and the use of averages, and other things like that.

[11:24] So, anyway, in terms of endurance training, since we’re there, what kind of biomarkers have you found to be the most useful to track your performance? Or what do you track around your capabilities for endurance training, and see as important?

[Ben Greenfield]: Oh, for endurance specifically?

[Damien Blenkinsopp]: Yeah.

[Ben Greenfield]: So for endurance specifically, that’s a great question. So one would be your level of HSCRP, which really that’s just for exercise in general. Or high sensitivity C-reative protein, just to make sure that your levels aren’t straying too high above 0.5. And the reason for that…

[Damien Blenkinsopp]: So that’s kind of your benchmark? You try to keep them under there? Where do yours tend to hover around?

[Ben Greenfield]: I actually fall below 0.2 now for HSCRP, probably because I eat a very anti-inflammatory diet, very clean. And I won’t insult your listeners’ intelligence by defining what a clean diet or an anti-inflammatory diet is, because it’s pretty easy to go out and figure that out with Dr. Google.

But I eat very clean. I also use a lot of anti-inflammatories. Like I make ginger tea, and I use a ton of turmeric, usually combined with black pepper to increase the efficacy of it, and I use percumin and I consume a lot of very dark and colorful vegetables with very limited amounts of dark and colorful fruits, and wild caught fish, and fats, and things that really help with inflammation.

And I’m also very careful with my training, where I do extremely focused and intense, but short, bouts of training with a specific purpose. I never go out and just pound the pavement for the hell of it, which is a great way to build up a lot of voluminous training based inflammation.

And so I have a very precise, dialed in training program that also includes things that help to mitigate inflammation, like foam rolling, and cold soaking, and these things that can help to remove a lot of these byproducts of metabolism that can create inflammation. So, inflammation is a biggie. Honestly, it doesn’t take a rocket scientist to figure out that if you keep your inflammation controlled, it’s a good thing.

So, a few others that I’ll pay attention to for endurance. When we’re talking about labs, as far as blood goes, TSH, preferably a full thyroid panel, is pretty prudent to pay attention to simply because high level endurance training can inhibit conversion of inactive to active thyroid hormone.

And because of the high amounts of cortisol that can potentially be produced through an improper training program can stress the body out enough to where you experience some hypothalamic pituitary adrenal axis insufficiencies, particularly high cortisol, creating a feedback loop that reduces the conversion of inactive to active thyroid hormone and thus an increase in thyroid stimulating hormone. So your body turns out a bunch more thyroid stimulating hormone to try and get more T4 present, even though a lot of that T4 isn’’t getting converted into T3.

And by monitoring TSH, if you see a pattern or a rise in TSH many times it’s concomitant with an increase in cortisol and stress, and often also accompanies a not enough eating period. Sometimes not enough carbohydrates is the biggest culprit, but in many cases just not enough damn calories, period. Damn, not referring to your first name but to the curse word. Just so we’re clear.

That’s another one is TSH. Cortisol, I alluded to, but when we’re looking at a hormonal panel, I also like to pay attention to sex hormone binding globulin. Because the body has this interesting mechanism where when it’s stressed out, when it’s in a time of famine, in a time of need, under high amounts of stress, doing a lot of migrating, a lot of moving with low amount of calorie intake, the last thing you want the body to do is produce a bunch of babies at that point.

And so sex hormone binding globulin often rises simultaneous to cortisol to keep total testosterone bound, and keep it from being available as free testosterone. So even if your testes are working just fine, or your pituitary gland is working just fine, –obviously talking about the males more than the females now– and even the leydig cells in your testes are producing testosterone just fine, if sex hormone binding globulin levels are really, really high that’s all for naught. And so that’s another really, really important one to keep an eye on. And that’s typically addressed by addressing cortisol.

[15:50][Damien Blenkinsopp]: Right. So, why would you look at SHBG versus free testosterone, or that marker? The [unclear 15:56]?

[Ben Greenfield]: Well, because if free testosterone is low, but if you look upstream perhaps it’s because total testosterone is low because the leydig cells in your testes are not producing enough hormone because you’ve got low levels of luteinizing hormone. In contrast to that, perhaps your luteinizing hormone production is fine, your leydig cells are producing enough testosterone just fine, your total testosterone is high, but it’s more of a cortisol issue than it is a central nervous system issue or a glandular issue.

So that’s why you test that versus just looking at free testosterone.

[Damien Blenkinsopp]: So basically, free testosterone could be many, there’s more reasons behind it, but the SHBG is more specific to endurance and specific dynamic.

[Ben Greenfield]: Yeah. Really, two reasons behind it. Either you aren’t producing enough total testosterone, or you are producing enough total testosterone but it’s not getting converted. So those are really the two main things to look at.

[16:48] [Damien Blenkinsopp]: So, are you looking at the standard reference ranges for that, or do you look for something a bit more precise?

[Ben Greenfield]: A lot of times you have to look at symptoms synonymous, because standard reference ranges are going to vary widely.

I’ve worked with a lot of endurance athletes who have very high libido levels, show no signs of over-training, have very robust nervous systems, high heart rate variability, low cortisol, and even low sex hormone binding globulin, but their total testosterone is in like the high 300s. Which, for a body builder they would scoff at that and say, oh that’s rock bottom low. Even though a lot of times hypogonadism is levels below 100.

And you’ll get many people who just feel like fricking crap at 300, and some people will be closer to 500, and some people will need levels of 700, 800, or even 1000. So it kind of depends. It varies widely, I suspect based on genetics as a big part of it.

So ultimately it’s really tough to hold things up to reference ranges. I mean, you can ballpark it. You can say well if total testosterone is starting to get below 300, that’s where we would really start to get a little bit concerned. But it really is kind of tough. A lot of times it’s a moving target based off of a cluster of other symptoms.

If someone’s complaining of low libido and low motivation, and lack of energy, etc, and their testosterone is at 400, well that’s a pretty good sign that 400 is not going to be adequate for them. So I know that’s one of those deals where it’s total soft science, but it does really depend. That’s one of those ‘it depends’ answers, but that is definitely a variable that I will look at.

[18:20] Liver enzymes is another one, like alkaline phosphatase, aspartate aminotransferase, the ALT, the AST, some of these liver markers just because a lot of times they can be elevated when excessive exercise is present. And so that’s another one to pay attention to. It doesn’t have to be excessive exercise; sometimes it can be alcohol, pharmaceutical intake, things of that nature. But liver enzymes are the one that I’ll look at.

Kidneys, a lot of people say to look at kidneys, but frankly it’s very rare for me to see an athlete who doesn’t have slightly elevate creatinine and blood urea nitrogen levels, which are two common markers in the kidneys that a physician will get concerned about if they see elevated, but that are very common to see elevated if an athlete is exercising anywhere in the 48 hours leading up to a blood panel.

So, as long as creatinine levels aren’t much higher than about 1.1, and as long as blood urea nitrogen isn’t through the roof and – I apologize, but off the top of my head I don’t remember the lab reference ranges for blood urea nitrogen. The reason being that I do most of my coaching for blood panels with a company called WellnessFX. It’s basically more like a dashboard with graphs, more than it is hard numbers, so occasionally I’m looking at graphs more than I am numbers.

[Damien Blenkinsopp]: And they just have those red zones.

[Ben Greenfield]: Yeah, exactly. They’ve got red, yellow, green, which actually annoys me some of the time. Because they’ll flag high LDL as red when I purposefully try to get my LDL high. So there’s some issues with the whole red yellow green type of quantification. But anyways, blood urea nitrogen and creatinine, even though a lot of people talk about those, they’re not super duper important in my opinion, because they’re always going to be a little bit elevated.

Vitamin D, that’s another one that I’ll look at just because of it’s importance. As you can suspect, a lot of these aren’t just specific to endurance, they’re specific to exercising period. Just as a hormone and a steroid, vitamin D is another important one that I’ll look at.

And then as far as other things, I typically will have most of the athletes I work with or the people I advise do at least once a year a full gut panel. You know, a comprehensive gut panel that includes parasitology, measurement of pancreatic enzyme production, measurement of yeast and fungus and any type of bacterial overgrowth in the digestive tract because I find that, especially when you’re jogging your body up and down for 10 plus hours while racing, having a really, really good gut and GI system and very efficient digestion is incredibly important.

And so I will look at things like presence of yeast or fungus, like Candida Albicans, or the presence of H pylori, or absence of hydrochloric acid, or absence of pancreatic enzymes, or overgrowth of specific bacteria, or lack of short chain fatty acids in the digestive tract, in the colon, and a lot of those things that tend to influence an athlete’s performance or their feelings of well-being. So that’s another thing I’ll pay attention to.

[21:18][Damien Blenkinsopp]: Right. A lot of people wouldn’t think of that as something performance related, more like a chronic issue related.

Have you got any case studies where you saw people, basically not performing but not having any negative symptoms in terms of GI distress or anything that they would have noticed, but when you put through these tests some negative results came?

[Ben Greenfield]: Sure. Now we’re delving a little bit more deeply. And I mean, obviously explosive diarrhea halfway through a marathon can be a good sign of digestive enzyme insufficiency, but so can, for example, vitamin B12 or vitamin D deficiencies, or even if you go more advanced and run like an organic acids profile, or an amino acid profile, severe imbalances of a lot of micro-nutrients.

Well if you’re not digesting your food efficiently, for example, if you’re not producing adequate hydrochloric acid, you’re not activating pepsin to break down proteins, beginning in the stomach an moving on to the small intestine, then you’re going to: a. have undigested protein fragments winding up in the bloodstream causing some auto-immune issues, and that can include fuzzy thinking, which no athlete wants.

But then you also can get amino acid deficiencies, like deficiency in the ability to create neurotransmitters, and also deficiencies in the ability to repair and regenerate skeletal muscle tissue, because you aren’t breaking down the proteins that you’re eating.

And the same could be said for something like inflammation in the digestive tract from wearing down of the microvilli. So perhaps you’re not producing adequate levels of lactase, so you’ve got some lactose issues and bloating and gas. Or you’ve got inflammation that is resulting in malabsorption of fat-soluble vitamins, so vitamins A, D, E, and K aren’t getting absorbed properly, or bacteria aren’t helping you to produce those, and so you experience hormonal deficiencies, or steroid deficiencies.

And so, yeah the gut is incredibly important, and that’s one of the things I’ve been kind of getting on companies like WellnessFX, for example, to do is to not just use the strategy of blood testing but also really pay attention to the gut. I mean, in an ideal scenario, what I would like to see is a done-for-you system.

And for me right now, what I do is just kind of string this together for the athletes who I work with. But a done-for-you system where you get your blood testing, you get your gut testing, and you get your genetic testing so we can look at everything from genetic snips to bacterial imbalances in the gut to all the blood and biomarkers, and have all of that done with either one panel or one service.

That would be really nice, because right now you’ve got to go to typically three different places. You’ve got to go to whatever DNAFit, or 23andMe, and you’ve got to go to DirectLabs, or Metametrix for GI affects, and then you’ve got to go to WellnessFX for whatever else. And then if you want to do food allergy testing, well then you’ve got to throw in a Cyrex panel, or something like that.

So maybe it’s a first world problem to want all this stuff to be available in one central location, but it certainly would be nice.

[Damien Blenkinsopp]: Yeah. It’s so near the early days from that perspective. There’s a lot of specialized, it’s still kind of specialized in terms of the labs. Each is in their little separate box and everything.

[Ben Greenfield]: Yeah.

[24:17] [Damien Blenkinsopp]: So, in terms of the kinds of decisions you’ve made, or you’ve advised a client based on some of these values, some of this data that’s come back, what have been the biggest changes that you’ve implemented to optimize training?

[Ben Greenfield]: You mean as far as training?

[Damien Blenkinsopp]: So, say the TSH came up too high, what would you do about that?

[Ben Greenfield]: Oh okay, so for high TSH, obviously it’s never a shotgun approach. It’s never a multivitamin. So for high TSH it may be looking at your carbohydrate intake. That’s the first thing that I’ll look at.

Even before you look at total amount of calories, you just make sure nobody is on some low, like 40 gram per day carbohydrate diet, because frankly a lot of the ‘low carb’ or ‘ketosis’ based diets that are out there were created for sedentary people. Even the bulletproof diet. I love the whole bulletproof philosophy, but it was written by a computer programmer, not by an athlete.

And so the levels of carbohydrate, and even the levels of calories in that diet, have to be adjusted and modified for a hard-charging athlete, especially an endurance athlete. So, otherwise with caloric depletion and carbohydrate depletion, you basically lose a lot of your ability to convert inactive to active thyroid hormone.

And in the case of calories, as you would deduce through common sense, when you send your body a message that calories are insufficient but you’re still requiring it to move a lot, your body down regulates metabolism. And one of the main ways it does that is by down regulating thyroid.

So, I look at carbohydrates, I look at calories, and then I also look at dietary intake of organ meats and fat soluble vitamins, which can also assist with thyroid health. So in my case, because I did an n=1 experiment about a year and a half ago where I did 12 months of ketosis.

Not cyclic ketosis, not cycling carbohydrates in and out throughout the day, but full on eating only 5-10 percent of my total daily intake from carbohydrates. Very low carbohydrate diet. Too low, in my opinion, for most endurance athletes who want to maintain optimal levels of health elsewhere.

[26:10] [Damien Blenkinsopp]: Did you see negative effects from that over the 12 months?

[Ben Greenfield]: Yeah, and that’s what I’m getting at with the thyroid. I started taking thyroid glandular extract. I took one called Thryo-Gold, which is made from New Zealand cows, that are like an A2 cattle.

A lot of A1 cattle has proteins in it that cause an immune reaction within the human body, but cattle that are breed via A2 are cattle that contain this A2 genetic profile that is more bio-compatible with the human body. And so I basically took a T1, T2, T3, and T4 combo, and that seemed to turn my thyroid around. But that was after I had already done a number on it.

So for thyroid, that would be an example of what I would do with something like thyroid, would be increase calories, increase carbohydrates, increase intake of organ meats and fat soluble vitamins. And then for a really hard-charging athlete who insists upon doing something like restricting carbohydrates to tap into the performance enhancing effects of ketosis, understand that you’ve got to get on extra help from the thyroid.

Since your body isn’t going to make T3, dump it into the body. And preferably get it from a whole source, like levothyroxine or synthroid. But a source that contains other elements of thyroid in addition to just T3, so you’re not creating an imbalance.

[27:22] [Damien Blenkinsopp]: Great. Well, connected with the thyroid issues, I was wondering if you’ve come across adrenal fatigue also. If that’s every come up with you or with anyone else.

[Ben Greenfield]: Absolutely. Adrenal fatigue, gosh. There’s like four chapters of my book on that alone. But adrenal fatigue, well what do you want to know about it?

[Damien Blenkinsopp]: Well first of all, have you looked at some of the tests? I’ve done some of the salivary tests.

[Ben Greenfield]: Oh yeah. Yeah, like an adrenal stress index is kind of gold standard, cortisol DHA. If you look at the cortisol DHA curve, that’s much, much better when you’re addressing something like adrenal fatigue versus a blood cortisol measurement, which is just a snapshot. You want to see a moving target of salivary cortisol levels, preferably matched to salivary DHEA levels, throughout the day.

[28:03][Damien Blenkinsopp]: I was just thinking, based on it’s endurance exercise, and it has this tendency to raise cortisol, that that would be more of an issue and something that you would keep an eye on. Or by monitoring TSH, does that kind of take care of itself? If the TSH is alright then you tend not to have an adrenal issue as well?

[Ben Greenfield]: No, not necessarily.

You can still have adrenal fatigue and have a thyroid that’s managed properly. Because what you would typically see in that case is someone is eating boatloads of calories and taking care of themselves from an energetic standpoint, but simply outputting too much energy. They’re just training way too much. Even though they’re supplying their thyroid with what it needs, there’s just too much training still.

And a lot of times you’ll see inflammation high, but yeah. Cortisol DHEA, and that adrenal stress index can be a good measurement. And there are less quantitative measurements. You could do a pulst test, where you look in a mirror and you shine a bright light at your eyes, and your pupils should stay dilated. But if it stays dilated and then just starts flickering rapidly.

[Damien Blenkinsopp]: Have you tried that one?

[Ben Greenfield]: I have, yeah.

[Damien Blenkinsopp]: Because I was just wondering. I did try it and I find it a little bit difficult to judge.

[Ben Greenfield]: Yeah, it’s certainly not as precise as a salivary measurement, but once you’ve done it a few times you can definitely see the pupil, and whether or not it’s actually flickering versus staying dilated. If you look at if for long enough, it’s just going to start flickering period, but if it starts flickering after just a few seconds, that’s typically a sign that your kidneys are not producing enough aldosterone, which is synonymous, or can accompany, adrenal fatigue.

The other one is just the dizziness test. If you lay down or you sit down and you stand up quickly and you get dizzy, that can be a sign of blood pressure mismanagement that often goes hand-in-hand with adrenal fatigue. And again, these are the super cheapo poor man’s methods, but it can give you clues.

And then there’s temperature tests for thyroid, the Broda Barnes Temperature Test, where you do oral and axillary measurements of your temperature in bed every morning, and keep a running graph. And if it’s consistently low, that can be a pretty good indication that even if you haven’t done a blood thyroid test that your thyroid might be having issues.

So, there are a lot of things. One of the best ones I like though is just pure heart-rate variability. Testing the interplay between your sympathetic and your parasympathetic nervous system by using something like a Bluetooth enabled heart rate monitor and one of these heart rate variability apps, and simply paying attention to whether heart rate variability is high or low on any given day.

And if it’s consistently low, and you see consistent suppression of both sympathetic and parasympathetic nervous system feedback, then that can be a pretty good sign that you’re on the cusp of adrenal fatigue illness or injury, and so that’s another really good one to pay attention to. And I do that one every day myself.

[Damien Blenkinsopp]: Do you do it in the morning as soon as you wake up?

[Ben Greenfield]: Yes, that’s gold standard, because that’s where most of the studies have been done on heart rate variability were five minutes resting in the morning.

[30:45] [Damien Blenkinsopp]: Right, right. I believe you use the HR…what’s the name of the company?

[Ben Greenfield]: SweetBeat?

[Damien Blenkinsopp]: Yeah, SweetBeat.

[Ben Greenfield]: Yeah, but because I want to build up that technology and add some features and stuff like that, I’ve actually white labeled their technology. And so I use the app called NatureBeat now, but it’s the SweetBeat technology.

[Damien Blenkinsopp]: Great, great. Yeah, she’s been on the show.

[Ben Greenfield]: Yeah.

[Damien Blenkinsopp]: So I was using that for a long time, and then I just recently started using iFleet, because I also talked to the guys at iFleet, and it does have this other thing that they just added recently. You might just want to check out.

It’s kind of interesting. It shows how high your energy levels are on a given day, so it kind of does this matrix thing. So it shows you if your in the bottom right corner, it means something a little bit different. So I’ve been checking it out. I’m still trying to understand what it means each day. But I do find that when I’m at the bottom, low energy, those days tend not to be good. Even if I have a high HRV.

[31:39] So anyway, out of interest, what is your HRV levels? Because you think normally endurance athletes have higher HRV, right?

[Ben Greenfield]: Yeah. Usually higher HRV, which isn’’t necessarily a good thing if you’ve got what are called HF to LF ratio imbalances.

You want your HF to LF ratio to be pretty close to one. That’s sympathetic and parasympathetic nervous system feedback. And if parasympathetic nervous system feedback, which would be your high frequency number, if that’s super duper depressed, and your LF is really high that can be an indication of aerobic based over-training, or vice versa.

So ideally you’ve got high HRV and a pretty close to a 1-1 ration between HF and LF. That’s what you want to go to. And you want both HF and LF to be up in the thousands. That’s a sign of a really robust nervous system.

So, my values tend to be between about 92 and 98, with HF and LF values that vary between about 4,000 to 8,000, around in there. Generally with a 1-1 ratio, depending on what my previous day’s training had looked like.

And I would expect, for example, this Tuesday I’ll do a CrossFit’s Murph and I’ll do that with a 20 pound weighted vest on, and just crush myself. And that will take me about an hour to do, and I guarantee my LF value will be tanked the next day. But I also won’t be doing any sympathetic nervous system training for like 48 hours afterward.

[Damien Blenkinsopp]: So you recover within 48 hours?

[Ben Greenfield]: 48 to 72 hours, depending.

[Damien Blenkinsopp]: These scores recover for you pretty quickly?

[Ben Greenfield]: Yeah, but I mean, if I were to do something epic, right? Like, usually something that gets you to the state of glycogen depletion. Or let’s say instead of Murph, I do double Murph, or I do a Murph with a 5k sandwiched on either end rather than just a mile, then it can take me several days to recover, for sure.

[33:23] [Damien Blenkinsopp]: If you had to pick one marker to optimize your endurance training by and make decisions on, which one of the ones we’ve talked about would it be?

[Ben Greenfield]: HRV.

[Damien Blenkinsopp]: Okay, great.

[Ben Greenfield]: Just because it’s easy, right? You don’t have to give blood.

And maybe at some point, once we’ve got the lab and chip technology finalized, and I can put a drop of blood onto a little dongle that will plug into my iPhone and I can measure, let’s say, testosterone cortisol ratios, maybe that will become a more valuable metric for me. But at this point, I would have to say something simple and easy to utilize and relatively inexpensive, the HRV would be the one that I’d choose.

If I had to choose an actual blood biomarker, tough to say. Tough to say. I guess I’d probably have to go with HSCRP, again. Just because inflammation is generally going to be high when cortisol is high. It’s generally going to be high when diet is crappy, it’s going to be high when triglycerides are high, it’s going to be high when omega-3 fatty acids are low. So, that’s a pretty good one to measure.

[Damien Blenkinsopp]: Yeah. So it catches a lot of things. Mainly whenever something starts going wrong.

[Ben Greenfield]: Yeah.

[34:29] [Damien Blenkinsopp]: Well so you’ve referred to over training quite a bit over this as something that you’d have to change. So HRV would be one of the first places you’d see over training.

Are there any other tell-tale markers, and what do you suggest, more to the point, because you mentioned earlier that you do very – is it short, intense kind of endurance exercises. And I think a lot of people when they’re thinking about endurance, they’re thinking about very high-volume, kind of long duration activity.

So how do you approach it, and avoid over training? What are the top things you’ve taken in over time?

[Ben Greenfield]: First of all, one of the common pitfalls that people fall into with endurance training is doing the long voluminous training every weekend. It’s very stereotypical that you’ll see in a lot of athletes these Saturday long bike rides and then Sunday long run, for example. Or in a marathon, the Saturday long run.

I’ve found that in most cases, you can maintain endurance really, really well. Unless you’re a professional athlete trying to perform at the peak of performance, most people can perform just fine. With doing digging into the well like that, really, really, deep for like a death march, a really long ride or something like that, you typically only need to do that one to two times a month. Not every weekend.

I’m a bigger fan of using shorter, very temporal based intervals. So to give you an example, for the Ironman triathletes that I work with, while their peers are out doing a five hour ride followed by an hour long run, my athletes will be doing two hours of 20 minutes at race pace followed by 5 minutes recovery. So a very focused activity with a specific goal in mind. And then they’ll finish that up with a 15 minute tempo run at a cadence of 90 plus.

So it’s all extremely high quality. And then once a month they’ll go out and do something big, something long, something voluminous that builds the mental tolerance to training, but that doesn’t dig so deep into the well as doing it every week.

And the reason for that is based off of the human body’s natural slow twitch muscle fibers. The human body’s ability to cool because we’re upright and not covered in fur and hair. Our ability to sweat, rather than pant, to reduce heat. And a cluster of other factors.

We’re pretty good at going for long periods of time. And when training for endurance, bigger limiters are things like power, speed, cadence, strength, the integrity of the fascia connective tissue, the intelligence to be able to use nutrients and calories properly.

And really pointing in one direction, and going for long periods of time is not that much of a weakness for the human body, but the problem is that it’s easy. And people take pride in it. They’re like, “Oh I persevered today. I did my three hour run.”

And my question to you is well yea, but what did you accomplish side from being on your feet for long periods of time? Which frankly I could stand up at my standing workstation and write an article for three hours and get the same amount of time on my feet as you just did out pounding the pavement. So it would be better in that case to do something with intervals at race pace for a shorter period of time.

Focus on cadence. Allow enough time before and after for a good warmup. Maybe some meditation and breath work. Some good recovery. And so that’s where the more intense, more quality, lower volume approach nine times out of ten trumps the voluminous approach.

The exception to that fact would be the person who has a lot of time on their hands to train: the professional athlete. Professional athletes, assuming they’re using this 80-20 approach, it’s called polarized training. 80 percent of your training is done aerobically, with about 20 percent done high intensity.

That approach works very well, and it is what a lot of the elite cross-country skiers and marathoners and cyclists etc. will use, but what is important to understand about that approach is it requires many, many hours per day.

That approach can require two to four hours per day of training, and even more than that, on weekends, for example. And the majority of folks simply don’t have the luxury of time available to utilize that approach effectively. That in a nut shell is my approach to training.

I’ve got a couple of athletes who I work with who are more, what I would consider to be on the professional level, who have that luxury of time. And I do train them with that aerobic approach, where they’re out doing long voluminous sets of training at a controlled heart rate aerobically, putting lots of time in the saddle or time on the pavement. But its very few and far between that I’ll recommend an athlete to train like that.

[Damien Blenkinsopp]: Great, great, thanks. That’s a great summary of it.

[39:01] I wanted to move on to, because I know you did this 12 months of ketogenic dieting. Could you talk a little bit about that? Give us an overview. What was your approach to that, what were you actually eating, and was there any specific goals to track over the year?

[Ben Greenfield]: Well yeah, for that specific diet, that was for a study at University of Connecticut that was done on, basically, a group of athletes who followed a high-carb/low-fat diet, versus a group of athletes who followed a high-fat/low-carb diet.

And it was basically a measurement of fat oxidation during exercise. And they also did muscle biopsies before and after exercise to see the rate of glycogen use as well as the rate of glycogen replenishment following the post work out meal to just see if the body does a better job at oxidizing fat, or at sparing glycogen during exercise when you’ve eaten a high-fat diet.

And it did turn out in that study that the athletes who followed the high-fat diet were oxidizing a lot of fat. The textbooks tell you that you can burn about 1.0 grams of fat per minute, and the group of athletes who followed the high-fat diet were burning 1.5, 1.6, 1.7 grams of fat per minute. Literally rewriting the textbooks when it comes to how much fat you can burn during exercise.

I haven’t seen the muscle biopsy data yet to see how much glycogen conservation actually took place, or whether or not the body became more glycogen depleted when using primarily fatty acids as a fuel. But ultimately, what that diet consisted of was really controlling carbohydrates.

Whereas I would normally – and this is what I do now – I would carb-cycle, or I would do cyclic-ketogensis or cyclic-ketosis, where I don’t eat carbohydrates all day long and at the very end of the day, typically in the post-workout scenario, with dinner I’ll eat anywhere from 75 to 200 grams of white rice, red wine, sweet potatoes, sourdough bread. You know, safe starches, not like pizza and ice cream, but good carbohydrates. And then the rest of the day just high fat and moderate protein.

Whereas on this full on ketosis diet, it was pretty much just things like bulletproof coffee, and high fat shakes and lots of coconut milk and coconut oil, and heavy cream and MCT oil and seeds and nuts, and just fats, fat, fats. Bone broth and avocados, and olives, and you name it.

And frankly, in my opinion, it wasn’t that enjoyable to have to not have sweet potato fries, and not have, even coconut ice cream has cane sugar in it. So you have to make your own with chocolate stevia. And so it’s a little bit laborious and a little bit tough, but I mean at the same time the endurance payoff was huge.

The amount of focus that I had for long periods of time. My ability to just hop on a bike and ride for hours with no fuel at all, with just water. It was pretty profound, because you produce all these ketones as a bi-product of fatty acid oxidation, and they’re used as the preferred fuel by the brain, by the heart, by the liver, by the diaphragm while you’re out exercising. And that’s a huge boon to an endurance athlete.

And like I mentioned, there’s some blow-back. Like the TSH could take a hit, the testosterone could take a hit. But ultimately, it’s a cool little bio-hack. If I could go back and do it over again, I would definitely start taking thyroid glandular earlier to stave off some of those thyroid issues.

I would,– it’s not legal – but I would really encourage folks to pay attention to testosterone. And I mean like, you can’t use testosterone in a WADA, or a USADA or like an NCAA sanctioned event, but my testosterone dropped so much during that experiment with ketosis, I would say if you’re not competing, use AndroGel or just some kind of testosterone support because your testosterone is going to fall to pieces.

And then the question becomes well is it really worth it to you if you’re doing this thing and you’re not even competing.

[Damien Blenkinsopp]: Yeah. Did you feel different?

[Ben Greenfield]: Oh, yeah.

[Damien Blenkinsopp]: Because we talk about testosterone with things like anxiety, your drive, your libido, of course. And so did you get any kind of low testosterone symptoms?

[Ben Greenfield]: Oh yeah. Absolutely. I mean even something as simple as only having to shave every four or five days, whereas normally I would just shave every one to two days.

[Damien Blenkinsopp]: That’s a benefit.

[Ben Greenfield]: I mean, little things like that, but you notice. Yeah, potentially. You save money on razors.

Yeah, the libido, sex drive, number of times having sex per week, desire to have sex, quality of the erection, all of those kind of things certainly they took a hit during ketosis. They weren’t good. But that was, mind you, ketosis in the presence of high amounts of physical activity. Even doing the ‘low volume approach’ it’s still a massive amount of work, right?

[Damien Blenkinsopp]: Right.

[Ben Greenfield]: You’re still working out 60 to 90 plus minutes every day, and longer than that on the weekends.

And you look at something like Dr. Terry Wahls and her ketosis approach for managing MS. Well sure. I mean, that’s going to work just fine for managing MS. I mean, going on a walk with your dog every morning, and maybe lifting easy weights, three sets of 10 for 20 minutes twice a week.

But once you jump into hard exercise, it’s a whole different type of ketosis.

[Damien Blenkinsopp]: Right, right. Just to be clear, were you getting better times? Did you feel like you were competing better?

[Ben Greenfield]: Oh, I was competing way better. Yeah. Absolutely.

[Damien Blenkinsopp]: Right. But it’s just the downsides to your lifestyle, to all the other things, were too great to do this on a constant basis.

[Ben Greenfield]: In my opinion, yes, because I don’t like being cold all the time, I don’t like not having libido. So again, I’m not saying you can’t do it properly, even though it’s way, way tougher once you get into training, but I think that you basically have to use supplementation pretty intensively.

[44:34] [Damien Blenkinsopp]: Did you kind of see the benefits evolve and get much better as the months passed, or is this something someone could do on a month basis, one month on and one month off?

[Ben Greenfield]: For exercise, you barely even see any benefits until you’ve been doing it consistently for about six months, and the real benefits start to manifest after one to two years.

But the other thing to realize is that right about the time I finished up the experiment, companies like KetoForce started coming out with beta hydroxybutyrate salts that could be consumed to elevate your ketone bodies, even in the presence of a lot of carbohydrates or glucose. And so it’s possible that now, since the experiment that I did, you could get the best of both worlds.

And I actually have some bottles of the beta hydroxybutyrate salts and the resistance starches, and a lot of the things that, if I had to go back and do it all over again, I would try to get the best of both worlds. I would eat more carbohydrates, but then I would also hack myself into ketosis by consuming actual ketones bodies.

The question there becomes a matter of long term health and gut health and how that actually manifests in terms of actual symptoms or the way you felt, or even I would definitely pay close attention to blood and biomarkers.

Were I to delve into that type of bio-hack? I potentially may. I could see myself, and obviously I’m at a point in my athletic career where I’ve still got a good eight years of hardcore performance left in my body, and I could see one of those years being spent utilizing a ketonic approach again, but with the incorporation of beta hydroxybutyrate salts, resistance starches, even higher amounts of MCT oils, particularly like the C8s and the C10s. And a little bit more attention paid to ways to get into ketosis that go above and beyond just carbohydrate restriction and exercise.

[Damien Blenkinsopp]: This is great Ben, this is a wealth of information.

[46:20] In terms of the biomarkers you would track, you said you would track some biomarkers if you were going to do this again what kinds of ones that we haven’t spoken about already would you look at? Did you track your blood ketones?

[Ben Greenfield]: Yeah. Breath ketones. I mean, urinary ketones become, many times, absent after a few weeks in ketosis just because you’re utilizing your ketones. Blood ketones are accurate but expensive and invasive to test, and breath ketones are pretty [easy].

There are breath testing monitors like the Ketonix device that, one breath and you know your ketones, and you’re good. So breath testing is a really good way to go as far as measurement of ketones. You look for values anywhere from 1.0 up to 3.0 millimolars. You’ll finish exercise as high as 7.0 millimolars.

You’ll rarely see ketoacidosis, which would be like 10 plus millimolars. It is a non-issue. I have yet to see any athlete I work with go under ketoacidosis, which would be an actual deleterious biological state. Not something you need to worry about unless you are letting yourself become severely hypoglycemic.

[47:20] [Damien Blenkinsopp]: So again, is that something you saw evolve over the months? Like your ketones ratings would get higher.

[Ben Greenfield]: Yeah. You get to the point where it’s just super duper easy to get into ketosis. Yeah. And your ability to go for long periods of time without eating just goes through the roof.

So ultimately, the biomarker I would say, in addition to what we’ve already talked about, would be breath ketones. And then pay attention to triglycerides too, because they’ve shown that compared to total cholesterol values, a better predictor of your coronary disease risk factors is your triglyceride to HDL ratio, specifically keeping that at one or lower in terms of your number of triglycerides versus HDL.

But I’ve found that some people will switch to a high-fat diet and have such a high intake of vegetable oils, and even an imbalanced high intake of animal based oils, like butter for example, versus olive oil and avocados. Their triglycerides go through the roof.

Pay attention to that HDL ratio. That’s my advice is make sure that that thing isn’t getting much above one, that would be another important thing to pay attention to, especially on a higher fat intake.

[Damien Blenkinsopp]: Great, great. Excellent points.

[48:25] So there are a couple of other things I’ve noticed you’ve done in your experiment. I read your book of course. One of the things that we’ve come across before – I spoke to Alan Cash from benaGene –oxaloacetate, and I was wondering what you’ve done with that and if you’ve tracked anything or learned anything about that.

[Ben Greenfield]: Yeah, obviously if you talked to Alan Cash your listeners can go back and listen to that to learn more about what oxaloacetate is. But in a nutshell, the reason that I used it was because it can increase the turnover rate of lactic acid into pyruvate, and increase the rate at which lactic acid is shuttled back up into the liver to be reconverted into glucose.

And so if you are eating a low-carbohydrate diet anyways, that by nature means you might not be taking as much exogenous glucose in, or might not even have as high a level of glycogen stores, but you can still take the lactic acid that you’re producing as a byproduct of metabolic activity anyways and have that reconverted into usable glucose sources to have a glycogen sparing effect and to get a little bit more intensity. And so the way that would be achieved if you’re going to increase the rate of that cycle, which is called the Cori cycle, would be via the use of oxaloacetate.

And so, I actually did use that. I don’t use it right now. It’s one of those things where it’s just like, I would benefit from it its just one more supplement to remember to take. But I certainly used it through that entire ketotic experiment with the oxaloacetate just to increase the conversion of lactic acid into glucose.

[Damien Blenkinsopp]: Right, it sounds like it would help specifically in that ketogenic diet state when you’re exercising.

[Ben Greenfield]: Exactly.

[Damien Blenkinsopp]: So you designed it that way? You decided to take it before, or was it something you came up with afterward to help?

[Ben Greenfield]: I talked to Alan at one of the Bulletproof bio-hacking conferences. We talked about the physiology of oxaloacetate, and then based on that I just kind of had a little light bulb moment, where I realized that if I was restricting carbohydrates anyway, that this was one more way that I could create endogenous glucose more quickly.

[Damien Blenkinsopp]: Great, great.

[50:27] Cold thermogenesis. Do you still play around with that? Is there anything like, for instance, have you seen your HSCRP any time, potentially when you first started it or did it a bit more intensively, change with that?

[Ben Greenfield]: Yes. I have not done a dedicated experiment with cold water exposure, cold temperature exposure, or the use of ice baths or cold showers to see the direct effects on HSCRP, although reduction of inflammatory cytokines has been observed in literature when it comes to cold thermogenesis and inflammation.

What I use cold thermogenesis for is increased conversion of white adipose tissue to brown adipose tissue. Simply because it’s very difficult to kill fat cells, but you can convert fat cells into energy utilizing and heat producing tissue. And that’s one thing that cold thermogenesis is good for. That would mean cold baths, cold showers, cold soaks, etc.

Also very useful for increased production of endothelial nitric oxide synthase, which can cause your blood vessels to dilate much more readily, which is good for everything from exercise to sex to heating your body when it needs to be heated. And then there’s also increased tolerance to the mammalian dive reflex, which is that activation of our sympathetic fight-or-light nervous system in response to stress.

And when you are able to withstand cold stress without taking that sharp influx of breath, that means that you have become more resilient and more resistant to subconscious activation of that fight-or-flight nervous system. You’re better at controlling stressful events that happen.

And so, what I do is I never take a warm shower. I do a cold shower in the morning, cold shower in the evening. I do once per week a 30 minute cold soak that gets me up to shivering level, typically needing to shiver for one to two hours afterward in order to regain warmth. And those are the ways that I use cold thermogenesis. I also keep my house relatively cold. My office is at about 55 degrees. In my home, typically I’ll sleep at 60 to 65 degrees.

It’s just a really, really good way to make yourself tough, to burn fat, and to increase blood vessel health. And it’s just super simple. And frankly, the other cool thing is when I go hunting or when I have long periods of time outdoors or when I’m at the beach and evening comes and I forgot my coat, I don’t get as bothered, which is just kind of nice. You’re just more tough.

[Damien Blenkinsopp]: It sounds like the only time it was an issue when you were doing you ketogenic thing. What was the issue there? Were you getting a lot colder, or?

[Ben Greenfield]: Yeah, but that was because of the thyroid. If you have hypothyroidism, cold thermogenesis is going to be very uncomfortable. Heck, even normal temperatures you’re colder during. So I was still doing cold thermogenesis then but it was quite unpleasant. It was hard for the body to get warm again.

[Damien Blenkinsopp]: Okay. Right, great.

[53:17] Some quick fly questions that I have just to finish off here.

First of all, if people want to connect with you and learn more about you and what you’re up to, where is the best place? Twitter, your website?

[Ben Greenfield]: Bengreenfieldfitness.com, because if you go there, you’ll find links to my Twitter, Facebook, Instagram, my blog, my podcast, etc. So that’s a good place to go as a portal.

[Damien Blenkinsopp]: Great, great. And who besides yourself would you recommend to learn more about endurance training, or some of the other topics we spoke about today? Ketogenic diets and so on?

[Ben Greenfield]: As far as people who have their head screwed on straight who are paying attention to the research, I’d say three people come to mind.

Number one would be Joe Friel. He’s coached a lot of professional cyclists, but also has just been in the sport a long time and pays attention to the science and the research and has a pretty good unbiased view of things.

Sami Inkinen, who is a top age group for Ironman competitor. He’s a higher fat diet, pays attention to quantified data, and is a smart, well spoken person who performs well.

And then Dr. Peter Attia, who I would not say is on the pointy edge of physical performance, even though he’s in much better shape than the average, general population. He’s not out doing Ironman triathlons or anything. But, as far as the science goes, he probably knows the science better than just about anybody else when it comes to being able to speak to these things, and he also does quite a bit of self-quantification himself.

So, those would be three people that would be good resources for this.

[Damien Blenkinsopp]: Great, thanks so much for that.

[54:48] Beyond everything, like all the biomarkers we’ve spoken about today, are there any other biomarkers you pay specific attention [to] on a routine basis, I don’t know whether it’s monthly –that you feel are important that we haven’t spoken about?

[Ben Greenfield]: I’ll finish with this because it’s important. And many times in our type of circles it’s not talked about, and it’s not quantifiable to a great degree, as far as I know. And that would be simply paying attention to your levels of gratitude every single day, and multiple times per day.

For me, I guess you could kind of quantify it – at least six times per day I’m grateful. Because I’m journaling, and at the beginning of the day I journal three things I’m grateful for, and at the end of the day I journal three amazing things that happened to me that day. So there’s at least six times per day that I’m being grateful for things.

And then I practice quick coherence technique, which is something you can read about at heartmath.org, which increases heart rate variability and decreases stress. And that’s where you simply think of something that you love or someone you hold dear, and you imagine intense feelings of gratefulness washing over your body and going into your heart after you feel those feelings of gratefulness.

Saying thank you to people, saying I love you to people, randomly calling up people and telling them how much you appreciate them. If you listen to my voicemail, I ask people to end their voice message by telling me one thing that they’re grateful for that day.

It’s certainly something that’s not super duper quantifiable, again, but it is one thing, not a biomarker, but certainly something I pay attention to every day is gratefulness for being alive, for the people in my life, for the experiences that I’ve had, and for simply being able to take one more breath.

[Damien Blenkinsopp]: Excellent. Thanks for that, that’s not the typical, but definitely something really important. So I can see how that would be useful. I do a meditation gratitude every morning too, and I find that really, really useful.

So Ben, thanks so much for your time today. It’s been really stock full of biomarkers and hacks and everything, so it’s really been a great episode. Thank you for your time.

[Ben Greenfield]: Awesome. Well thanks for having me on, Dam.

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Can physicians improve health outcomes using new self-tracking tech with their patients? Or is the tech still too inaccurate or impractical? We take a hard look at the reality and potential with a physician testing quantified self practices in his clinic for the last 3 years.

This episode is about quantified medicine or the reality of cooperating with your physician using self-tracking and observation. Working with such feedback aims to bring fourth an integrated approach to health and performance.

Previously, we have looked at the value of a good physician on your team when looking to improve your health in episode 22 with Bob Troia, and at the potential of wearable measuring devices in episode 24 with Troy Angrignon.

Does the Quantified Self approach offer medical benefits? What is the potential of tracking your data and teaming-up with your physician during the healing or performance improving process? What are some simple ways to help yourself optimize yourself?

I think it is hard to take measurable insights and extract it in a medical, steady kind of way. And that’s why I continue to not be afraid of computers taking over my job, because ultimately I think there is a combination of metrics and data, and also presence and attention and experience that work together, and that’s why I think the medical profession has hope.
– Dr. Paul Abramson

Today’s guest is Dr. Paul Abramson who runs an integrative medicine practice in San Francisco. He earned his medical degree at the University of California in San Francisco (UCFS). Importantly, he also holds a degree from the Center for Integrative Medicine at the University of Arizona. As a member of the Clinical Faculty at UCSF, he is doubly board-certified in Family Medicine and Addiction Medicine.

Being a former electrical engineer, Dr. Abramson’s interest in patient self-tracking sprung early in his medical career. In 2007, he founded the My Doctor Medical Group – his medical practice institution offering customized coaching models for individuals. He has adjusted the Quantified Self Approach aiming to gain insight into specifics of patients’ health. He has seen the ups and downs of working with this type of quantifiable feedback. In his practice he cooperates with patients and asks them to be introspective. Given his originality and accumulated experience, Dr. Abramson is an important figure in shifting the paradigm towards personalized medical care and all-important patient involvement.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. Enjoy the show and let me know what you think in the comments!

itunes quantified body

What You’ll Learn

  • Dr. Abramson’s interests in integrative medicine (4:04).
  • How Dr. Abramson defines integrative medicine (4:51).
  • The integrative approach means pivoting through the complexity of conventional therapy and the larger sphere around it (07:10).
  • Early on, Dr. Abramson pivoted towards a novel paradigm of patient self-measurement and observation (10:58).
  • Patient compliance is a problem for those who do not wish to continuously self-observe (14:24).
  • Using biomarker wearable meters provides knowledge important for informed behavior modification (16:39).
  • Dr. Abramson’s team places value on introspection and subjective observation of experience (20:02).
  • Patients are expected to self-explore and support their symptoms with subjective observations (22:53).
  • Determining useful metrics in medical practice requires careful deliberation over their reliability (27:14).
  • Simple subjective data on patient experience can be acted upon in complex medical conditions (29:16).
  • Patients with high intrinsic motivation are better-fit for using metrics in medical care (32:28).
  • Dr. Abramson has successfully applied awareness building exercises in individual coaching models (34:15).
  • Mobile apps can be used to track patient data and integrate it in could-sharing services (37:33).
  • The challenges of self-tracking broadly differ between lack of patient motivation and too-narrow hypotheses about undergoing causes (40:13).
  • Success with self-observation depends on developing optimized coaching matching individual patients (42:23).
  • There is less pressure on doctors’ medical authority positions when collaborating with patients in the context of team-care (49:50).
  • The more responsibility patients take, the more they acquaint themselves and the doctor with their health dynamics (52:16).
  • The biomarkers Dr. Abramson tracks on a routine basis to monitor and improve his health, longevity and performance (54:41).
  • Dr.Abramson’s one biggest recommendation on using body data to improve your health, longevity and performance (58:55).
  • Best ways to connect with Dr. Abramson, who is responsive on social media (60:00).

Thank Dr. Paul Abramson on Twitter for this interview.
Click Here to let him know you enjoyed the show!

Dr. Paul Abramson, My Doctor Medical Group

Tools & Tactics

Diet & Nutrition

  • Autoimmune Protocol Diet: The Autoimmune Protocol (AIP) diet is an elimination diet that works to reduce inflammation in the intestines caused by autoimmune triggers.



  • Continuous Glucose Monitoring (CGM): Promises greater accuracy than standard one point in time glucose monitoring by capturing the variance of blood glucose over time (Note: in Episode 22 we saw an experiment showing the detriments of just taking one point in time readings). Blood glucose is continuously recorded at frequent intervals such as 1 or 5 minutes depending on the device used. While not a widely established practice, Dr. Abramson claims that continuously tracking blood sugar levels offers insight into fine-tuning medication and behavior adjustments to optimize patient glucose-levels. It’s early stages, but there are a few Continuous glucose meters (CGMs) on the market. Current devices include the Medtroronic MiniMed 530G, the Dexcom G4 PLATINUM System and the Abbott FreeStyle Navigator II (available in UK only).
  • Blood pressure: Blood pressure is expressed in terms of the systolic (maximum) pressure over diastolic (minimum) pressure and its measure is in millimeters of mercury (mm Hg). Normal resting blood pressure in an adult is approximately 120/80 mm Hg. Among numerous indications, blood pressure is used as a biomarker to determine the risk of stroke and coronary heart disease.

Lab Tests, Devices and Apps

  • Zeo Sleep Manager: Zeo was Dr. Abramson’s favorite Sleep Manager (device and app combo) until the company went bankrupt. Zeo tells you how you really sleep, and helps you find ways to improve your sleep. It accurately measures sleep quality and quantity at home. It also discovers factors which harm your sleep cycle.
  • Withings WS-50 Smart Body Analyzer: The Withings company offers devices designed to monitor various aspects of your body. Tracking tools include weight and body composition, pulse, air quality screening, etc.
  • ResMed S-Plus: The company ResMed is focused on healthy sleep. To this end, it offers devices which monitor personal sleep parameters, room air quality, etc.
  • Beddit: The company Beddit offers devices which track sleep using a sensitive force sensor which detect small vibrations caused by your heartbeats, breathing, and movements to provide you with data regarding your sleep.
  • Evernote App: In the context of tracking subjective experiences regarding health, Damien suggests using this app to take notes in a form of a health-diary.

Other People, Books & Resources


  • Dr. Andrew Weil: Founder & Program Director of the Center for Integrative Medicine. Dr. Weil is an influential figure for Dr. Abramson’s interests in integrative medicine and his, overall, career.


Full Interview Transcript

Click Here to Read Transcript
(04:04)[Paul Abramson]: I’ve been very imbued in the conventional science-based – I put science in quotes – world. I’ve also been very interested in alternative points of view and meditation, and what I would call consciousness and behavior, and the things that are, in essence, insubstantial in a material sense, but I think are often just as relevant to our lives and well-being.

So in that vain, I have individual interests and pursuits in those areas, and then I went to work for Andrew Wylie in Tuscon at the University of Arizona in his integrated medicine program there. I was a residential fellow for a year, and we swapped patients there and had case conferences with some of his…

(04:51) [Damien Blenkinsopp]: To take a step back, what does integrative medicine mean? Because we haven’t really talked about it on this show before.

[Paul Abramson]: Integrative medicine has 100 definitions, and it has been, I would say, used and corrupted by a variety of different people and interests over the years.

As I define it, and I think I’m pretty much in line with Andrew Wylie on this, integrative medicine is a way of looking at all of the available approaches, perspectives, tools, tests, treatments that are out there. And then looking at each individual as an individual, and trying to make a match between what’s going on for them and what is the best combination of approaches.

So in essence it includes all of conventional medicine and science-based, or whatever you want to call it, conventional medicine, and it includes alternative things. And it includes consciousness based things, and it includes mind and body and it can even include spirituality and things that are unknowable as part of the paradigm by which you try to help people both understand what’s going on for them and come up with a plan of what to do next.

So I think it’s completely non-exclusive, and I also apply a very discerning and discriminating kind of eye to it, in that of all the available options out there I’m going to evaluate each one on how useful do I think this is? And there are some things that do not need my sniff test, or my deep investigation that I do not… And once I’ve determined that I’m not really interested in something, or I don’t think it’s going to be fruitful for me as one of my tools, I leave it to the side.

So I do weed things out. It is not an indiscriminate approach of ‘all is good’. It is more like, I’m going to start with an open mind and then apply appropriate skepticism and investigation to choose what tools I think are going to be helpful. And they may vary depending on the individual.

So I do not apply a one-size-fits-all approach to anybody. There’s no one test or one treatment that I think is applicable to everybody. Nor is there one paradigm that I think is applicable to everybody. So, for some people that is dis-concerning.

(07:10) [Damien Blenkinsopp]: So in integrative medicine, is there an actual organization behind that, or is it more a term used for people who are dabbling in functional medicine, the alternative, and the…

[Paul Abramson]: Well, there is now a board certification in integrative medicine for medical doctors. There is a consortium of academic centers in integrative medicine that includes many of the big tertiary care centers in the United States that have integrative medicine centers and research programs.

And I think a lot of that comes into this kind of definition, where it’s consistent with the conventional medical world and a much larger sphere around it.

[Damien Blenkinsopp]: The functional medicine has an organization behind it, so does integrative medicine tend to relate to that more because there’s a big organization behind it? Versus some of the other things you were talking [about], which I imagine don’t have as much structure to them.

[Paul Abramson]: Well integrative medicine ultimately is, I think, integrated, meaning it’s not an either-or proposition. It’s, ‘whatever works’.

Whereas some of the other things out there are more alternative. Where it’s more of an ‘us versus them’ kind of situation, where we have a certain truth and those other people, especially either the conventional people or the alternative people, are biased, wrong, or otherwise not reputable in some way, and therefore you should pay attention to our perspective.

That is not, to me, integrative. But I think the conventional medical world falls into that trap, and I think the functional and alternative medicine world falls into that trap. Equally.

[Damien Blenkinsopp]: It’s kind of like Republicans and Democrats.

[Paul Abramson]: It’s kind of like Republicans and Democrats.

And in reality I would say my flavor of integrative medicine, or what I consider, is it’s not exclusive in that way. It’s like of all the things out there, some of them are valid, some of them are not, some of them work for some people, some of them don’t work for some people.

And you just have to be creative, and you have to be discerning and discriminating enough to not get overwhelmed by the complexity. You have to be able to take this, in essence, if you are not ready for tolerating ambiguity and dealing with massive complexity, then it’s easier to track into something that is simpler, where it’s more clear cut and there is right and wrong.

Whereas if you want to take the big picture, you have to help people weed through all of this complexity to come up with a relatively normal, simple approach that is going to work for them. And then you have to be willing to measure and then accept if it is not working out you’re going to back up and take another set of things and take another approach.

Then in the start-up technology world out here they call it pivoting, where you do something, you go full worth at it, and then you try it to the best of your ability, but you have to be constantly measuring your success. And if it’s not working out, you have to get over your ego and your attachment, and you have to back up and re-think and pivot, and keep moving.

Yeah, that is the [unclear 10:10] approach to medicine that I can think of.

[Damien Blenkinsopp]: That’s a very interesting point because – and you’ll know better than me – people when it comes to health, fitness, these diets, and these types of areas, they get very, very emotional about it. They tend to become fans of a certain approach rather than another.

I guess pivoting is, I understand because I’m an entrepreneur. My first company, I didn’t want to let go of it. I didn’t want to change it at first, until the pain in terms of profit loss got enough that I was like, “Okay, I have to be serious.” And I was taught to be able to pivot and make decisions based on data.

So I guess that probably happens a little bit in the medicine world as well. People eventually get to this point of pain, where they’ve been following some course because of interest, of love, and then they go, “Okay I have to try and get some kind of data.”

(10:58) Now, we first met, albeit kind of briefly because you were doing a talk, at the Quantified Self conference in 2013 – end of 2013 I think it was. And so that’s also one of the things you’ve dabbled in a bit in you integrative medicine. Could you talk a little bit about why you started taking an interest in that and have made that a part of your practice?

[Paul Abramson]: Well I think it does come back to what we were just talking about. You have to gather data about what’s going on for each individual to decide, is this working, is this not working. Or, are there things happening that are not good, that should trigger us, like your losses in your start-up.

The earlier you can detect and decide that things are not going to go down the right path, you should pivot. And yet if you’re not sure, you might continue to go on for a while and take more measurements. But you have to be constantly…

And so I was struggling in medicine with a lack of feedback on my patients. We were meeting and setting a treatment plan in place, and they were going off to do it. And I just was not getting enough feedback to know whether it was working, whether it needed to be adjusted, or whether we needed to completely pivot and try something else.

And so the promise with the Quantified Self approach is that it’s not so much that there is a new sensor or a new test that is interesting to me, but it’s a new paradigm, it’s a new concept that people are going to observe themselves, and then perhaps feed that back into a medical doctor or some other practitioner or some helper that they have, a coach.

But many people just decide to do it for themselves, where they’re moving along with a plan, and they’re measuring, and they’re questioning, and they’re constantly just trying to decide,” Do I keep going, do I add, do I subtract, or do I pivot?”

And I started doing these kinds of experiments with people where you can then take all of human behavior and make it an experimental approach, where, instead of saying, “You have to take this medication for your high blood pressure forever.” People hate that.

What I do is I say, “Wow. You’re blood pressure is really high. We’ve measured it over a whole month and it’s always really high. We know that’s going to wear out your blood vessels, and your kidneys, and your brain, and it ages you faster to have high blood pressure all the time. So, why don’t we lower it? And then, why don’t we start doing some experiments to see if we can find the cause, or reverse the cause, or come up with other approaches that are more agreeable to you, if you’re not really into taking pharmaceuticals every day.”

Which many people aren’t. And at such time as those thing start working, we can think about revisiting. I just say, while we’re doing those experiments, let’s limit the damage. And people respond much better to that. Instead of saying, “Oh, I’m just going to keep the high blood pressure going, and then in six months I will have lost 40 pounds.”

Maybe that happens, maybe it doesn’t happen. Maybe they lost 40 pounds and their blood pressure is still through the roof high. It’s a realistic approach that takes measurement into account, but also addresses what’s going on right now.

And the tools we have from Quantified Self, some of the technology but more the paradigm of self measurement and observation, gives us some hope that the culture could shift into that kind of approach.

(14:24)[Damien Blenkinsopp]: It’s interesting in a kind of work relationship. How does it change the work relationship between you and the patient when you introduce this? Do you work out some specific metrics with them, or is it really very different?

Have you seen this evolve in your practice? Because you’ve been doing this for a few years now, so I’m sure you’ve cut some things that didn’t work, and taken some things that did tend to work, and you’ve kind of got some type of best practice that you’re starting to put in place.

[Paul Abramson]: Well, it’s been humbling. People are very different.

They’re different in their background, they’re different in their medical and psychological situation, they’re different in their social circumstances and their family, and what the support is in their life to do things. And so some people actually just want me to say, “This is what you’ve got, this is what you have to do,” and to prescribe to them. And they go home and they take their drugs.

And we limit the damage, as best we know how with modern medicine, and sometimes that works out, and sometimes that doesn’t. But they don’t have time or interest or, even maybe the perspective, to take a different kind of, more proactive approach.

And for those people, after I challenge it a little bit and determine that it is in fact how they want to be.

[Damien Blenkinsopp]: That’s interesting. Are they not interested enough in their health to, or is it because they’re so busy with other things in life? What is the [reason]?

[Paul Abramson]: For whatever reason, they are not in a position where they want to do something that takes more work. What really sort of takes up more subjective view of reality, like there is a way.

There are many choices out there, it’s not really black and white. Some people really want the black and white. It’s easier for them psychologically, and it’s sometimes they’re just so busy, they’re like, “No way I’m going to have time to do experiments, or even to take my blood pressure twice a week.”

We’re just going to have to go without that. Especially diabetics. A lot of them just can’t check their blood sugar. Type 2 Diabetes, you know, it’s not really medically mandatory in many conventional settings for them to check their blood sugar at all time. You just take the medications and get some blood tests every few months and see how things are going.

That’s very unsatisfying for an engineer like myself. I really would want data and feedback and optimizing. But many people are really not into that. It’s either a cultural thing, or just a logistical thing. They just aren’t going to do that.

(16:39) [Damien Blenkinsopp]: Just out of interest, have you looked at the continuous glucose monitors?

[Paul Abramson]: Oh yes.

[Damien Blenkinsopp]: Have you been using those quite a bit? Or have found them useful?

[Paul Abramson]: Well, I mean they are generally able to be covered by insurance. They’re very expensive.

[Damien Blenkinsopp]: Yeah, about a 1,000-1,500 dollars, something around there.

[Paul Abramson]: The supplies are also very expensive. Each and every week you need a new implanted sensor that could be hundreds of dollars. So, it can really add up in a hurry per month and the initial costs. Such that many people aren’t going to do that.

Now if you’re a Type 1 Diabetic from a young age or even an older age where you have no insulin around, and insulin pumps are in the offing, then often they can be covered. But for Type 2 Diabetics it’s usually a completely out-of-pocket expense. And what I’ve found is that there are often incredibly great insights that one obtains from the continuous glucose model, but only some people get on-going benefit.

[Damien Blenkinsopp]: What kind of [insights]? Does it enable you to take some specific actions when you see some kind of behavior that they’re undertaking which is interfering with your goals, or…?

[Paul Abramson]: I’m not really offering generally to watch their data continuously.

[Damien Blenkinsopp]: Yeah.

[Paul Abramson]: What we are doing is having them get self-feedback, and then take notes in one way – electronic or paper – of their experiences with that data from the glucose monitor. Because you have to calibrate them with a finger stick multiple times per day, and you have to use it properly to try to get valid data. And then you get to see in real time if you eat something, or if you exercise, you get very quick feedback about how it affects your blood sugar, both immediately and later.

And so you can get pretty profound insights about that, and they are sometimes very unexpected. That some things lower your blood sugar and some things raise your blood sugar, and they don’t match what the conventional wisdom says should happen.

And then somethings people just have to get it in their face that, “Wow, if I exercise my blood sugar really is so much better.” It’s motivating enough that it’s going to make them exercise more.

But a lot of people, after they get those insights, if they’re Type 2 Diabetic, they can simply just use those wisdoms to change their behavior, and they don’t have to go through the hassle of calibrating and wearing an implanted monitor that has something go into their skin changed every week and calibrated several times a day. A lot of people don’t really want to do that on-going.

So then when you look at the up-front expense for something that they’re only going to use for a relatively limited period of time in most cases – because most people are not going to want to be doing that level of hassle if it’s not required because they’re not Type 1 Diabetic – a lot of people chose not to do the continuous model.

Maybe when we get the truly non-invasive blood-glucose sensor that is both accurate and possible. When I was an electrical engineering grad student at Stanford in the early 1990s, I was doing consulting for start-ups. Before there was the first technology, the first internet tech.

And I worked for a couple of different start-ups that were trying to get non-invasive blood glucose monitors, where they would shine a light through you, or they would use ultra-sonic. They would use various technologies to try to get, from the outside, your blood sugar. And the problem is glucose is such a small molecule, and so hard to differentiate from other molecules that really a lot of companies went belly-up back then, and they are still failing today.

(20:02)[Damien Blenkinsopp]: I think there’s a couple of watches. I’ve seen them around. I haven’t looked into them. I was concerned about the accuracy. I guess I’m a bit dubious about [them].

Because even the continuous glucose monitor, which you were just saying you have to calibrate it, right? And it’s got something actually implanted in you. So the accuracy of a watch with optical – I think they’re using optical – would seem kind of not achievable at this point.

[Paul Abramson]: This is the exact technology that they were trying to come up with in the start-up in 1992. And it ultimately did not kind of work out. And I think that at some point someone is probably going to do it, but to my knowledge it has not yet been done in a valid enough way that you could actually take action on the results.

But maybe there is something that I don’t know about that came out this year, and I will continuously watch that Weiner Chart. [unclear, 29:48-] at that, somewhere about 15 years ago after watching failure and failure.

So, I would just say that the measurement technology concept is something that you need to be very skeptical about, because if you’re going to take bold action based on the numbers, it better be accurate and reliable and reproducible and usable. So that is an on-going concern for me.

Now, more subjective measures, what we really came to in our self-tracking program here, one, is that we don’t apply a similar methodology to anybody. Everybody kind of gets a custom approach based on where they are in their readiness to do things, and what problem they want to solve.

But we’ve also really heavily weighted it toward, what I would call, subjective measures that require them to actually stop and pay attention to what’s going on in their experience. Because the objective measures that don’t take any [action], the passive tracking approach where I wear a monitor and it spews data out at gigabytes per minute, it does not require awareness and it doesn’t require self-knowledge. The learning is later when you look at the data.

Whereas if you aim to gather the data, if you have to introspect and think and become more aware of what’s going on about your pain level, or whatever your symptoms are, or your emotional state, or in any way something that you have to pay attention to measure – because we don’t have a measurement for headache except by your self-report – the data gathering itself becomes a therapeutic tool.

The act of tracking is part of the treatment in that they become much more aware of what is actually going on for them, so that when we start trying to change things or treat or affect things in a positive way, they actually have more basis on which to do that, and we can identify more potential targets for more interventions.

(22:53)[Damien Blenkinsopp]: So you think basically building their awareness so that you can create that feedback is one of the most important parts of it?

[Paul Abramson]: For us, it is. And I’m a behaviorist at heart. I like to have people try things overtime, and to see whether building new tracks and new behaviors in their brain can affect their body and their experience and their entire reality.

[Damien Blenkinsopp]: So do you then find that patients are able to come to you with insights more so than before? Because all traditional [unclear audio cut, 23:25]. I have some mystery problem. I’m coming to a doctor, and the first thing to do is talk about my symptoms. Go for a questionnaire, try and figure out what’s going on.

Do you find that sometimes that first picture, say compared to a second picture when you’ve had them self-tracking something you thought was relevant, could be quite different? Because it is a subjective experience, and they learn to improve their self-awareness and have a better hold of what’s going on. And maybe, do they sometimes come up with some insights like, “It’s funny. I’ve noticed that every time I do this, then I get these symptoms.”

[Paul Abramson]: Right. Well people often come to their doctor – and that’s my frame of reference, because I’m a medical doctor and people come to me – they come with symptoms, but they also come with conclusions. And they might be already having diagnosed themselves, or they might just have made some assumptions or conclusions about why they’re having the experience that they’re having.

And I think the self-tracking paradigm encourages them to back up to the raw symptoms, and also the circumstances that they find themselves in. You know, looking broadly at what are their circumstances and what are their symptoms in as concrete a fashion as possible. And not making any assumptions. And then we make some hypothesis. But we frame them as hypothesis and not conclusions, and that gets them into an exploratory mode.

Whereas if someone comes to me and says, “I have a urinary tract infection.” And I am a [unclear, 24:50] and I have eight minutes, I will prescribe ciprofloxacin to them for the urinary tract infection, and they will go away. Especially if they say, “Oh I’ve had them many times and I know what they’re like.” That is not my style of medicine.

I’m going to say, “Well what are you actually feeling?” And they’re going to say, “Oh, I have burning when I urinate” or “I have fevers” or “I have back pain” or whatever. It’s very likely in someone coming to the doctor that they are correct, in that circumstance, but sometimes they’re not. Sometimes they have a yeast infection and it’s not a bladder infection, and giving them antibiotics makes it worse.

So I think you should always back up. But then especially if it’s something vexing, they have probably been trying to figure out and fix it on their own for some time. Weeks, months, years, decades sometimes. So if it were something, if their conclusions were correct – not their diagnosis, but their assumptions and conclusions – I believe they would have figured it out, and they never would have met me.

So therefore, the fact that they are coming to me with the time and expense and the hassle of going to a doctor, it’s very intimidating for some people, it means they are probably ready for a pivot. It’s a sign that it is probably time to take a different approach.

So if I can get people to back up and look at the raw data, the raw symptoms, and then we can look at all the possibilities and start to make some hypothesis. And some of the hypothesis might be the conclusions they have drawn, but they have to be willing to have some flexibility about looking at other options. Otherwise, I might be a poor match for them.

If they just want someone to take their conclusions and follow their line of thought, then my view is, okay, they either don’t need me at all, or they only need me because I – in California – can order laboratory tests for them. Or I can order medications for them that they can not legally order on their own. So in essence I am just a proxy for them having gone through the license pathway that I’ve gone through, and I’m not really functioning as a physician as I define it.

And so I try to resist getting involved in just being a tool that they can wield, and I try to work with people who actually want to back up and really take a look at what is going on.

(27:14)[Damien Blenkinsopp]: So what kind of metrics have you typically found to be useful? You said the qualitative. Are these ratings from one to 10 for symptoms? What kind of things have you found that are useful?

[Paul Abramson]: A wide variety of things. With each metric we have a discussion about what is the, what are we going to track?

Let’s say for a headache, are we going to track mild, moderate, severe? Are we going to track zero to four? Actually, the numbers and bins of data collection that you define dramatically affect the results of your tracking. You have to all agree on what each bin means.

What does three stars mean? It can vary widely over many people, and that makes it useless. And then they have to have written down what each metric means so that they can apply it as consistently as possible over time. Because if they drift in what a headache of three means, then their data is going to be very hard to use.

So, we try to apply this sort of N of 1 controls as best we can to define things clearly, to re-visit them, to keep people calibrated. And then try to figure out is it a negative two to two scale, or is it a zero-four scale that’s going to be helpful. And try to make it as simple as possible so that people can actually do it in real life.

Sometimes you have to use subjective narrative data, and that’s why we’ve taken a coaching model rather than a computer analysis model. Because the most interesting things sometimes are the things that they write. Their observations about the process, or about the data. It could be a picture of something, it could just be a description of how they were feeling at the time that they had the high-blood pressure. That’s actually much more interesting.

[Damien Blenkinsopp]: So is that like a journal alongside whatever you’re tracking?

[Paul Abramson]: Yeah. And it could be an electronic journal, or a paper journal. My challenge with technology tools is they have to beat paper. If they do not win over paper, then you have to question why you’re using technology.

(29:16) [Damien Blenkinsopp]: It’s interesting that you’ve brought that up, because I struggle with my own problem, just figuring it out, and what kind of first worked for me was using EverNote as a journal.

[Paul Abramson]: Sure.

[Damien Blenkinsopp]: Just as kind of like a diary every day, one note for every day in a folder which was called ‘Health Diary.’ And then also tracking some metrics. And like, “Oh, that’s interesting. I wrote– “

[Paul Abramson]: Paper apps. It’s almost paper.

[Damien Blenkinsopp]: Right. Yeah. And it’s easy to search. I mean, that’s why it’s nice, because if you have some kind of hypothesis in your head, you can select that folder and you can search for that keyword, and you’re like, “Oh, look. It happened on four days, and maybe it coincides with the metric.”

[Paul Abramson]: Sure. And that’s what I would call primitive technology like paper. And sometimes it is the best approach, because something much more complicated will keep you from gathering the data, because it’s too cumbersome.

It’s very hard to apply machine learning and machine interpretation of data because the raw numbers rarely have the meaningful insights. And our basic model, we’ve gotten more flexible about exactly how we implement it.

Initially, we were doing a weekly coaching model, where people would track, the data would be shared with a coach who would meet with them – in person or virtually – every week to review their data and basically elicit their memories of what happened that week that they had not taken down as part of the data. So they would use the pictures or numbers or whatever they had tracked.

People remember a week. Most people. Whereas if you go back a month, people do not remember the moment to moment experience they were having. Which is probably why psychotherapy is typically a weekly model, because you don’t have to reinvent the wheel every time, you can build on the previous week because you remember.

And so the coaching model would allow people to tell the story around the data, and then the coach would concisely record the story and plug it into the project, or the experiment that we were running, and try to write down the story and the insights that could be taken. And then the insights and the summary of the story could be fed back to me, the physician, where very quickly I could think about it and apply my perhaps greater perspective or set of ideas, and make suggestions.

And so it became very time efficient for me. Rather than me going through the data for an hour every week, I can go through the coach’s notes for a few minutes and be almost as effective. And in some cases much more effective than I could be trying to be the coach myself.

The raw data was almost never the actionable. Now, that’s not always true. If we’re just doing a very simple tracking experiment where your blood pressure is 220 over 120, and we want it to get lower very quickly, and we’re going to track what you’re doing and what medications you’re taking, and how often you’re taking it, and track your blood pressure.

There you actually do have a much more concrete, discrete kind of experiment that you could apply some sort of automation to. But that’s not typically why people are coming to me. Most people are coming with much more complicated and murky problems where subjective data is really the actionable data.

(32:28) [Damien Blenkinsopp]: If we’re talking about the situations where you’ve found this most useful, is it it the more mysterious, people haven’t been able to figure out any[thing], the complex, multi-factorial potentially.

But as you mentioned, is there also something on the very hard side, nearly technical, where you have a blood pressure marker and it’s a very focused metric, that you are like, “We have to get that down.” From doctor’s experience and everything, this is the thing we need to focus on. So you know ahead of time what you want to focus on.

Are those the kind of two situations, or are there other situations where…

[Paul Abramson]: I would say it’s a whole spectrum, but the key factor is that if the tracking based on insights and memory and subjective recall are round objective data that you’re gathering is by it’s nature very labor intensive. Like this process, to really do a meaningful tracking experiment, is labor intensive and costly in various ways.

You have to hire help, you have to spend a lot of time, you have to think about it. You have to be involved in the process, and for that reason, that typically is applied to problems that are either very urgent or long-term vexing for people. They tend to be more complicated because they are at the end of their rope, and they need help, and they are ready to do anything just to figure this out.

[Damien Blenkinsopp]: Right.

[Paul Abramson]: And that’s a wonderful situation to be in.

[Damien Blenkinsopp]: For a doctor, yeah. Compliance.

[Paul Abramson]: Their intrinsic motivation is very high. The outcomes tend to be good in anyone who comes to a doctor with high intrinsic motivation to do whatever it takes. And we do select in our practice for people with that description. So our outcomes are phenomenal, but part of that is selecting some people who are ready to do whatever it takes to figure this out.

(34:15) So the other area other than complex medical mysteries that we’ve applied this to, well there are several areas. One, our awareness building exercises, where about half of our practice is also a complex addiction treatment practice for high-functioning professionals. And some very intelligent people, many of them in the tech industry, who have what I would consider very mundane addiction problem.

[Damien Blenkinsopp]: Is this like caffeine, or are we talking more…

[Paul Abramson]: Alcohol, cocaine, prescription opiates.

[Damien Blenkinsopp]: Okay. Is this quite common now? Because we all hear bout the performance culture, and everyone–

[Paul Abramson]: It is incredibly common now.

It has always been incredibly common, and yet it continues to be incredibly common. And the more fast and stressful and complex society gets, as we’re currently going through a little boom here in San Francisco, I would say it increases. And the number of people who go out of control increases, where it gets beyond the place where they can self manage, and they seek professional help.

So we are often trying to get people to do very basic tracking [endeavors]. Whether it’s their internal mood state, or their discomfort level, or interactions they’re having with other people. Or whatever triggers they encounter that trigger them to want to self-soothe or improve their performance by taking their substance or alcohol of interest. And it’s a very simple tracking model aimed at getting them to be more aware, so that they can then have more decision over their reality.

The other one is, like the blood pressure example. Where we are trying to achieve, or what’s been going on forever, is the diabetes blood sugar tracking model. Physicians have been asking people to track their blood sugars for a long time now, and it’s actually very useful.

The last realm, I would say, is in the performance improvement category. People who are okay but they want to be better, or they want to achieve a certain goal, whether that is in their body composition or it’s in performance at a triathlon, or it is in their work performance and their attention and their ability to accomplish things.

It’s more of a positive desire to improve by tracking and feeding that. That’s very motivating for me, and yet it is hard to find the people who want to do the self-tracking approach to that, because it’s pretty labor intensive and these tend to be busy people.

So if you’re an Olympic athlete and you have a whole team of people geared up at measuring you, at feeding back and changing your performance and changing what you do, and you have all that support around it, I think people can pull it off, if they’re a competitive high-level professional athlete.

For the regular person without that support team, we have had some challenges trying to construct a model that is both affordable and does not require an NFL team support staff to accomplish, and also doable by people who are also leading lives and not full time training. That’s an on-going exploratory area for us, and trying to find what is a model, in a manageable way.

(37:33) [Damien Blenkinsopp]: In terms of any tools you use, just kind of talking practicalities here, are you just asking people to use a little mobile phone app and put down a note in that, or is it sometimes Excel, or is it basically whatever they need, you’re like, “What would you find easiest to track this metric that I want you to look at.”

[Paul Abramson]: We have been using the mobile phone app that we’ve been working with a developer on called MyMe, which I have been on record has having mentioned over the years, which is a very simple way to just set arbitrary buttons up for whatever they want to track. And set whatever ranges of metrics you want to track, take pictures, etc. and then collate it on a central server where they account is owned by the individual, not by me, but then they choose to share their data with the coach or with me during the sessions.

Otherwise they hold they data and own the data, and we just keep in our files our observations of the sessions with them while looking at the data. And so that keeps it simple from a privacy standpoint and from a daily curation standpoint. And it’s worked fairly well.

We also, if they don’t like that tool or if they have different things they want to measure, we will take a whatever-works approach and try to get them to use other tools, most of which are not geared towards this. Most of them are geared towards other applications, most of the existing tools.

Amazingly, there isn’t a good, flexible generic tool that’s consumer available, where you can also involve a team. And maybe there is. Now, when you can share the data but it’s also designed at helping analyze things and helping collate and curate data.

And so MyMe is working on that. It’s not yet available to consumers, it’s just sort of for clinicians and doctors and people who are working with people who are self-tracking.

[Damien Blenkinsopp]: So there are other people like you working with MyMe?

[Paul Abramson]: Yeah.

[Damien Blenkinsopp]: Okay. Alright. All this stuff we put in the show notes.

[Paul Abramson]: Then there’s various companies that have tracking devices, and each one has their own cloud where they track the data from their own devices, and some of them will integrate data from other devices apps. And it’s coming together in some ways that I think might be good, but it’s been so slow to develop that I’m frustrated.

[Damien Blenkinsopp]: Yeah.

I used to be a telecoms consultant, and I worked in the interactive television market in the UK, which was one of the first markets in the world, and they had this walled-garden approach to it. And we were all talking about the open, like you have to open it up. And it took nearly a decade to happen properly.

And it’s always the same, except for the internet, luckily, which was pretty much open to start with.

(40:13) So, that’s great. What are the biggest challenges you’ve come across in trying to make self-tracking work? Have you had any failed, like – I don’t know how to put it – have you had failed self-tracking projects, where you’ve just been like, “Okay, after six months of tracking let’s just ditch this?”

[Paul Abramson]: Basically, they fall into two camps. One is where the self-tracking paradigm is too much work or isn’t intrinsically rewarding enough for the person to keep them going. Where the time and expense and hassle and all that isn’t worth it, and they drop out once they just get frustrated, or don’t continue.

The other is that their hypotheses are too narrow. The hypotheses they are willing to consider are too narrow. And we explore those deeply and broadly and do not find the answer in that narrow set of hypotheses, and they tire of doing the project, because it seems hopeless.

Whereas, I actually believe that there is always a way, but it may not be a way forward that people expect or desire.

[Damien Blenkinsopp]: So it’s basically like a process of elimination with one experiment, another experiment?

[Paul Abramson]: Well if the only hypothesis is that some food is causing my symptoms, and we just need to find what food, combination of foods, or other environmental physical inputs, are causing my symptoms.

And once we really convincingly do out that experiment, either they are willing to do the experiments, one, and the answer is not food – we believe that for a while. Or they are unwilling to do some of the experiments because they are too attached to certain things.

[Damien Blenkinsopp]: I love coffee.

[Paul Abramson]: Or marijuana, or [unclear 41:55]. Unwilling to give up certain things. But we look at everything else, and everybody gets tired. Those are the places where actually there’s a different paradigm that we need to apply. We need to do a pivot, but they don’t want to pivot.

And then you run into a dead-end in the start-up of events, or start-up company ends, ceases to be. And everybody goes off to do other things, and that is sometimes what happens.

(42:23) [Damien Blenkinsopp]: Great. And you referred to earlier that you had a lot of success with this. Could you share some of the success stories you’ve had? Has this improved your practice, would you say immensely, a bit?

[Paul Abramson]: I would say it has improved it measurably, but not immensely.

[Damien Blenkinsopp]: Immensely is a big word.

[Paul Abramson]: We are still working on optimal paradigms, to make the paradigm match the individual, and to try to bring it into a combination of energy and time and price that can match anybody. And we have not yet figured all that out. So that’s why it’s not immeasurably.

If we can apply these kind of concepts to every patient, and successfully because we can custom make it for each individual than it would be game changing. And that’s what we’re aiming for.

So I say this, successes are where either there is a simple answer, or a complex simple answer. It’s too complex for them to have figured out by introspection and their own tracking, but with some professional help we can get to that slightly more complicated insight that allows a dietary change or experiment or supplements or changes in their medications, or some other intervention to suddenly work. And then sometimes the tracking helps them to implement that intervention.

If it’s a food change, sometimes that takes a lot of time to change habits, behaviors, and family food production dynamics, etc. And sometimes the self-tracking is very supportive in that. Or, we exhaust one avenue of exploration and it gets them to the place where they are ready to consider other paradigms, where maybe it’s not food, maybe it’s, I don’t know, my relationship with my husband and son.

Maybe, as one patient found out, there was some very, very stressful, vexing, and long-standing family dynamics going on at home that clearly, once we got to know them, were contributory to the situation and symptoms.

[Damien Blenkinsopp]: What kind of symptoms, just to give people a reading on this?

[Paul Abramson]: The common classes of symptoms that people come to that are hard to diagnose are fatigue, pain of various kinds, neuropathic pain or muscular, skeletal pain, and gastrointestinal symptoms. And when those are accompanied by relatively normal tests and investigations from a conventional paradigm, many times they run into roadblocks with the conventional medical world, where they say, “Well you’re normal.”

So, you are plunked into a wastebasket diagnosis that doesn’t really describe why, it just describes what is going on in a very descriptive, but not very helpful way. Chronic fatigue syndrome doesn’t, in it’s current form, really help people to move forward, except weight and exercise, and similar things that are not typically very satisfying to people. And when they work, it’s great, but for some people that’s not the whole answer.

It could be very inflammatory conditions and rheumatological conditions that do have objective markers that are abnormal that don’t fit into any paradigm. So that I’m tempted to throw heavy drugs at them. And yet they just run into a diagnoses appended by the word NOS, not otherwise specified, meaning it’s not something that the conventional world takes a strong interest in, because they don’t have a discrete category to put it in.

And so that is one common class of people where sometimes it is what they think it is, because they have been reading blogs on the internet that say that food is the cause. If you change your food, you can cure anything. That is a common paradigm that you read about on the internet, especially people promoting a certain food paradigm, that basically all mystery illnesses should be treatable with food. Or are from some food trigger, that if you eliminate it or figure it out.

Hence the autoimmune protocol diet, which is an extreme elimination diet, or is very specific and very hard to implement, and may help some people, but for most is just, it’s not the end all answer. And so many people come very frustrated and wanting to find [some solution], but they’re still on the food path.

And once we kind of figure out that maybe there are other factors involved, even medical or psychological or social or spiritual, we can come up with a more integrative approach that is much more fruitful for them, either to fix their symptoms or to make it so that the symptoms are not as disabling, or that they can do everything they want to do in life because they’re able to mitigate the symptoms and improve their ability to function with those symptoms.

Because it’s of my opinion that getting the symptoms to go away, while it is always the goal, sometimes in this world there are mysteries, and being comfortable that sometimes there is a mystery and you have to work with it is the paradigm shift that has to happen.

Now, you don’t want to start with that, because ultimately people come to a doctor to get cured. And that’s really the cultural paradigm that we operate in, and I like to acknowledge that, and I like to participate in it, but I also like to continue to try to expand the paradigm to include other things.

[Damien Blenkinsopp]: So you’re saying you can improve the situation as well.

[Paul Abramson]: Yeah. And sometimes actually taking a more open-minded approach about what could be contributing and working on function rather than cure. Improving function rather than the functional medicine paradigm/vision that underline all illness, there is some root cause that you can discover, and once you discover the root cause, everything will get better.

And that is wonderful when it happens, and yet sometimes you have to take a more solution focused and practical approach to, “What do I want to accomplish in my life? How can I get there?” Sometimes that actually causes the symptoms to diminish, even though you never really find out what caused them.

So I think it’s helpful to keep an open mind about that, and yet most people in our society come in with a materialist obsession that it must be some biochemical or discoverable, testable thing that is causing my symptoms. And we have to work with that for a while.

And either it’s true and we cure them and we’re heroes – I get to be Dr. House every so often where I discover that mystery root cause, and it’s beautiful. But other times we have to take a more practical approach.

I think in the psychotherapy world, there’s the Freudian analytic perspective, where you find that one insight from your childhood and then your current problems will get better, or there’s the cognitive behavioral approach where, we’ll let’s just deal with what’s going on now and how you’re going to deal with it, and maybe what happened in the past will sort of take care of itself. And so I think that can be applied to human medicine, or physical medicine, as well.

But I always meet people at whatever level of the materialist spectrum their on, and I go there first. Because ultimately, they need to do the experiment for themselves. They cannot take my word for it.

(49:50) [Damien Blenkinsopp]: Right.

It sounds like a very team focused approach to the whole doctoring thing, which isn’t really traditional. It sounds more from the modern world. I mean, we’re seeing team building and team practices in a lot of what we do in the world now, thanks to corporates and so on. Would you say that it’s changed the way you approach the practice, and the way you work with patients?

[Paul Abramson]: I think I’ve always taken this approach to working with patients. It’s not new to me. And yet, I think you’re right, in the conventional paradigm, it is hard to find. There’s a lot more words and verbiage around this team approach in the healthcare world now because of the politics going on, but in practice it’s still really hard to find a collaborator, someone who is more focused on doing the process right than on the outcome.

And we’re going to really focus on improving the process and changing the process dynamically as we go through working with each individual. That comes from my engineering background in systems engineering and out of control system theory and designing things is that you have to constantly change your approach based on what’s going on. And that takes feedback and communication, and it takes two people who are aligned working together.

Now there is a power differential. I have an MD, I wear a stethoscope, there is some value to that role differential. Someone who is looking for help from a professional who, in theory, has maybe some things to offer based on my experience and training and insights. And at the same time I like to also align with whomever I’m working, and work together so that we’re focused on if the process isn’t working. We can talk about that and fix the process.

If we get to the answer and the conclusion, we can celebrate together. And if that is vexing and takes longer, or is more difficult to find, well then we can pivot together. Or they can separate from this, and they can move on to other paradigms or other people to work with, and that’s fine too.

So there’s less pressure, in a certain sense, on, “I’m going to throw this problem at the doctor and the doctor is going to spit an answer back at me,” because that’s an all-or-nothing kind of proposition. Either it works and you’re happy or, much more likely, it’s not exactly right and somehow there’s been a failure.

(52:16) [Damien Blenkinsopp]: Would you say you need the patient to take some responsibility? The example you just gave is basically where they are saying alright, I don’t have responsibilities, just give me the fix.

[Paul Abramson]: Well, the more responsibly the patient takes, the better. An extreme example is the patient who does not consult a doctor and just does the [unclear 52:31] on their own. And those people exist. There are many of them. They achieve great results and I never meet them, except at Quantified Self.

If you are doing it on your own successfully, then you never meet me as a patient. However, in many cases people get frustrated, or they need new ideas, they need new paradigms, they want to explore with someone who can meet them at their level and have a very, very quick and useful conversation, and then help them to implement.

And I have the tools of pharmacology and laboratory testing and other testing, and access to specialists. You know, I have all the medical tools at my disposal, if they are appropriate.

[Damien Blenkinsopp]: And the experience. It’s all good doing an n=1 experiment, but if someone has been overseeing hundreds of experiments they learn things from those experiments in themselves, which could be relevant to you case.

[Paul Abramson]: I think so, except I’m continuously amazed at how individual people are. Even in problems that are relatively, I would say, conserved among individuals, like alcohol and the human brain. It’s really not that, there are only a few different ways that that tends to manifest on an obvious level, how people relate to alcohol, and yet their individual circumstances and details are unique, which makes every approach unique.

And so I say, I have gotten some insights from the self-tracking that apply to others. I think it is hard to take measurable insights and extract it in a medical, steady kind of way. And that’s why I continue to not be afraid of computers taking over my job, because ultimately I think there is a combination of metrics and data, and also presence and attention and experience that work together, and that’s why I think the medical profession has hope.

If you can provide presence, and attention, and experience, and knowledge, and then integrate data into that, you can actually be helpful to someone more frequently. And so that’s why I do what I do.

(54:41) [Damien Blenkinsopp]: Paul, I also just wanted to find out a little bit about you, and what you do with yourself when it comes to the Quantified Self, or any kind of tracking of metrics or biomarkers. Is there anything that you track for yourself on a routine basis, or you’ve explored, potentially?

[Paul Abramson]: Right now I’m tracking sleep, mostly just sleep duration. I think I’ve gotten the insights about sleep quality from various previous tracking endeavors. More as a behavioral thing to try to get myself to lie down more, which is particularly vexing for me.

And I’m tracking weight and body composition as I do different dietary experiments. Partly for my own health, and partly just to experiment with different dietary approaches. And, I’ve done many experiments when I have had problems that I wanted to fix, or wanted to understand better.

And some of them haven’t been fixable, but I understood them better and that helped me to deal with them. Headaches, and other things that I’ve talked about in the past. So I would say I use my baseline as I’m not doing lots, and lots of time intensive of self-tracking, because I don’t have the time involved.

The investment of time and resources is more than my available disposable resources, and the problems aren’t serious enough to warrant giving up other things. But when something important comes up, I start to implement more tracking.

(56:03) [Damien Blenkinsopp]: Right, right. So, in terms of the sleep quality you mentioned, what do you use to track that? Because I know sleep is a bit of a tricky area to track. Are you using MyMe today to track your hours, or what are you doing for that?

[Paul Abramson]: It all started with the Zeo – rest in peace – which allowed you to get some, albeit not 100 percent accurate, EEG data out of your sleep and sleep stage, and it was very nice. I didn’t mind wearing a headband every night, which some people found objectionable.

Now there are better tools, some of which I’ve experimented with, from Withings and ResMed and Beddit, where they’re less invasive tools to track your sleep that don’t require a headband. I think right now I’m using just an app on the phone that lays on the bed and has an alarm built into it and tracks start and end time of sleep.

It also records sounds, so if you snore it will give you all the snippets of snoring through the night. It’s just a simple app on the Iphone. I think I use the simplest tool for whatever I’m actually interested in. So right now I just set my alarm, and when it wakes me up I know how much time I was asleep.

And I have some subjective notes I take about that, like how was my sleep. And I’ve found that those notes correlate pretty well with reality when I’ve used actual medical sleep tracking devices that you use for sleep studies on myself in the past.

I’ve found that Zeo correlated well enough that I could actually use that data. And now I don’t actually need the Zeo even to know what’s going on with my sleep, because I know what it feels like.

[Damien Blenkinsopp]: I actually do the same as you, I just track the number of hours I sleep with a little timer on my Iphone. I just click it when I go to sleep, and I click it when I get back up.

Out of interest, how many hours do you sleep? What do you consider good or bad?

[Paul Abramson]: My personal ideal is 8 hours, almost exactly. 7.9 to 8.1, somewhere in there. And when I get that much…

[Damien Blenkinsopp]: You feel better?

[Paul Abramson]: Everything improves.

[Damien Blenkinsopp]: That’s good.

[Paul Abramson]: Both subjective and objective.

[Damien Blenkinsopp]: And have you got any little tools that have got you there? Because I’m always at seven. I’m always trying to get to eight but it’s hard.

[Paul Abramson]: Right. Well my particular app tracks over the last 14 days what my cumulative sleep deficit is compared to eight hours.

[Damien Blenkinsopp]: That sounds scary.

[Paul Abramson]: It is. And so when I get up above 10 to 15 hours of sleep debt in two weeks, other people don’t behave as well. I mean, that’s my observation. I’ve found that I’m not performing as well, and it manifests as the external world not cooperating.

[Damien Blenkinsopp]: That’s interesting. That’s good, then it goes back to you saying not everything is about food, and sometimes it’s the other psychological or emotional things, which are probably harder to identify.

(58:55) What would be your number one recommendation to someone who is trying to use data to make better decisions to improve their health, performance, or longevity, or any aspect of themselves?

[Paul Abramson]: I would define a relatively simple goal that actually really matters to you. Either it’s something terrible that you want to fix, or it’s something really juicy and rewarding that you want to achieve, and then set up as simple a self-tracking experiment as you can. Most people cannot pull off complex self-tracking unless they have diagnosable obsessive-compulsive disorder, or some spectrum of that.

So you have to just start with simple things that are as easy to track as possible, and some goal that’s really motivating, so you have the best chance of actually doing it, and seeing if this modality, if this type of thing, works for you. Some people find it intolerable, some people find it absolutely fascinating and motivating. And you can always add complexity later.

And then if you try, and it’s a great modality for you but you can’t pull it off, you need more accountability or more insight or more help designing experiments, that’s when you involve a coach all the way up through a medical doctor who’s interested in this kind of thing.

[Damien Blenkinsopp]: Great, great. Thank you for that great recommendation. Totally agree with it.

(60:00) So what would be the best ways for people to connect with you? Is it Facebook or your website, or where do people usually [reach you]? Are you active anywhere, or how else would people try to connect with you?

[Paul Abramson]: I’m variably active on Twitter, at PaulAbramsonMD. We do have a Facebook page and Google+ page. I’m easily findable on the internet. I usually do respond to social media.

If people want to become patients at my documedical group, my practice in downtown San Francisco, they can just call us up and we can describe how it works and how people can come in. I usually don’t work as patients with people that I have not met and examined, for personal and professional reasons.

[Damien Blenkinsopp]: Yeah, isn’t that a legal requirement in California?

[Paul Abramson]: It’s subjective. And yet I find that my intuition and my ability to be helpful to people improves dramatically if I have sat in the room, if I have had sometime in a room with them, and if I have laid my hands on them and examined them. Things work out much better.

I have tried both ways, and so I’ve just decided that I’m going to meet with people who can meet with me here in San Francisco. And that does restrict my ability to work with some people.

Otherwise, I can have theoretical conversations with people. My time is pretty darn limited in terms of how much banter I can do on social media, but I do my best to be available.

(change)[Damien Blenkinsopp]: Excellent. Alright, so we’ll put all of those in the show notes, and your website of course. Is there anywhere else you would suggest people look to learn about Quantified Medicine, for want of a better term. Are there any resources you’ve come across that you found helpful, and might be helpful to people?

[Paul Abramson]: Well the Quantified Self movement – it’s really more of a movement than an enterprise – but it holds meet ups all over the world, in many cities, and it also has an annual conference, or semi-annual I think, in the Bay Area. And frequently there’s the one in Europe.

So that’s a wonderful community to connect to where there’s an inner sanction of people of all different persuasions. And so you can always find someone who wants to do something similar to you in that community, because it’s a very heterogeneous community.

As far as others, there are so many different things going on in medicine around self-tracking. I think the reason Quantified Self appealed to me is that it does not have a strong vested financial motivation or conflicts of interest. And so you can go there and everybody is pretty much there just to be there. There are some people tying to sell things, but they stick out pretty obviously.

And it’s very egalitarian and anybody can speak. So I like that, whereas everything else you have to filter through the business model perspective. If you can do that, especially here in the Bay Area and in Western Europe there’s a lot of enterprise going on around this.

So it’s more about finding things that speak to you. I don’t have any particular points of focus.

[Damien Blenkinsopp]: Great, thanks. Well Paul, thank you so much for your time today. I really appreciate it. It was a great discussion.

[Paul Abramson]: You’re very welcome, it’s been great to be here.

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How well are you aging? We look at an attempt to make an aging biomarker index accessible to consumers that tracks their true biological age and provides feedback recommendations to improve how they age.

In this episode we take another look at longevity through the lens of aging biomarkers. This time taking a look at some of the most well research-supported biomarkers to predict how well we are aging. Or more to the point, how badly we may be aging, and get some early warning indicators, about having to intervene to assure we avoid shortening our lifespan.

Specifically we look at InnerAge, a new panel of aging biomarkers developed by the consumer blood testing service InsideTracker.

The panel provides an index estimating longevity based on a combination of biomarkers, and based on the results, makes recommendations to improve your longevity (AKA put the biomarkers back in the optimum zone, reducing the associated risks of shortened lifespan).

“…for each of those biomarkers, we have an intervention that you can take in order to optimize your InnerAge, and it’s very important for us to take markers that you can [have an impact on]. For example, we are not taking a marker of a disease like BRCA1 or other markers that show whether you have cancer or not, as you cannot do an intervention for that.”

– Gil Blander, PhD

Today’s guest is Gil Blander, the founder, president and chief scientific officer of InsideTracker. Gil has 18 years of experience in systems biology, computational biology, aging, metabolism and caloric restriction research.

During his career he has worked at MIT, the Weizmann Institute, and several systems-biology and computational biology companies. In this interview he walks us through the new aging panel, InnerAge, and the research and thinking behind why the company chose each of the biomarkers in the panel.

The episode highlights, biomarkers, and links to the apps, devices and labs and everything else mentioned are below. Enjoy the show and let me know what you think in the comments!

itunes quantified body

What You’ll Learn

  • Gil’s interest in biomarkers arose at the age of 12 when the death of a close family member made him think about age and longevity. (5:12).
  • Gil founded InsideTracker, with the aim of having a way of doing a monthly health check-up with optimal values for various biomarkers that are tailored to each individual (8:06).
  • When we look at biomarkers in the blood, they can show us where we are in terms of health and based on that, we can find optimal zones for each biomarker. (9:30).
  • The team of scientists and two year research process it took to cut down the aging biomarkers from hundreds to the top five (12:55).
  • How InnerAge uses an algorithm to estimate your chronological age, and recommend interventions based on your biomarker results (17:06).
  • Examples of some of the interventions including food supplements, exercise and lifestyle changes used to push biomarker values back into their optimum zones and reduce risk of shortened lifespan. (18:58).
  • Other biomarkers included in InnerAge are vitamin D, testosterone for males, CRP (22:35).
  • Why testosterone was included for men in the panel and why they have used different optimum ranges according to age and fitness activity (23:03).
  • InsideTracker is building its own database with information from athletic populations that do primarily strength or primarily endurance training. They are mining the database to determine optimal biomarker levels for each population. The benchmarking tool can be used to tell you how you compare with the rest of the population For example, a large percentage of the population has low vitamin D levels, but InsideTracker can tell you what percentage of the population shares those levels (25:47).
  • For benchmark levels of the biomarkers, InsideTracker shows the optimal range, which is their range, the normal range, which is what is used by the diagnostic companies and out of normal. For some biomarkers, even more ranges are shown (28:55).
  • An interesting biomarker not included in the panel is cholesterol. There are no scientific papers that have shown the correlation between cholesterol, or LDL and longevity. New guidelines by the American Heart association state that cholesterol is not as important as was once thought (30:00).
  • Cholesterol is a building block of testosterone, so if cholesterol is low it will be harder to make testosterone. If you have good metabolism, you can metabolize cholesterol (31:50).
  • CRP is another biomarker included in the InnerAge panel to capture the inflammation dimension of aging. (32:38).
  • InsideTracker should be used repeatedly so that you can see the trends in your values. Samples should be taken at least a couple of times a year for average users (35:09).
  • Other scientists working on aging is Nir Barzilai from New York City and Cynthia Kenyon from UCSF (37:29).
  • Currently, InsideTracker is developing an app that will help you maintain weight, biomarkers and activity (41:46).
  • InsideTracker uses LabCorp request to send samples, but it also uses home kits. They hope that in the future, home kits will improve. (42:18).
  • Theranos’ innovation in finger prick blood samples for a wide range of blood tests. (44:20).
  • Gil Blander’s own personal routines for tracking his own biometrics with InsideTracker and other tools, and the current devices and other services he uses.

Thank Gil Blander, PhD on Twitter for this interview.
Click Here to let him know you enjoyed the show!

Gil Blander, PhD

The Tracking


  • Fasting Glucose: One of the most commonly used biomarkers. It is used as an indicator of blood sugar regulation and can be indicative of longevity as blood sugar disregulation lies behind many common health issues such as diabetes and obesity. Gil mentions that while blood glucose should be between 65 and 99 for everybody, his aim was to find optimal levels for different populations.
  • Total Testosterone: Low testosterone has also been linked to depression and decreased cognitive ability. Since testosterone levels decline with age, it can be used as a biomarker of aging. Gil Blander included testosterone as one of the biomarkers in the InnerAge panel.
  • Vitamin D (25 Hydroxy Vitamin D): Also referred to as Vitamin D 25-OH. InnerAge panel includes vitamin D as a marker of longevity. This is measured in ng/mL and InnerAge uses ranges of between 40 and 50 ng/ml depending on your profile.
  • Total Cholesterol: Has long been thought to contribute to cardiovascular disease. However, re-evaluation of scientific evidence has shown that cholesterol is not harmful for most people. Cholesterol is a building block for steroid hormones, such as testosterone and estrogen and is an integral part of cell membranes. Since recent scientific data do not support the idea that high cholesterol causes heart disease, Gil Blander has decided not to include it in the InnerAge panel.
  • High Sensitivity C-Reactive Protein (hs-CRP): We’ve discussed this common biomarker of inflammation often on the show. As a general rule, the closer your marker comes back to 0, the better. InnerAge includes CRP in its panel because they implicate higher inflammation as a dimension of aging. Gil Blander notes that because exercise increases inflammation, the test should not be taken for approximately one week after vigorous exercise.
  • Alanine Amino Transferase (ALT): This biomarker of liver function is also included in the InnerAge panel. Normally, levels of ALT in blood are low, but increase if there is liver damage, which may be chronic and ongoing. The Liver is looked at for longevity in this case as its role in detoxification is considered an important predictor of health and longevity.

Lab Tests, Devices and Apps

  • HRV from ithlete: This is an app for iPhone and Android that tracks HRV. It can be used to maximize athletic performance and maintain good health. Gil Blander uses this to track his HRV, as does Damien.
  • MyFitnessPal: This is an app that is used to track nutritional intake. It can be used to track intake of calories, macronutrients and micronutrients as well as energy expenditure. Gil Blander uses MyFitnessPal to track his food intake
  • Nutrino: Nutrino is a “virtual nutritionist” app that connects to wearable devices like Whitings and Fitbit and makes personal meal recommendations. It includes information on what to eat and when to eat it. Gil Blander uses it to track his nutrition.
  • Withings WS-50 Smart Body Analyzer: Gil Blander uses this scale to track his weight and store the data daily.
  • Fit Bit Charge: FitBit is a wearable tracker used by Gil Blander. It monitors physical activity and sleep quality.

Other People, Books & Resources


  • Simon Wegerif: was mentioned in the context of his interview on QBP and his app and HRV platform ithlete.
  • Lenny Guarente, PhD: One of the leading researchers on aging and is considered to be the father of the new aging research.
  • David Sinclair, PhD: David Sinclair is a professor of genetics at Harvard Medical School is one of the leaders of aging research. He is also involved in the biotech community and has started several companies.
  • Bob Troia: Bob Troia is known for his n=1 experiments in self-tracking and biohacking. He was a guest on episode 22 of QBP and is a user of InsideTracker.
  • Nir Barzilai: Nir is one of the scientists involved in developing the InnerAge. He is the director of the Institute of Aging Research at the Albert Einstein College of Medicine. He is studying the effects of the environment, especially nutrition, on extending the lifespan.
  • Cynthia Kenyon: Cynthia Kenyon is a professor of biochemistry and biophysics at UCSF and is one of the scientists who has helped develop InnerAge. She is one of the pioneers of research in genetics of aging.


  • LabCorp: Laboratory Corporation of America provides lab testing and services. InsideTracker currently uses LabCorp for its lab processing.
  • Theranos: A lab testing service that tests on very small amounts of blood, taken from the fingertip. Their tests promise to be a lot more affordable, convenient and faster than tests from traditional labs.

Full Interview Transcript

Click Here to Read Transcript

[Damien Blenkinsopp]: Hi Gil, thank you so much for joining us today on the Quantified podcast.

[Gil Blander]: Thank you so much for inviting me. It’s a great pleasure
and I already listened to a few of your guests and I really appreciate it because the
quality is very good.

[Damien Blenkinsopp]: Thank you, that’s a great compliment coming from
you. As we’re going to see, you’ve been pretty busy yourself doing some good stuff.
So, could you share first why you got involved with your interest area—what is the
story about why you do what you do at InsideTracker today?

[Gil Blander]: It’s a great question. Apparently everyone is asking me this
question. My scientific journey started at the age of 12 when one of my closest relatives
passed away, triggering my quest and a thirst for knowledge in our body age. Basically,
at that time I decided that instead of being a physician or physicist, what I wanted to do,
I decided to become a biologist. The reason for that is that one of my relatives passed
away and I started to realize that I’m not immortal anymore, and I realized that one day I will be gone. I wanted to live forever; I wanted to stop the clock; I wanted to try to delay the aging-related diseases. So that basically pushed me to become a scientist and to focus and to have my lifetime goal in aging research.

So I’ll fast-forward a few years: I decided to study biology, graduated from Tel Aviv
University with an undergraduate in biology, PhD from the Weizmann Institute of
Science studying aging, and then I came here to MIT in Cambridge, Massachusetts,
and I joined the best lab that studied aging in the world. I studied aging there for five
years, published a lot of interesting papers, did very cool research, but very early when I arrived here to Cambridge, I started to be exposed to what we call “the Kendall square
environment.” There are hundreds of start-ups in biotech, pharmaceutical, and high-tech. I started to be exposed to them and I started to talk with a lot of founders. I started to do some partnerships with them and I very soon realized that I will contribute much more to humanity if I would start my own company than to be a professor in the academia that publishes a paper once a year and maybe five people will read the paper. I realized that that should be my next step.

Even having realized that, it took me some time because I really like the work in the lab
and I did a very cool experiment. So after five years at the MIT, I left MIT and I joined a
couple of biotech companies and worked there just in order to learn and understand the
industry. Also, I really wanted to learn more about systems biology. So I spent a couple
of years there and then, during that time, I was exposed to two other PhD scientists that were really intrigued by the aging process as well, but also were trying to change the equation between healthcare—basically that the healthcare is taking care of the sick and not of the healthy.

We came at that time with the basic of InsideTracker. The basic is very simple. First of
all, all of us are a machine and like a machine, we need to take care of ourselves.
Today, we are not taking care of ourselves. If you look at that, you go to the physician
mainly when the machine or “us” is broken down. When we are breaking down then we
go to the physician. So we decided to find a way to have once a month to have a
check-up that we can basically check ourselves, find what is not completely optimized
with ourselves, then intervene, and then have our body good for a few more months.
I really like the analogy of the car: so every 5000 miles, you take the car to the
technician. The technician plugs a computer into the car, the computer tells the
technician exactly what should be done in order to make the car good for another 5000
miles, should he replace oil or the oil filter and so on. The technician does that and then
the car is good for another 5000 miles. There is a lot of research that shows that since
the time that this routine schedule of maintenance for the car was introduced, in the
80s, the lifespan of the car increased from around 100,000 miles on average to around
200,000 miles on average.

So we said let’s do something similar. We cannot obviously plug a computer into our
body, but we can plug a needle into our vein and extract the liquid gold that we have in
our veins, called blood. Then when we extract the blood, we can look at the biomarkers
that show where you are staying and based on that, you can find optimal zones for each biomarker. I can give you an example; let’s look at the most boring, maybe, biomarker that you know, which is glucose. For all of us, the optimal zone is between 65 to 99. It doesn’t matter if you’re male or female, young or old, Olympian or couch potato, someone that is obese or someone that has a BMI of less than 15; all of us should be between 65 to 99.

We said that that’s wrong; let’s find an optimal zone for each of us based on age,
gender, ethnicity, and athletic activity, and other criteria. Let’s find an optimal zone that
is matched, and then find whether you are within your optimal zone, above or below. If
you are not in your optimal zone, we can subscribe you an intervention that includes
food, supplements, exercise, and lifestyle changes, that basically will help you to bring
yourself to the optimal zone, and when you bring yourself to the optimal zone there is a
good chance that you will optimize your health, your performance, and hopefully, your

So that’s basically the background of InsideTracker. I just want to say that all of our
recommendations, the zones, everything, is extracted from peer-reviewed scientific
literature. We have a team of scientists that do that, so we are looking at it very
seriously and taking it very seriously.

[Damien Blenkinsopp]: What are the most common use cases you have
today? You mentioned a few different things like athletes. What are your clients today?
What are they mostly using it for?

[Gil Blander]: We have three main segments of clients: we call them the
train, the gain, and the pain. The train is, as you said, is an athlete: someone that wants
to shave two minutes off his marathon time; someone that wants to play at the fourth
quarter; someone that wants, basically, to approve his athletic performance. The gain is
an interesting segment. People—that are more like me—that are trying to reach to their
forties, trying to stay in their peak performance, trying to reach the afternoon and have
enough energy and enough patience to play with their kids; people that are trying to
perform better in their work, so a lot of executives; those are the gain population. The
pain are people that are sick.

Currently we are mainly trying to serve the train and the gain, because we feel like the
pain, which are sick, have already someone taking care of them—that’s the physician,
and wishing that the physician is doing a good job. We also don’t want to get into all the
regulation—when you are sick, there is more regulation. We are trying to have a proof
of concept or to show to the train and the gain that we can help them a lot, and maybe
in the future, we’ll go also for the pain, but currently, the main customer segment that
we are trying to approach are the train and the gain.

[Damien Blenkinsopp]: Thank you very much for that. You have just
created this new panel, which is called InnerAge, and it’s specifically targeted at aging,
whereas the rest of your platform, as I understand, is a bit more general. When you
were looking at the criteria for selecting biomarkers, how did you go about that? What
kind of criteria were you looking for in order to select the biomarkers that you’ve put
into that panel?

[Gil Blander]: First of all, we built a team of scientists, and actually we
recruited new scientists and we work with our scientific advisory board. I want to
mention that two of those scientific advisors that we have, one of them is Professor
Lenny Guarente from MIT, who is considered to be the father of new aging research
era and is by far considered to be the initiator of the aging research in the world and
considered to be one of the five top researchers of aging in the world.

Another scientist is Professor David Sinclair from Harvard Medical School. He actually did his postdoc at the lab of Lenny Guarente. Now he’s also considered to be one of the leaders of aging research. He’s also extremely involved in the biotech community; he’s started a lot of companies, and one of them called Sirtris—which use what they call resveratol (which I assume that you’ve heard of), a small molecule that is in high concentrations in red wine and has been shown in a lot of studies to increase longevity—was sold to a big pharmaceutical company a few years ago for $720 million. So both David Sinclair and Lenny Guarente help us to do that.

As to your question, we basically spent almost two years looking at hundreds of
biomarkers and trying to see what is the effect of those biomarkers on aging or
longevity. Basically, we were trying to pinpoint, looking at the scientific publications,
which are the five that are the most related to longevity.

[Damien Blenkinsopp]: So, just to take a step back—when you’re talking
about longevity and aging, are we referring to mortality here? Some people when they
think about aging, they’re thinking about their skin and how they look and things like
that. Are we talking about longevity in terms of how long we’re going to live, or is it
other aspects also?

[Gil Blander]: It’s a good question, and the answer is yes. I can give you
again the example of glucose, which is one of the markers that we have in the
InnerAge. We looked at the data and we found a lot of data that showed, not surprisingly, that when your glucose is high, you might compromise your longevity. But
we were looking for better data and we found it in the scientific publication that was
published based on the Framingham Heart Study. I don’t know if you’ve heard about it?

[Damien Blenkinsopp]: Of course, yeah.

[Gil Blander]: It’s basically a study that was done here in Massachusetts,
in a small lake town next to Boston. They followed up the population of this town for
tens of years and measured some biomarkers. What they found is that there is a strong
correlation for the level of glucose at a certain age and your final longevity. Let me give
you an example: if you are 40-years-old or 35-years-old and your fasting blood glucose
today is 70, you have a good chance to reach your 90s; if your glucose is a bit higher,
let’s say 80, you have a better chance to live to your 80s; and if your glucose is in the
90s, you have a better chance to live to your 70s; but if it’s 100 plus, you have a better
chance to live only to your 60s. So based on that, we took the data, we compiled it, and
then you can basically take a person and say, this person’s age is 40, his glucose is X,
so basically based on the glucose, the predicted longevity will be 80. He’s now only 40
so he has, just by the glucose, 40 more years to live.

Now we’re looking at a few other markers, so each of them show us what the effect is,
then we compile it all together using an algorithm and that’s what we show you as the
InnerAge. We show it to you in comparison to your chronological age, meaning what is
your age today.

[Damien Blenkinsopp]: So it’s an estimate of your longevity based on an
average person? The trendline I guess you’re showing is chronological age against this
biological age, and it’s showing it against, say an average 80-year-old or if you’re doing
better than the average, maybe you’re going to live to 100?

[Gil Blander]: Yes, so it uses the average but also, I want to say that it
shows what is happening with you today. It doesn’t say, and we’re not trying to say that
if you’re a 40-year-old male and your InnerAge is 30, we’re not trying to claim that you
will live 10 more years than what you’re supposed to or than the average. What we are
saying is that if you continue to stay like that, you have a chance to live ten years less
or ten years more. So that’s a very important point.

What is also very important is that for each of those biomarkers, we have an intervention that you can take in order to optimize your InnerAge, and it’s very important for us to take markers that you can intervene. For example, we are not taking a marker of a disease like BRCA1 or other markers that show whether you have cancer or not, and you cannot do an intervention for that.

[Damien Blenkinsopp]: Right. We don’t have any ideas about what exact
tool we could use to change the fact that, apart from having surgery and having your
breast removed in that case, but there’s no specific intervention that you have linked to
those. So you stick to things that are actionable, which is great; that’s what we like to
hear on this show.

[Gil Blander]: They are actionable and more than that, they are simple
interventions. So it’s a food supplement, exercise, lifestyle changes, so similar to Inside
Tracker but a bit more simple. And the simplicity comes with the next feature that we
have in InnerAge, which we called “focus foods.” So focus foods are basically nutrient-
heavy foods that will help you to optimize all the biomarkers that are related to InnerAge that are not optimized for you. So basically, focus foods are foods that are personalized just for you based on the level of the biomarkers that you have and they will help you to optimize all the biomarkers that are not optimized just for you.

For those foods, you don’t need to change completely your routine. What you need to
do is pick a couple of them and start to integrate them into your diet. So for example, if
you need to consume more oatmeal, eat it every day; that’s it. You don’t need to
change completely your behavior. Or if you need to eat strawberries, just try to integrate strawberries. Don’t change all your diet. So what we’re trying to do here is very simple because, as you know, it’s very hard for us to change our diet completely. You have a lot of influence on your diet, you are at home or at the office, you are commuting, you are travelling—it’s not easy. But when you have only a few food items that you need to incorporate all the time, it’s much easier to do that.

[Damien Blenkinsopp]: Could you give us an example—you gave us a
blood glucose example—as to what kind of recommendations the tool would make: I’m
40-years-old and my blood sugar is currently at 95. My fasting blood sugar I guess
we’re talking about.

[Gil Blander]: First of all is nutrition. To optimize your blood glucose, it’s
very important to consume foods that are rich in fiber because the fiber helps our body
to absorb the glucose and then the level of the fasting blood glucose decreases, and
that has been shown to increase your longevity. So one thing that it’s very important to
do is to try and consume more food that is high in fiber. Another thing that it’s good to do is to exercise more. Again, depending on the person; if you are a professional athlete, don’t exercise more. But if you are not, exercise more. Also maintain a healthy weight. There is a lot of data that shows in the literature that if you are overweight, you tend to have higher blood glucose. So there are a lot of interventions like that.

Each of our users receives the intervention based on this information. So if you have a
high BMI or you are heavy, you will receive the intervention of lose weight. But if you
are not, you won’t receive it. Or if you are exercising five times a day, you won’t receive
a recommendation to exercise more. But if you are not exercising at all, you will receive
it. So there are a lot of interventions that are personalized and coming to you based on
your profile and based on what will help you to optimize yourself.

I just want to add that we are also taking into consideration your dietary preferences. So you can tell us that you are on the Paleo Diet; you can tell us that you are a bachelor, live in town and don’t know how to cook; you can tell us that you are gluten-free; so we have a list of a few kinds of dietary requirements that you just need to click and then the algorithm will provide to you the food that is good for you and will help you to optimize yourself.

[Damien Blenkinsopp]: Which other biomarkers have you looked at for the
InnerAge panel? Which other ones have you included today?

[Gil Blander]: We discussed the glucose, we also added vitamin D, we
added testosterone for males, we added CRP, which is a marker of inflammation, and
ALT, which is a marker of liver function.

[Damien Blenkinsopp]: Vitamin D, a lot of people talk about that today, so
that’s common about the benefits to the immune system and so on. Testosterone, I
think, is not so obvious for a lot of people—what’s the issue with testosterone? Why’s
that important when it comes to aging for men?

[Gil Blander]: That’s a great question. What we have seen, and I assume
that you’ve heard about it, that the level of testosterone is decreased by 1-2% every
year when we are getting old. Testosterone is important for our muscle tone, it’s
important for our sex drive, it’s important for our mood. So it’s very important to maintain a healthy testosterone in order to maintain the health and longevity.

What you eluded in your question is, is testosterone as important as glucose? and my answer is definitely not. So each of the biomarkers that we included has its own value or its own weight. So, if you ask me if you have low testosterone and have a high glucose, what is more important to take care of? I would say definitely start with your glucose, and then move to the testosterone. But the testosterone is also very important and there is a lot of data in the scientific literature that shows that.

[Damien Blenkinsopp]: I believe there’s a lot of research on strength and
muscle: the higher the levels of muscle you have going on older in life, the better your
longevity chances. So that correlates also with the testosterone.

In terms of testosterone, what kind of ranges are you looking at? Because there are
obviously the lab ranges we often talk about here—you have the LabCorp range for
example—which isn’t necessarily, and I imagine is probably, not the same as the range
you’re looking at, so what kind of reference range are you looking to get people into?

[Gil Blander]: As I mentioned before, we have what we call the optimal
range or optimal zone, and that’s calculated exactly based on the papers, like I told you
before, looking at the population of thousands or hundreds of people and seeing what is the level of testosterone at specific ages. Then we can from that come with an optimal zone based on your age, based on your gender—obviously, because males and females are completed different—also based on your athletic activity. Those ranges come in based on all the demographic information and then we subscribe to you the optimal zone that is good for you. Your optimal zone might be completely different for a person completely similar to you but in a different age or ethnicity or so on.

[Damien Blenkinsopp]: That’s interesting. Do you look at the difference
between someone who’s doing endurance training versus heavy-weight training, the
different approaches?

[Gil Blander]: Yes, we are extracting the information that we can from
the peer-reviewed scientific literature. For some of them we have data, so we are doing
that; for some others, we don’t. Basically, we are trying to extract the most that we can,
but I want to admit that we don’t have everything because not everything is published in
the scientific literature. In order to try to fill the holes of that, we are building our own
database and we are mining the database. We have a lot of athletic active population
who are doing either strength or endurance, so we are starting to extract information
from there and then help our customers to compare themselves more to their peers
than compared to a couch potato doing nothing.

[Damien Blenkinsopp]: Great, I understand. So I’m guessing it’s early stages
in terms of mining the information from the client base. When do you expect to bring in
the first bits of information from that and analysis to help improve the tool?

[Gil Blander]: We are actually doing that already. We have what we call
a benchmarking tool that shows how you stand compared to InsideTracker
community. So for example, we can see that a high percentage of our community have
a low vitamin D. But you want to know whether it’s 5% or 20% or 40%, so we are
showing and sharing it with our community. They like it a lot because sometimes people say, “Oh, I have low D but it’s 50% of the population. It’s not so bad.” So some people like to see, “Oh, everyone’s having this issue so I’m not…”

[Damien Blenkinsopp]: Right, yeah, it’s not so bad.

[Gil Blander]: “… I’m not going to die tomorrow.”

[Damien Blenkinsopp]: Are you able to tunnel down and say, it’s athletes
like me, say I’ve put into your system that I’m an athlete and I’m eating Paleo, would it
be able to position me compared to that population, or is it early stages for that still?

[Gil Blander]: We are doing it currently just for specific customers; we
are basically tailoring it for them. We have what we call an InsideTracker Pro, which
we’re working with some professional athletes, teams, some gym chains, and others.
For them, we are doing what we call a tailoring solution for them. But we don’t supply
that yet for the person that comes to our website. We are working on that and we hope
to have it soon.

[Damien Blenkinsopp]: In terms of the number of users you need to make
this really useful, how many users do you have today and how many would you think
would be important to have to really make lots of statistical analysis? I guess you have
ideas about doing data mining and a lot more exciting and intricate things.

[Gil Blander]: We have many thousands of users. Obviously I cannot
expose the number. I have a statistician on the staff that helps us to analyze and to
evaluate each of them, so basically we are doing rigorous scientific work and statistic
work, and based on that we decide whether we have enough power to share it with our

[Damien Blenkinsopp]: In terms of the benchmarks you’re using, we’ve
already discussed that they’re different to the lab reference ranges, so when I go into
the system would it also show me for instance the normal reference ranges and how
yours are different? Or will people just get your reference ranges? So that they can
compare—say they’ve had tests outside of your system in other places before, when
they’ve been given other numbers.

[Gil Blander]: Yes, it’s a good question. We are showing base, what we
call the normal and out-of-normal, and then we are showing the optimal. For some
biomarkers, we are showing even more ranges. I can give you an example of
cholesterol. There is an optimal, then you have a normal, then you have a near-normal,
you have high, and you have very high. So, sometimes it’s more complex than just
optimal, normal, and the out-of-normal. But in most of the biomarkers, you see the
optimal, which is our range, you see the normal, which is the range of the diagnostic
companies, and then you see the out-of-normal, which is out of the diagnostic
companies. Most of the time, our optimal range is consumed by the normal so it’s a
subset of the normal.

[Damien Blenkinsopp]: Right, I understand. So out-of-normal range means
the standard labs like LabCorp or based on the research and so on; thank you. Which
other biomarkers did you look at that you decided not to include in your panel?

[Gil Blander]: In the InnerAge panel?

[Damien Blenkinsopp]: In the InnerAge one, yes.

[Gil Blander]: One interesting biomarker is cholesterol, which when we
started to work on that I was sure that cholesterol would be part of the panel. I asked the
scientist that worked on this marker after a couple of weeks that he was working on
that, “Okay, show me the papers.” He said, “Gil, I cannot find any papers.” So I told him,
“Are you kidding me?” Well, you have cholesterol, you have statins, and you have
lipidol, and a business of, I don’t know, ten billion dollars. So I told him, “You know what,
I will spend.” I spent four weeks on that and I couldn’t find anything. You could find old
papers but old and new papers haven’t shown a strong correlation between cholesterol,
or LDL, and longevity.

Very interestingly, exactly a year ago, the new guidelines of the American Heart
Association came out, and basically said that cholesterol is not as important as it used to
be. It is important if you are overweight, if you have high inflammation, if you are not
athletically active, if you have a family history of high cholesterol, or if you have blood
pressure, but someone that doesn’t have most of those, it’s not as important as it used
to be. That was a big surprise for me, but apparently we came to the same conclusion
that other agencies or all the scientific community came to, so that was a very big

[Damien Blenkinsopp]: There is definitely a lot of movement going on
around the cholesterol markers. One interesting thing with that in relation to your
testosterone is I found it’s easier to get my testosterone raised when I have higher
cholesterol. So I think if you’re on a lower cholesterol diet, it can be more difficult to
raise your testosterone, which you’ve included in your panel.

[Gil Blander]: Yeah, it makes a lot of sense because if you look at that,
testosterone is a derivative of cholesterol. So basically, cholesterol is one of the building
blocks of testosterone. So when you have low building blocks, it’s harder to build the
building. Actually, a couple of weeks ago, another news about cholesterol came out,
and what they’re saying now is that cholesterol is not evil. You can eat cholesterol as
much as you want if you have a good metabolism and your body can metabolize the
cholesterol. It’s not like everyone needs to run away from cholesterol. Again, don’t eat it
like crazy, don’t eat 50 eggs a day, but if you eat one or two eggs a day, you should be
all set, other than someone that has all the risk factors that we discussed.

[Damien Blenkinsopp]: You’ve included CRP. The reason everyone was
focused on cholesterol was for heart disease, but it turns out that hs-CRP is a better
marker, correct? Is that why you’ve included it?

[Gil Blander]: Yes, but CRP is not only for that. CRP is basically a
marker of inflammation and it’s related to cardiovascular diseases, but it’s also related to
a lot of other diseases, including cancer, and even diabetes. So, CRP is a marker of
inflammation, and inflammation is more and more considered to be a big, big problem,
not only for after athletic activity that your inflammation is increased but also for the
average population. Definitely inflammation is very important.

[Damien Blenkinsopp]: As you just mentioned, with athletic activity the
marker would go up, so I guess your tool comes in pretty useful in this situation because
you’re looking at those different populations and saying what’s normal for them.

[Gil Blander]: Exactly. It’s normal that your inflammation will go up after
athletic activity. For example, after a marathon run, I would suspect that your CRP
would be high. But it’s not normal that it would stay high for a week after that. So what
we are doing is we are asking our users to test themselves at a certain time when they
haven’t been running a marathon the day before, or maybe haven’t been highly
athletically active for a week before, and do it also after a day of rest. Then, if your
inflammation is high, that means you have some issue. It could be that you over-
exercise, could be that you have some injury, and it helps us and it helps our users to
pinpoint what the issues are that they have.

[Damien Blenkinsopp]: Great. It sounds like you’ve put a lot of controls in
there. Have you done the same thing with blood glucose? I’m just curious because we
had someone else on the show before, Bob Troia, “Quantified Bob,” and he’d been
tracking his fasting blood glucose daily and I was quite surprised to see how much it
went up and down most days. He was doing football practice some evenings, so he had
some correlation differences between the mornings after the night he’d been in football
practice and exercising versus a normal day when he hadn’t been exercising the day

[Gil Blander]: Yes. First of all, I know Bob very well; he’s a user of
InsiderTracker and he’s a very interesting person. I completely agree with you. A blood
glucose, even fasting blood glucose, can change based on what you have done the
night before. What we are reaching or trying to do with our user or trying to explain to
everyone, it’s not only one time point and InsideTracker is not a tool that you should use
once. You should use it and use it again and again and again, and then when you start
to use it again and again, you see where is your field—Is it running between 80 to 90? Is
it running between 90 to 110? Or is it jumping all over? And usually it should be more or
less flat. And you can also start to see the trend if during the aging process or when you
are becoming older and older, you’re starting to see a trend of increasing it. So I
completely agree with what Bob has showed, but what we are trying to do here is not
looking at one point, not even two points, in order to see a trend you need to have at
least a few points.

[Damien Blenkinsopp]: How often do you recommend people take the
blood samples for the tool?

[Gil Blander]: We recommend that you do it at least a couple of times a
year. We have some users that are doing it four times a year; we have some athletes
that are doing it even once a month in order to really keep them in top performance, but
the average users that we have are doing it around twice a year.

[Damien Blenkinsopp]: Okay. That sounds about similar to me, actually—
what I do—so I’m glad to hear that I’m average in terms of how often I do these panels.
To learn more about InnerAge and any resources of our aging that you’ve come across,
first of all, where can we get information on InnerAge itself?

[Gil Blander]: Everyone can come to our website, it’s insidetracker.com,
and there we have a link to a page that we developed that shows what is InnerAge, an
explanation about focus foods, an explanation about the science, why those
biomarkers, and about the scientists who developed it. We developed a lot of
information for that because we know that it’s the cutting-edge and people need a lot of
information to understand what we are doing, so we devoted a page with a lot of
downloads that you can read PDF after PDF and spend maybe a full afternoon learning
about InnerAge.

[Damien Blenkinsopp]: So you’ve mentioned the scientists you’re working
with on this tool. Is there anyone else you would recommend to get more information
about aging, or are there any references like books or particular presentations that you
found useful in your research?

[Gil Blander]: Yeah, there are a lot of good scientists that are studying
aging. I mentioned Lenny Guarente and David Sinclair. There are a few other leading
scientists that are studying aging. One of them, which is a very interesting person, his
name is Nir Barzilai, located in New York City, and he’s studying mainly long-lived
humans and trying to see what are the changes in their genome and their proteome
compared to the average human, so that’s an interesting person to look at.

Another very interesting scientist is Cynthia Kenyon, who is from UCSF in San Francisco. She’s
focused mainly on the insulin pathway, which is very related to glucose—insulin and
glucose. She started with the model organism slow worms, and now she’s also working
on other model organisms. So I think that if you are looking at, or your audience will
look at those four, you can find a lot of very interesting information.

[Damien Blenkinsopp]: Great, thank you very much for that. What would
be the best ways to connect with you personally? And you on Twitter, Facebook?
Where do people connect to you? Where are you most active?

[Gil Blander]: I actually like Twitter a lot so I’m on Twitter. They can find
me, it’s GBlander1 and they can find me there. If someone has any questions, they can
contact us via our website. On our website there is contactus@insidetracker.com and I
would be more than happy to talk with them.

[Damien Blenkinsopp]: Great, thank you, Gil. I just wanted to learn a little
bit about you before you go, are you using your tool every month? What are you doing
in terms of tracking your biology at the moment?

[Gil Blander]: It’s a great question. I’m using the tool at least four times a
year. There are some months that I’m maybe testing every day. There was one day
that I was testing myself like four times because I’m all the time trying to find new tools.
So we are using home kits and different labs, and often my arm is completely dotted
with blood stains.

On top of that I used to use other Quantified Self tools. I used in the past the HRV from
Ithlete, which you interviewed Simon, and I think that it’s a great tool for the athletically
active population. Currently what I’m testing every day, or all the time, is my activity,
and my weight. I’m trying to use some other tools, so we’re trying to develop now a new
nutrition tool for our users, so obviously I’m using some nutrition applications,
MyFitnessPal, Nutrino, and others. So I’m using a lot of different tools but in the day-to-
day and in the last year, I measure my weight every day by Withings, which is a
European company, which have a great wireless scale. And I’m measuring my activity
using Fitbit, but I did test it from the 23andme to measure my genome, so I’m trying,
because I’m working on that, I’m trying a lot of different tools.

[Damien Blenkinsopp]: It sounds like you’ve got involved in a lot of them. Is
there any key insight; what have you learnt about yourself so far? Is there one important
thing that you’ve learnt from these activities?

[Gil Blander]: Yeah, I leant about myself that data is the key for me. For
example, when I’m measuring my weight, every day I’m measuring it here in the office,
after that I make a decision, should I eat that or should I eat that? Because it’s showing
me every day whether my weight went up or went down. So I succeed to maintain my
weight more or less stable. When I’ve seen that my weight is too high, I use some tools
to see if it’s helped me to decrease it. For example, I did an experiment when my weight
went up after the holidays. I started to log my food in MyFitnessPal and I lost like eight
pounds in a week and a half. The issue is that you cannot continue with it forever
because it’s very time consuming and annoying to add what you ate every day. So it’s a
good intervention but it’s for the short-term.

What we are trying to develop here in InsideTracker currently is find a tool that will
help you to maintain your weight, maintain your biomarkers, maintain your activity,
which is more seamless, and it’s not easy. We have a team of scientists, exercise
physiologists, coaches, and nutritionists who are trying to do that. But it’s definitely not

[Damien Blenkinsopp]: Yeah, great. Well keep me updated if you’re
coming out with something interesting; that would be great. So one thing you did
mention right there, which I forgot to mention, is I think that InsideTracker, currently
you use LabCorp request to get people’s samples. So you give them some requisition
forms and the person runs down to LabCorp and it gets sent to you, but you said you’re
also using home kits. Is that something that’s going to change in the future or is that just
for you in experimentation?

[Gil Blander]: No we have home kits. So if someone wants to use the
home kits, we have them; we are using home kits. The problem with the home kits is
that we tested a lot of vendors and most of them haven’t had the precision of the
measuring of the biomarkers to be good enough for us. Because we are giving you an
optimal zone, you should have the precision. So we came with two vendors that are
precise enough, but the number of biomarkers is limited. So for one of them we have
only five biomarkers; the other we have seven. But we are still using it because some
people are too lazy to go to the lab, some others don’t live in the U.S., and currently the
lab availability is only in the U.S., so they can use our advanced home kit and we are
sending it all over the world. So because of those reasons we are still using the home

We also hope that in the future, the quality, the precision of those home kits will be
better, then we could use more and more biomarkers. I really hope, and I think that it
will happen that in the next five years, we won’t need to go to the lab at all, we can use
our iPhone. Basically we are saying that you can bleed on your iPhone, spit on your
iPhone, pee on your iPhone, and then receive a lot of information, so that’s our goal. I
think that it will happen and what is nice about InsideTracker is that we are a
technology diagnostic. We don’t care where the information comes from; what we care
about is the quality of the information because we are running it via our analytic and
then providing to you the ranges and the recommendations. So as soon as the
technology will be good enough, we will integrate it.

[Damien Blenkinsopp]: I’m sure you are aware of Theranos and what
they’re doing. I don’t know if you know, but would you think that their services would be
accurate enough for you when they get to market? Or do you think they’re still focused
on being in or out of normal range and it’s not necessarily sharp enough for you?

[Gil Blander]: Theranos is very interesting. What is interesting is that
instead of taking the blood from the vein, you take it from the finger like the home kits
that we’re using. What is also interesting is the volume: because you’re taking it from the
tip of your finger, you cannot extract a milliliter; you are talking about microliters. What
is also interesting, that they promise, is that you can do it on time. So you receive the
information immediately, while when you do it at the lab it takes a couple of days, and
when you do it with the home kit it might take a couple of weeks. What is happening
with this—at least today, and I don’t know, I hope it will improve—is that even though
that they have a machine that can do it in place, they are sending it to a central lab. So
basically you go to one of the clinics of Walgreens. Currently only in…

[Damien Blenkinsopp]: I think it’s Arizona.

[Gil Blander]: Only in Arizona.

[Damien Blenkinsopp]: There’s one in San Francisco I think, as well.

[Gil Blander]: There should be one in Palo Alto, yeah. So you prick your
finger, they fill a small vial, and then they courier it to the lab. The lab do their analysis
and then you receive the result, I assume a day later, I’m not sure I haven’t tested it. So
you lose the value of the immediate response, that we don’t have, but it sounds like (at
least what they claim is) it’s accurate, which is great. Also, another advantage that they
have is the price: their price, at least the sticker price—what they show on their
website—is much lower than the price that a biophysician would do it, which is great
value. But again, it’s only available in Arizona; it’s not immediate. I think that it’s still an
intermediate solution. So it’s nice progress but it’s not the end product. The end product
will be the…

[Damien Blenkinsopp]: The iPhone.

[Gil Blander]: … your iPhone, yeah.

[Damien Blenkinsopp]: Thanks for the commentary on that because it’s
hard to know actually what’s going on and how far the progress. So it’s still in a trial
stage, Theranos.

[Gil Blander]: I assume so but my knowledge is the same as your
knowledge. I don’t have any internal knowledge about that.

[Damien Blenkinsopp]: Great, thank you. Well Gil, thank you so much for
answering all our questions today. You’ve given us some great insights into how you’ve
constructed your aging panel there.

[Gil Blander]: Thank you so much and I’m looking forward to really cool
entrepreneurs in your future podcast.

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