Longevity is often sold as a future achievement. More years. Better biomarkers. A longer runway. Dr. Deborah Kado brings the conversation back to something more human: the ability to keep moving through life with strength, balance, purpose, and dignity.
00: 080 - - > 00: 02. 470 align: start position: 0% Is longevity science just basically a sexier way of saying gerontology? Yes, because at a party everybody wants to talk about longevity, but who wants to talk about gerontology? Well, I do. Why do you prefer healthy longevity over health span? If you're 40 and you get rheumatoid arthritis, your health span is done. Can you not lead a healthy life? Absolutely, you can lead a healthy life. Just because you have a chronic condition doesn't mean that your health span is over. I like that. I think that's a nice reframe. Otherwise, you can be defined by the diagnosis. Absolutely. Are there any parts of the current longevity conversation that frustrate you? Tell me what's new. Tell me what I can do to extend my life by X number of times. That's what's going to sell. That's what's going to get clicks. There's just so many basic things that actually don't need to break your pocketbook that you can do to help your health. Eat right, do physical activity, sleep, you'll be fine. Do you see some patients that are on like a cocktail of medications? I've had patients come to the bone clinic literally with a cooler full of supplements. They were 25 and I thought, "Wow." If you go to an 85year-old, you say, "Oh, you might really consider seeing a geriatrician." And they'll be like, "Am I that bad? Is there something about me that makes you think that I'm ready to kick the camp?"00: 01: 21. 429 - - > 00: 01: 21. 439 align: start position: 0% 00: 01: 21. 439 - - > 00: 01: 23. 109 align: start position: 0% We were just having a bit of a giggle off air that that longevity science. Yes, it it really is a hot topic right now. No kidding. Right. And so I'm interested off the top here as a gerontologist and a geriatrician of which we will define in in a moment. Is longevity science just basically a sexier way of saying gerontology? I will just say yes probably because at a party everybody wants to talk about longevity but who wants to talk about gerontology? Well, I do. That's why you're here today. Good. So familiarize us with with these
terms. Okay. If someone hasn't heard of a gerontologist before or gerontology, what what is that the study of exactly? And how does that differ from from geriatrics? Okay. So, a gerontologist is someone who studies aging at any point in the lifestyle and from all different types of angles. So it could be from a biological angle, it could be from a medical angle, it can be from a social angle, philosophical, just a policy, all over the spectrum, psych psychology. Whereas a geriatrician is actually a practitioner, usually an MD or a DO who gets specialized training in how to provide clinical care to older adults. So to be a gerontologist or to study gerontology, there's no it's not a specific degree as such. No, it's not. There are undergrad courses that people can take with a gerontologic focus. There are probably master's degrees that I don't know about that would be in gerontological science. They're definitely PhDs in gerontology. I think yeah I think a lot of people that I see who sort of um say they they work in the field of gerontology are often biologists or had some sort of undergraduate science degree. Correct. And then they've chosen to study the biology of aging. Correct. Yeah. And and geriatrics. So you're both gerontologist and and geriatrician. Correct. And so geriatrics, if if I was a medical student, what would the pathway look like for me to become a geriatrician? How long would that take? Actually, it's not too bad. It's the general in the United States, four years of medical school training, three years of residency, or in family medicine, which is also a three-year residency. And from there, you do one additional year of training specifically in
geriatric medicine. And do you think that the public have a pretty good idea understanding of the role of a geriatrician and where they fit into health care and the kind of the the breadth of their their knowledge and role in improving the health of elderly? I would argue no. I would say actually very few just because there's so few in the United States for example. So, just about depending on what estimate and what year you look at, but somewhere around 7, 000 practicing board-certified geriatricians across the country. I would also posit to say that because there's not a lot of education in geriatric medicine across our United States medical schools that there are a lot of doctors in practice who also don't really get a sense of what geriatricians do. So sometimes what they if they know about a geriatrician and let's just say we're in the inpatient setting, they might call for a geriatrician's help and think that it's all for social reasons as opposed to understanding the true differences that happen with biological aging and how that might affect both diagnoses and treatments. You said to me in in an earlier conversation that we had that there there are less geriatricians today I think in in the US than when you first started. That's correct. Yet I have to imagine there's more elderly. That's correct. So what's going on there? And is that how is that affecting clinical care? Just like in geriatric medicine when we think about conditions that affect older people, we use the term multiffactorial. There's not just one cause for why we might see a manifestation of an illness or disease in an older adult. Same idea with why there are so few geriatricians. I think one is people in medical school are not exposed to geriatric medicine because there's so few. And so if you an internal medicine teacher once told me if you don't think of the diagnosis you'll never make the diagnosis. Same thing if you never encounter a
geriatrician why would you think to become one? So that's one. Two, I think that in previous years it's it's not cool. It's like not competitive. It doesn't have some cache. Like if you say I'm a dermatologist or I'm a cardiologist or I'm a neurosurgeon, whoa, that's that's something special. But guriatrician, oh yeah, that you take care of old people about to die. Like, you know, so I think it's that kind of identity of what people think a geriatrician is like. And then I think they're not the highest paid specialty in the setting in in the United States. So uh so compensation when medical school education has been increasing in costs. So I think uh that those are some good reasons is built into that this this kind of idea that that many of us hold in society that just getting old is it's a bit depressive and and late in in life you know how much can I actually do when these conditions are a result of of aging will I be able to make a difference yeah I think that's the that's that's kind of the standard by which people think right that um and I think I've been really lucky in my career in that I've been able to live and watch patients over even decades how they do and I have been convinced by them that it doesn't have to be that way it can be but it's not necessary so but the overriding images are such that uh people tend to view the negative and they might hear someone say getting older is you know, not for sissies because they might be facing loss of function, things that they used to do that they can no longer do, things like that, but there's a lot of positives about being able to survive into old age. Also, you shared a story that I heard
elsewhere about an an elderly man named Ralph. Oh. which seems to have you've carried it with you and it seems to have I guess in some ways kind of influenced the way in which you you see elderly people today and perhaps gives you you know I guess greater appreciation for for them as humans and and able to see them as as a human. That's probably true. So that was when I was age 10 and my mother took me to a local nursing home along with other students in my fifth grade class. She was PTA president and this was some an activity that we could get out of class and go to a nursing home and help residents with their art projects and we would get to go multiple times during say a semester. So the person that I tended to work with was a an older man named Ralph and I didn't call it dementia at that time but clearly he needed my help and trying to do the art projects as instructed. one of the art projects I was helping him with on particular weekend uh week. I I made a mistake in the steps to make whatever it was we were making. And I yelled in the art room, "I'm getting as scenile as you are." And then we proceeded. He was he he didn't seem to respond in a negative way, but my mom sure did at driving me home at the end of the day. And I think that caused me to really have empathy um to really think about it from that person's point of view. And so that was a gift that my mother gave me that I think uh made me well suited to pursue a medical career. Do you think we we live in an agist society? Oh, for sure. Yeah. And in what ways does that
affect the people that you see clinically? I'd say culturally depending on who that person is, the age of society has affected their own expectations about what they might get from a doctor's visit. I think just the kind of the overall expectations that people just assume that people become infirm and lose their mind and can't take care of themselves is a an expectation as opposed to not necessarily so common as we get older. And so I think those those factors that seem overriding, for instance, I teach this course. I ask students, medical students, what percent of people they think in the United States who are older reside in nursing homes, and their estimates are generally somewhere in the 10 to 20% range, but it's really like more 2 to 4% long-term care. So, we just have this idea because it's so kind of prevalent everywhere that that's what it looks like to get older, but it's not necessarily. So, if you interview people who are older, how do they feel about this situation? Cuz a lot of it seems like it's younger people, I guess, projecting on onto them about, you know, what what is it like to be old? Does quality of life deteriorate? Do we have any data where someone has been followed through? let's say from midlife into elderly and you're able to assess for them how does quality of life change. Are they are people lonely, sad, depressed or people finding joy and and are happy and do we have is our attitude towards aging simply a projection and not accurate? I'm just going to go to the 101 person year old. I don't think that that patient views thinks about it in that
way. I think he's just living his life. He did tell me he was a physicist in when he was still working and he he did say that he bought all these books on quantum mechanics and quantum physics that he was looking forward to reading. But then when he opened one of the books, he felt like he just got through three pages and then it was done. Plus, he's had some more visual challenges. So, he's seen the op opthalmologist, but they've allowed showed him that if he uses increased light, he has certain lenses, he can read. But he doesn't frame it like I am 100 and and I was thinking about this when I was 60 at all. I think he's just living his life. And he's been lucky to be pretty much um uh disease-free. How common is that though? Uh so there are studies that look at this and I can't give you the exact estimates at this point. I would say it's more common now than it used to be. But what's really struck me is that these things really apply to people over under the age of 65 such that I have seen frailty in my younger patients that where they should be thinking about this. It's not just older people. And I thought that was very preient because it really just depends. It just is that after the age of 65 we see a greater spread but it's not that frailty cannot happen earlier in life as well. I heard you share some other research on attitudes that I found really interesting that perhaps our attitude towards aging could actually affect our I think it was risk of dementia. Oh right. So that's a study that was conducted by Becca Levy out of Yale. She's a psychologist and she went back to data from the Baltimore Longitudinal Studies of Aging and they for some reason a while back when these people were in in their 30s filled out a
questionnaire about their attitudes regarding aging. So this is a while back and then in the late 1990s I think they did the genotyping for the APOE E4 phenotype which if you have two copies you're at a substantially increased risk of dementia. And she found that when she paired those initial surveys when these guys are 30 to whether or not they developed dementia in the end that those who had better attitudes towards aging had a 50% decreased risk of developing dementia many many decades later. This was not only seen in those people who are ApoE4 positive, which is a great thing because they could you could see that attitude would matter for people who are genetically at risk, but it was also true for people who didn't carry the gene. So just their attitudes kind of predicted whether or not they would develop interesting dementia later. Is that that your biology is is kind of affected by your psychology or is it that people who were more positive were more likely to engage in healthy behaviors and look after themselves? So, it's a great question. It's one of those chicken and egg things, right? So, I think for sure if people have more positive attitudes, they're probably going to have more proactive behaviors for sure. So, it's a behavioral thing, but there could be something else. It may not not it may not be that simple. And do you see that that clinically with with elderly the more positive they are and perhaps more purpose they have and joy that they have in a day-to - day the more likely they are to engage in in certain interventions and healthy behaviors. Oh, for sure. Yeah. I was just thinking because um thank you for doing your homework and bringing up these stories from other times I've been interviewed, but I was thinking about new stories that to share and I was thinking of patients who I had earlier on in my career when I was still at UCLA and I did really have a a patient who was just
lovely and then he became my patient for the next six years making it into his mid' 9s and actually suffered from worsening postures. the stuff that I study. He was somebody who got more bent over, was harder to walk as he got into his 90s and um didn't have any osteoporosis. So, he was one of these guys who had postural changes that was affecting his gate. And he would tell me, "Oh, what I like to do is I go to Costco because Costco the shopping carts are not as low, they're higher. So when I can walk all around Costco around and around Costco and get the free samples and uh have a pretty good day of it as as opposed to going to Safeway I guess where the carts would would be very painful for him. So he was someone who had a positive attitude and was always so grateful. every time I saw him, he made my day better. And uh also taught me about studies and research like why it's so hard to show, for example, a a an exercise intervention makes a difference besides not doing an compared to a group that doesn't do exercise. So because of his posture, he agreed to enroll, I think he was 90, into this three times a week yoga intervention to show that to see if yoga with back extensor strengthening could decrease his kyphosis, as we call it, this forward curvature of the spine. And he he did the whole 12-week intervention. He loved it because he was a widow and all the mainly women in the study. So it was great socialization for him. He completed the study. He came back to me in clinic and he says, "Dr. Kado, you know, I'm just really disappointed in the study." And I said, "Oh, why?" He goes, "Well, no, I really I wish I could have gone longer. I would have stayed longer, but of course these studies have to come to an end and they're expensive to run." He says, "But did you know those examiners took six weeks to have
me have a follow-up visit? Do you know how much function I lost by not having that every every three three times a week? And it I always now I was just recently thinking about the stories thinking this is why exercise studies are so hard. I'm sure the study researchers were trying to get everything lined up but they just couldn't get him in to do the repeat measurements. So he was like I got worse in that time. If you had caught me on that day that I finished the exercise session you would have seen an improvement. bit of wisdom in that. I think getting off the dating apps and into a yoga or Pilates class, Jent. Yeah. When you're working with a patient, and you just mentioned then with him, I think six or eight years, you said you were working with him. There's a popularized term in longevity science right now, health span. And I know that you see it a little bit differently, but I'm interested in as a geriatrician, what's the goal when you're working with that that patient, what what do you think is is the goal? Like if you were to do your job as effectively as possible, what's what's the outcome that that person really wants? So that's a great question and this would be true to any geriatrician who's trained in 2026 is the goal is what's important to the patient. So that's what all the geriatricians who we teach say you've got to assess what matters because what matters differs. So what matters to me may not matter to my patient and that's what you should try to elicit in a patient's visit. Uh, and sometimes people have trouble just elucidating what that means for them. But that's not age related necessarily. I think if you asked the 18-year - old what matters, they like, well, you know, a lot of things matter. I'm not sure like what is the goal? But that's what we try to say get the patient in who's a geriatric patient
to think about. And most commonly what matters to an older adult is to be able to be independent and live independently and hopefully stay in their own home. I think that's the most popular um answer. And then a geriatrician's job would be to try to facilitate that as best as possible. So to break it down and say, well, what what is it that we should prioritize that will help you stay independent living in your own home? Right. Yeah. And is that processed? The way that I'm seeing a geriatrician, what I'm hearing from you, it's almost like a quarterback. It's pulling all of these pieces of of information from different team members together and then looking at the patient as a whole. Is where I can imagine if they're just having if there's no quarterback and there's just specialists, they might not necessarily be speaking to one another and miss that bigger picture. I think guriatricians are very good at the holistic view of a person and all those factors. So the guy who coined the term geriatrics was back in 1909 physician I think his name was Ignat in New York City and he both recognized that older people may have specific physiological challenges as they get older but a huge factor of that was also how social demographic factors affect how people age. So yeah, guriatricians know more about that, those aspects that make it possible for someone to live independently. They know more about what resources are, where someone can potentially, what is realistic, how much these things cost, all those things. Yeah. Why do you prefer healthy longevity over health span? Yeah. So the reason why I want to promote healthy longevity is because over a lifespan
people can get challenged with a health condition. So are you telling me that if you're 40 and you get rheumatoid arthritis, your health span is done because you have to go now for infusion therapies and you're at the doctor's office and it's a chronic health condition and you're at risk for all these other things. then your health span is over. I don't like to frame it that way. I think it's, you know, you have a condition, you have ulcerative colitis, which is an inflammatory bowel disease. You you deal with it. It's not fun to have for sure and it's associated risk. But can you not lead a healthy life? Absolutely you can lead a healthy life. So that's why I call it healthy longevity because hopefully you can live a long time. And just because you have a chronic condition doesn't mean that your health span is over. I like that. I think that's a nice reframe, right? Otherwise, you can be defined by the diagnosis. Absolutely. And sometimes people define you. So, I'm thinking of another patient when I was at UC San Diego and started the bone clinic. I had this lady who had terrible rheumatoid arthritis. She was 84 and she had osteoporosis. That's why she came to see me. And I think she had limited mobility and her hands were completely deformed. like she probably couldn't pick up a pen very well to be able to write. She was still working and she and I came up with a treatment plan. She continued to work. Her work was to help opioid addicted patients and she was kind of the therapist to help them become not addicted anymore. And she had a lot of passion for her work. She had no intention of stopping her work. And yes, she had to make special accommodations because the rheumatoid arthritis in her case was very deforming. But she didn't really complain of pain, although I'm sure there was pain involved. She just did. With with your understanding of what matters most, I want to bring this back just for a moment to the current longevity conversation, right? because
you're working with people who are at a stage of their life where a lot of people right now that are in that are sort of optimizing longevity. I mean the the overall goal is to as far as I'm aware for most people is to get to 70 80 90 and be in good health being functionally independent as you're talking about because you're speaking to the people this is what they want. So if you're 40 now you're likely to get to 70 80 and that's what you're going to want too, right? And you sort of alluded to it that there are things early in life that will affect that and and we're going to get into what you can do later in life and how you treat patients. But do you ever get frustrated? Are there any parts of the current longevity conversation that frustrate you that that are perhaps um shiny objects or distractions from the things that you feel really matter that that really make a difference in terms of setting someone up to be functionally independent at 70 and 80? They don't cause me anger as much as sadness. Um because I think there is such a hunger to try to optimize one's health and there's a lot out there. I mean I've uh I really don't do podcasts but I have been recently watching some podcasts and I watch these advertisements that promise so many things. I never click on what they're going to say they're going to sell you, but I listen to they sound pretty compelling. And I'm sad because there's just so many basic things that actually don't need to break your pocketbook that you can do to help your health. But I would posit that the stress if you don't have a place to live
an ability to get food um and shelter if those basic things or even I would say health care access to health care would if you have those basic things I think you can really live a long life to be and the I these are my hundred year olds who are coming through the door so it's not like you have to have a certain amount of money to access a certain amount of preventative care so that you can catch things early so that you can be treated early so that you can live a long life. In fact, I think it's I don't see that. I just see people who really focus on the importance of living a full life and feeling like they're contributing to whatever it is is important to them that tend to have the best prognosis. So in terms of elevating that across the country, reading between the lines, it sounds like addressing socioeconomic disparity is a big lever. Huge, which is this is not new. This is like world history, right? They're always the halves and the have nots. And if you don't have, you're at a higher risk of not living a long healthy life. If you have access, you're going to try to optimize that and more likely to live a long healthy life. But it's not a guarantee. And this is where the conversation, just to paint it, just to be very blunt, is where it is not as sexy because when you're talking about unemployment rates and housing and evening up the playing field, this is a privilege conversation. And all of a sudden that whole longevity discussion is very different to what's the latest compound NMN or NAD that's going to you know help me live an extra 10 years. Yeah. In fact, I think people oh don't tell me what I already don't know. Eat right uh do physical activity, sleep,
you know, you'll be fine. That's boring. Tell me what's new. tell me what I can do to extend my life by X number time. Yeah, that's that's what's going to sell. That's what they're going to get clicks, etc. But for some people, that's what they feel that they need to do. Um, and that's okay. They can pursue that if it makes them feel better and they want to believe the latest and greatest that works. The only thing I I would say is that and this is getting deeper and more philosophical is that there there is something in chasing the magic bullet that allows us to escape and not sit and deal with the feeling of like life is it's finite and I'm not going to be here forever. So that that is a really good point. I think that some people and this is coming from my teaching the Stanford undergrads that and the Stanford undergrads in the class some of them are really quite honest that death don't even say the word it's too frightening it's the unknown and so so it's easier to kind of focus on the shiny objects to try to avoid death but that you know, I don't know. I think that unless you're thinking about like an AI generation of yourself in the future that would make you immortal and then that that's important to you. I mean, people are chasing that. So, it's really and again, it's like what are the goals? What's important to people? And yeah, I'm sorry that it's not sexy, but it is actually true. And it bring me up to another story if I may share. Yes. I mean that's why you're here in that I think I was actually still in training at UCLA. So the government at that time I I did my training in geriatrics and part of it was at the VA in LA. So they give you a government
Ford car, you have my Thomas map and I'm going to all these different areas all around the greater LA County to do home visits. And I was just driving past Rita to get here. And it reminded me that on this particular visit, I went to see a veteran who was living in a home that was probably about 1, 200 square ft. So, not large. It was um a family that there was I think there were I just saw the mom and I think four kids ranging from maybe 14 to two years old and three bedrooms with a veteran living with them. So, the veteran shared the room with a 12-year - old son and then the three other kids were in another small room and then the parents were in the third room and very pristine, nice house, nice happy household and a wonderful veteran. And I thought these guys are so they're racially distinct. They were not family. And yet this family brought this man, a veteran, into their house on a date to live with them. And I was thinking about the poor 12-year - old boy. I'm like, if I were a 12-year - old boy, I wouldn't want this like 78-year - old guy living in my bedroom. You could barely fit two twin beds in the bedroom, but he was very clean. The boy was so happy. And I thought, this is a happy family. Whereas I went to other addresses and 90210 type addresses and such sad families like no life around lonely. What are certain things that can we just create what they term age friendly health systems so that no matter who you are if you touch an older adult you should be aware of what the four M's are which is what matters to them how are they moving are they mentating and are you reviewing the medication list and there's actually a 5
M there actually 10 M's but don't ask me to name them but the fifth M which is getting more traction now is multimorbidity so really thinking about how these different conditions interact with each other and that's something that geriatricians because that's who we care for, probably the best adept at doing. Let me tell you about something I've already done twice this year and am committed to doing quarterly to stay metabolically healthy. Something that reversed my biological age by quite a bit. We all know that fasting has real benefits even independent of weight loss. I've had numerous scientists on the show, Dr. Courtney Peterson, Dr. Vault Longo talk about this, but actual fasting is difficult. And to really activate repair processes, you need to go multiple days without food. And that's the exact problem that Prolon set out to solve. Prolon is a 5-day fasting mimicking diet. You get plant-based soups, snacks, and drinks that keep your body in a fasting state while you're still eating. It was developed over decades of research at USC's Longevity Institute. And what I find most compelling, it's designed to nudge your cells into autophagy, the cellular cleanup process that won a Nobel Prize back in 2016. Clinical trials have linked the program to fat loss while importantly protecting lean muscle and to improvements in visceral fat levels and metabolic markers. And it's super simple to do. Each order comes as five boxes labeled by day. There is zero planning needed. You just open the box, eat the food across the day, and your cells will gradually shift from build mode to repair mode. If you're ready for your own metabolic reset, for a limited time, Prolon is offering the Proof listeners 15% off sitewide, plus a $ 40 bonus gift when you subscribe to their 5-day program. Just visit prolonlife. com / theproof. That's p r o l o n l i f e. com / theproof to claim your 15% discount and bonus gift. We talk a lot on this show about
important biomarkers like Apo B and blood pressure, V2 max, etc. Here's one that most men have never measured. Sperm health. Possibly the only biomarker that nobody volunteers at dinner. I did a test recently and I am pleased to report back that the boys are there in numbers and swimming well, very well. Swim Club have shared some of their own customer 90-day results and they are striking. One man nearly tripled his total sperm count from 217 million to close to 600. Read that the way that you'd read any before and after. This is an individual customer, not a controlled trial. Not a promise, but encouraging nonetheless. What's not in doubt here is the science of the timeline. Sperm takes roughly 72 to 90 days to develop. So, what you're doing now turns up in a sample a few months from now. If you're not where you'd like to be, there is a real window of opportunity to work with. That's the thinking behind Swim Club's 90-day protocol developed with Stanford urologist Dr. Michael Eisenberg. Clinically studied ingredients at effective doses in one daily dose, not a generic fertility supplement. Male factors are involved in roughly half of infertility cases. So gents, it's time for us to be proactive. For listeners of the show, Swim Club is offering 25% off your first order when you use the code the proof at checkout. Head to swimclub. co / theproof 00: 35: 26. 310 - - > 00: 35: 26. 320 align: start position: 0% 00: 35: 26. 320 - - > 00: 35: 29. 190 align: start position: 0% to learn more. What's the value that you you through your experience working with elderly, the value that that you feel is offered? It's the life's lived experience and if they're willing to share that and people are willing to listen I and I honestly think that's what happened to me. I mean I started in the field what when I was in my 20 30 well maybe 30 and for older adults and I think that the those years in
and treating and listening to patient their stories and seeing how their lives transpired over at UCLA I was there from 98 to 2012 so 14 years of taking care of people over their older years. I they started at 65 so some of them made it to 100. Watching that and how they made their decisions and their personal inner relationships, their attitudes, their behaviors, all of that. Right. There's a lot of wisdom that can be passed down. Yeah. Through observation and through through giving giving them the chance to share and listening. For sure. So you started at at UCLA, you started in in geriatrics, then you shifted to research and then back to geriatrics. What what's your kind of academic work journey looked like? Okay. So I started an internal medicine residency training and I decided upon getting exposed to research and I studied kind of whether vertebral fractures were associated with worse outcomes such as mortality because we knew that people who have hip fractures would about a quarter would pass away in the ensuing year. And we found that those who had vertebral fractures were more likely to die and that if they had more severe fractures or were more numbers 1 2 3 four and greater than five that it was a upwards curve. The more fractures you had the more likely you were to die. So that was kind of the first uh study question that had legs that then caused me to think well why are they dying and that that people who get vertebral fractures might be more bent over. And um the reason why I even thought that is because I went back to the death certificates to try to figure out why are these people dying and there was a good number who were dying of uh pulmonary related causes like emphyma or pneumonia or pulmonary ambulis. And so
thinking, well, okay, it's it's compromising lung function. And and then we were able to use a small subset of uh women who had gotten spinal curvature measured by an architect's flexi curve and show Yes, it's the curvature that was associated with increased dying. You mentioned the the four M. Yes. Is that the framework that you would use clinically with a a patient? So we realize in geriatrics and this is a credit to Dr. Mary Tanetti who was in male and really did a lot of the early work in the epidemiology of falls. She worked with the John A. Hartford Foundation um the Institute of Healthcare Improvement and I think oh a Catholic hospital foundation can't remember the exact name I'm sorry but they they realized that they're never going to be enough geriatricians to take care of all the aging populations. So what are certain things that can we just create what they term age friendly health systems so that no matter who you are if you touch an older adult you should be aware of what the four M's are which is what matters to them how are they moving are they mentating and are you reviewing the medication list and there's actually a five M there actually 10 M's but don't ask me to name them but the fifth M which is getting more traction now is multimorbidity so really thinking about how these different conditions interact with each other and that's something that geriatricians because that's who we care for are probably the best adapted. And the third one was mentating that's to do with cognition. Gotcha. Okay. So So your your work in the the bone clinic must hold you in very goodstead given how important mobility and frailty is in this population. Yeah. So I maybe I'll go back to doing just bone clinic. Right now I'm just seeing the veterans in the multid-disciplinary geriatric clinic and teaching the fellows. But I would say that was the interesting thing about
being a geriatrician and then being mistaken for an endocrinologist and then so opening my clinic to 18year-olds and upwards is that I realized that I was actually practicing geriatric medicine principles across the lifespan, not just for those over the age of 65. So I think that's right. Uh when you think about bone health, if your patient can't remember to take their medications, then it's the lost cause. You better assess the cognition of your patient and and people who get osteoporosis tend to be older. So that's a factor and guriatricians will pick that up. Whereas other doctors will just pretend like, oh well, they they can say hello, they can get here. They're dressed okay. Yeah, they're a little weird in their history there, but we'll just uh that's not my thing. and we'll just uh here's your prescription. Have a nice day. See you in 3 months. I had a couple of conversations on on bone health and osteoporosis with exercise physiologists. Oh, I know who that is. You saw those? I didn't, but I know who she is. Yeah, cuz we we've collaborated together from Belinda Beck. And then Laura. Yes. And Belinda Beck. Yes. From Australia. Wonderful work. Lift more. So, we we spent like a couple hours going over the principles of exercise and how do you stimulate the bone? I've always been interested in and and I think this this is something you'll have experience with. I'm I'm certain you will. How you apply those principles which might be very easy or or relatively simple to apply for a 30 40 50-year - old that's in good health, doesn't have sore knees, osteoarthritis, mobility issues. 00: 41: 43. 589 - - > 00: 41: 43. 599 align: start position: 0% 00: 41: 43. 599 - - > 00: 41: 46. 230 align: start position: 0% How do you go about applying those that the type of exercise, prescription, the evidence-based way to stimulate bone within a population of people that do have more injuries and aches and pains and joint restriction, etc. Well, I start where they are, but I
think this was would be a great conversation because I think Dr. Belinda Beck and I have been at bone meetings. cuz I'd come to her poster like your patients had vertebral fractures and you're having them do these things. How did you how are you sure that you didn't cause any injuries? And she's like I don't know we didn't have any complications like wow that's impressive. So I think for those who are at risk it's always best to be with someone like Dr. um Al Gian Gregorio and Dr. Beck because this is their experience. But of course not everybody can see them. So but there are physical therapists who are very much trained and have an interest in balance and will have read their studies to be able to get a sense of what they should be doing. So for me I start with every patient in the clinic just doing something very simple as to observing watching them get into the room watching them sit down asking them to stand up and all my traineees know I do this and if they feel safe and I'm stand by what we call standby assist if they can't stand up but and if they can and they've used their arms then I'll probably ask them how they're feeling. And if they're feeling okay, I'll tell them, "Can you sit down again?" And then, "Can you try to stand up without the use of your arms?" And if they do that, then pretty good. I say, "How are you feeling? Are you feeling dizzy?" And it's like, "I don't know, easy peasy." Then I'll look at their stance. And if their stance is widebased, then I'll ask them, "Could you just move your feet a little bit closer?" And then I'll keep on escalating the ask. So, if they're doing it, then it will be one foot kind of slightly opposed and then all the way in front. And then I often get, are you giving me a drunk driving test? If they do that, I'll make them do it on the other side. And if they can do that, then I ask them to lift a leg. And if they can do that, I ask them to lift the other leg. And if they can do that, then I ask them to close their eyes. And
generally, some people, I would say probably even in the 40s, may have difficulty with any of those initial steps. And so it just makes them aware because if they've come to me for low bone density found on a DEXA scan, I'll say it may not have any consequence to you, but if you fall down, you're going to be more likely to fracture. So let's let's f focus on that. And then if they're super able to do all those things, then I'll probably just rec recommend the US recommendations for physical activity in muscle strengthening. I will talk about power. I'll talk about balance. I'll talk about aerobic and kind of doing a popery of those things. If they have trouble at any of those earlier steps, so the semi stand semi um then I'll probably refer them to physical therapy. So you really kind of try and find their limit in whatever domain that is whether it's power or balance or or whatever. Can you speak to our audience here who who they might be in their 30s, 40s, 50s and they're listening to us and and perhaps they have a parent who's in their 70s and 80s so this is very relevant to them. But I think you you just mentioned power and I believe it was your research and I think I've seen this elsewhere that really stresses the importance of like how quickly you can produce force and and why is that important for someone to be training earlier in life and how does that connect to this whole frailty picture? because I feel like a lot of the exercise that I see and the programming that's done that's out there is more around like slow controlled movements and I'm not sure people fully appreciate that when we're talking about falls and how how do you reduce your risk of having that fall like you said which could could create a fracture if you have the right conditions and then the downstream repercussions of that you spoke to there's high mortality rate etc
etc so if someone wants to get to 70 and 80 and and have good power. What's the key to that? Yeah, it's doing it. It's moving. But I guess there are different types of muscle fibers and it's the fast twitch tibers that tend to go down with age and those are the ones that allow you to generate short bursts of energy. So I think it's those but I would say things that need that require kind of quick movement and reactivity jumping. So how did we assess power in the study you're referring to? I think the reason why we didn't see power related outcomes is because it was a how do you measure that? But the way we did it was with a force plate and so we could get separate the strength from the velocity and really look at the power itself and it that's that was the metric. While strength is important and how fast you move is important, it it was really that coordinated power uh variable. I think what you're saying is is consistent with what other guests have have said on this show and and Laura would would reiterate. Point being that it's not just about can you slowly move the heaviest weight possible that these other types of exercises where the weight and load might be a little bit less but you're moving quicker are complimentary and additive and important when it comes to if you have a trip can you catch yourself and while I think being proact proactive about it earlier on and and building muscle and strength strength and power is so important. I will say that it's just moving in your life, not being a couch potato. So, none of my 90 plus year olds are the ones you see on the internet and saying, "Look at they're running a marathon or they're doing track and field or they're a gymnast who can still do, you know, whatever handsprings."
It's just function. And then uh and it's it's um it's also carefully curated in that you want to be smart as you move because we do lose muscle, we do lose bone density, we may lose sight and other senses that would make us at higher risk of having a fall. So you have to be conscious of your body in space. And so I've been recently interviewed, I'd say in the past few years about why tennis is the best sport in the world. And I was thinking about that this morning because actually I saw the 79year-old who loves to play tennis but now has some issues with his knee. Um, best as in most fun or best as in longevity. Best in some longevity. The whatever the tennis association, they're getting a lot of mileage out of saying it's the best sport. But I was thinking because I think I saw two two of my patients were previous tennis players. Oldest was 90. Um I love the sport. I'm not good at it cuz I didn't. But anyway, so I'm not trying to diss the sport, but I was thinking if I could peg what I think based on experience of watching my patients, those who've done well, it's the dancers. Well, there's coordination, mobility, social, and memory. A lot of memory. So, if I had to choose one, I would say it's dancing. What about musicians? How do they do? Musicians are great, too. And if you are a wind instrument player, you've got it hands down because you have got that lung capacity and breathing. It's amazing. Wow. Yeah. That's protective. So play tennis and and take up some type of music instrumentation. Yeah, music is interesting. I I love music. I think any of those things that bring people joy because I think joy in itself is so healing in so many ways. Obviously the the resistance training
and and the just just moving your body like we're talking about throughout life will hopefully help reduce your risk of having the fall. And then the resistance training will will help build the skeleton. So if you did fall, hopefully you don't get a fracture. But I have to imagine that also part of that strategy for you is using certain medications to improve the the bone's capacity to absorb force and not break. What is Can you walk me through sort of current best practices when it comes to to bone medications? like what are the most popular ones and and most effective? Well, Simon, I'm glad you brought this up because I think the bone medications largely the besposinates have really suffered in public perception thanks to a number of sources probably the internet but also making the front page of the New York Times in 2016. Um what happened? Can you walk us through Um I think and also the Wall Street Journal I think it was a headline along the lines like fearing the worst side effects millions frogo uh the use of the number one treatment for osteoporosis. What was the side effect that so so bisphosinates were the first FDA approved uh therapy in the United States for osteoporosis back in 1995. that was the Londonate. And in about 2008, I believe it was Diane Sawyer, if people remember who she is, she she reported the news network that on TV, because we still had TV back then, that that I think it was somebody in New York just stepped off the subway and suffered a thigh fracture without falling down. And so then they started noticing that people who had been on a Londonate or the brand name Fosmax for longer periods of time seemed to be at risk of uh developing a spontaneous
fracture of their thigh bone which is really unfortunate for the field because that's you take the medicine to prevent the fracture and here's the medication looking like it's causing the fracture which in some people it does. So that caused um a lot of people not to take the medicine. Um there was also earlier in the I'd say around 2005 or six. Uh there were reports of what they call osteonnecrosis of the jaw where people would then be on this drug and then have a tooth pulled and then the po the bone in the jaw not healing becoming what we call necrotic or dead tissue in the mouth which does not sound fun you know at all. And so I think those two side effects in particular led to a downturn people wanting to take these medications because it was very well publicized. But in 2026, what we have found is, so we'll just start with the osteocrosis of the jaw is the risk of that is about 1 in 1, 000 people who are getting four times the dosage that we give for osteoporosis because it's also used in breast cancer survivors to prevent breast cancer from going to the bone and has been shown to improve survival. But they had to they at that time were getting much higher doses through the vein. For the run-of - the-mill take a pill once a week on an empty stomach with a full glass of water. They don't even have estimates. I've heard anything from 1 to 50, 000 to 1 in 100, 000. Being that bone practice was my only practice from 2008 until 2021, unless they had cancer, really didn't see a side effect except for one non-English - speaking patient who didn't even know that they were supposed to stop it once they had this problem. But it was also treatable. So really, really rare, but it did scare the dentists as well. So that if you needed a tooth implant, nobody wants to touch
it. So what we do now is we basically say, "Are you taking care of your teeth? Do you need any teeth pulled? Because if you do, you should get them pulled now. Go to your dentist, floss your teeth. If you don't have gingivitis or poor teeth, you're not going to have this complication. So, that's one. The other one with a crazy fracture of the thigh, Rick Dell, who was a orthopedic surgeon from uh Southern California, Kaiser, actually looked at every single patient X-ray that came in for a hip fracture and kind of figured out who's getting these fractures, how are they related, and he did show and publish that the longer you were on an oral bisphosphinate, in this case it was most likely fossamax or alendinate, the first one, the more likely it would be that you would have this kind of complication and it was really high in people like me small Asian thinframed females very high like nine times more so the idea is how the bisphosinate works is by preventing the bone resorbing cell known as the osteoclast from resorbing. So, it's favoring the formation of the bone with the osteoblast. And so, over time, that looks pretty good because you're having less bone loss. And even on a bone density scan, you'll see an improvement in bone density. But more important than looking at the density scans, the the multiple randomized control trials showed a decreased risk of fractures of about 50%. Um, but if you imagine biologically if you're just going to cut just shut off bone resorption forever, that for some people that's not a good idea. That can lead to more brittle bone because the the osteoclass, which is kind of breaking down bone, that that process is needed for the remodeling. Yeah. And so they've kind of shut it down. And it's interesting. I think I was at a bone meeting a couple years ago where now, and I didn't even think about this, but I watched this presentation. I
don't know if it was published yet, but they can look at the blood vessels. I never thought about it because they're so microscopic. But of course, blood vessels have to get all the way to the out exterior of your bone. But if you know, you eat a chicken, it looks pretty hard on the outside. You don't imagine that there blood vessels there, but there are. But what he showed this guy was from Germany that I think with bisphosinates that blood supply uh for some people would get more le more compromised and then if you don't have blood supply that's when you might see the beaking you so you can see radiographic changes that are concerning for possible being on bisphosate too long and so there's a physiologic reason that it happens but not in most people right not just some people and the good news is if you find out that you're at risk and the way we do it clinically is if you have pain in the thigh, we now can get some bone density scanners will scan down to the thigh to look for those early changes that would make you worried or a plain X-ray can even do it. Then you just stop the medicine and it will res it will be fine. There's the risk goes down. So that's how you think about it clinically when you're managing someone that's on bisphosphinates. So say they've been on them for like a decade. Well, I probably would take them all. I would look I'd say what are you doing about balance? I always start with what are they eating? So, we talk about diet because that matters and what are they doing? What what they're doing in the terms of the physical activity including balance whether they say I'm a self-defined klutz and I say that's a bad idea. Let's stop that. All those things first and then depending on what their family history is, what their personal fracture history is, then we go to the drug. And I spent a lot of time on bisphosinades because they're still the number one drug and they're not without consequence but every single drug that has been FDA approved since which they're amazing tools out there they all need to be followed up with a bisphosinate in the ideal world because all of them if you give yourself an injection every day say
with terraparatide that was FDA approved around 2002 that builds bone or a baloperatide which is 2017 a daily injection that also builds bone and then risoamab which is two shots a month for a year. Is that prolio? Is that the same? No. Oh, I forgot about yeah no prolio's denosimab that was 2010 was FDA approved. That's one shot twice a year. Any of those medicines once you stop them you will have an increase in bone resorption and and just like exercise if you stop exercising you're going to lose your muscle mass. So all those exercise trials whatever. Yeah. And you can't just keep keeping those bone building. You can't just keep taking those bone building indefinitely. So for Romosamab, right? No. And for the two anabolics terraparatide and abaloparatide terraparatide which was older had a two-year black label blackbox warning because with 70 times the dose given to rats. Some of them form bone tumors. So they didn't want to have people just be on it forever. But then after 20 years on the market with no real bone tumors in humans they removed that blackbox warning. So some people are taking it for longer than two years but nobody really wants to give themselves an injection every day forever. And then Albaliparide I think is still two years. Which of those different drugs reduces fractures risk the most? Good question. So I think you're getting pretty good data from the bisphosmates honestly 50%. But if you're really talking about like what mimics exercise the best, it's going to be Romizab, the latest one known by its brand name Evinity, um that you see the biggest gains in bone density. You also saw in their trial a reduced risk of not only
vertebral fracture but also hip fracture. So the two daily injections, they didn't show a reduction in hip fracture, which most people are interested in. And I don't want to forget poor thank you for bringing up I had put out prolia or denosimmab which is the once every six month injection it's a monoconal antibbody that works to prevent bone resorption as well and it was shown to be effective with no changes in the bone micro architecture over 10 years. The problem is is that when you stop it, the bone resorption starts and there's been increased risk of developing vertebral fractures after stopping. So you have to follow it up with something else. How often are you kind of deprescribing? You sort of mentioned before that you might take people off bisphosphinates. And I have to imagine that when you get a patient, particularly if they're new and they've been seen by lots of doctors, they could be on all sorts of medications. And at least my understanding is that that can be in it in and of itself a risk factor for false. Oh, absolutely. As a geriatrician and older populations, a lot. We know from large observational or epidemiologic studies that the more medications you are on, including supplements, the worse uh the worse you might do health-wise. So really, in fact, just point blank, the 100-year - old I saw last week, uh, less than five medications, no no supplements, although we did give them vitamin D. So you do you see some patients that are on like a cocktail of medications where over over a decade or longer they kind of been given a medication maybe it had a side effect swelling or something and then they were given another medication for that and then something else on top of that and all of a sudden it's kind of unclear like are a lot of these medications just for side effects or questionable indic indications and
unknown drug interactions. I've had patients come to the bone clinic literally with a colar full of supplements that I think I took a picture cuz they were 25 and I thought wow one of them I actually referred for a bone biopsy because they were fracturing but the bone density was fine but I said we have to stop these supplements because I don't know what they're doing to your body but you're fracturing your bone density is fine and I've done the secondary workup it's not like you have some other underlying metal ical condition, but I really don't think these 25 supplements are helping you. Yeah. But that was hard because people, you know, people have to do what they believe in. Yeah. And she was clearly attached to those medicines. Had a very nice cooler, very stylish. That was part of her identity. It was tough. Is that tricky if they've been prescribed those by other physicians? Oh, yeah. That is true because you're almost, you know, indirectly, I guess, questioning a decision that they made and then there the patient might be confused. Should I be trusting what Dr. such and such is saying to me? Or they go back and see that doctor and that doctor's like, "Hang on, the geriatrician's taking you off that drug. I don't understand." Yes. So, you bring up a really good point. What do you do when experts don't agree? I had one who kept on coming back, too. I mean, I was like, "You're not taking any of my advice, so why do you keep on coming back to me?" She goes, "No, I like having debates with you." The optimal BMI for an older adult is probably 27, men and women, and that's more than I am. And if you get lower, like less than 22, that's a risk factor, broadly speaking. So, I think it's more about function. It's like, can you get up from the floor? If you're on the floor and you find yourself, can you get up by yourself? I don't care what weight you are. I mean, you could be pretty heavy. And if you get up from the floor and you're super heavy, I'm doubly impressed. So, if it's
hard on the joints and their other aspects metabolically, they're not healthy. They have diabetes. That's a different subject. But just weight of itself, I'm not concerned. It will come as no surprise that your brain runs on nutrients. B12 deficiency is associated with a 2 to four-fold increase of cognitive impairment. Low choline blunts the production of acetylcholine, the neurotransmitter that's most tied to attention and memory. And most people have no idea if they're getting enough of either. IM8 is a complete daily nutritional system, not a neutropic stack, but the foundational nutrition that your brain needs alongside a healthy diet. 90 ingredients at clinical doses, one single sache, methylcobalamin B12 at 200 micrograms, choline at 55 mg, saffron extract at 30 mg, which has shown cognitive and mood benefits in clinical settings. And it's NSF certified for sport, meaning that every single ingredient is independently tested and confirmed at the stated dose. No fillers and no cheap substitutions. Start today and use code simon imatealth. com for 10% off plus a free welcome kit. That's code simon imatealth. com. It's not just the things that we can see, taste, smell, or feel that shape our health. Something slipped by completely undetected. BPA from plastics and receipts. Pifers from clothing. Yes, your favorite active wear. Mercury from fish. These are just a few of the everyday items that contain compounds linked to hormone disruption, cognitive decline, and illness. Yet, very few of us measure and therefore understand our cumulative exposure over time. Tory and I are planning to have kids sometime in the next few years, something that we're both very excited about. So, recently, we've been looking under the hood a bit more closely, doing what we can to optimize fertility, pregnancy, and most importantly, give our future children
the healthiest possible start. On the male side of the fence, evidence increasingly links exposures like heavy metals, peers, and microplastics to poor sperm health. To get these chemical and environmental exposures tested, I use Function. 160 plus lab tests a year, including heavy metals like lead and mercury. With Function, I get a clear read on where I actually stand today. Check your health the way that I do. Function provides 160 plus lab tests for just $ 1 a day and member pricing on advanced imaging. Join at functionhealth. com / simonhill 01: 06: 38. 069 - - > 01: 06: 38. 079 align: start position: 0% 01: 06: 38. 079 - - > 01: 06: 41. 349 align: start position: 0% and use the code simon25 for a $ 25 credit. So, what do you do clinically to to kind of um reduce that confusion or keep the other doctors happy? Well, I feel like I'm less concerned about keeping the other dogs doctors happy. I love to engage in conversation if people want to talk about it just to see maybe I'm missing something. In fact, I had this one chiropractor who was fantastic who's written a big book about and has done so so much research in bone basically because he was an athlete and was surprised to find out at a young age that he had osteoporosis and really thoughtful but I think there was a point where where um you know you have to engage in the conversation but it's okay to come up with different inclusions uh conclusions cuz we don't I think you have to find the ground truth for yourself and what you feel comfortable with at the end of the day so that when you wake up the next morning you know you feel okay um and that's up to the individual but for the patient I just share my what I think is my honest point of view and they can either say I think you're full of crap goodbye or they can say actually what you're saying makes sense and can you help me with this and then then we we have a
working relationship and what I down through starting the bone clinic or even at UCLA when I was in the bone clinic at an orthopedic hospital, it was really, you know, talking about what matters to the patient and then really saying, let's come up with a plan that works that makes sense um to you. And this will include, you know, what are you eating? You know, what what kind of activity are you doing? Let's come up with a med medication regimen. Maybe it doesn't fit for you now. Maybe we delay it for a few years. See how you feel. If you really improve your balance, you're not having any falls, you having any fractures, let's get you off the medicine. Maybe you don't need medicines. Or maybe, you know, you just prove that you just had another fracture and and we we have this problem. Or maybe you have a parathyroid problem. So, we send them to a surgeon for a parathyroidctomy and that really helps. So, yeah, it's an individualized plan for that person. But you've seen clinically deprescribing can improve someone's functional independence. Oh yeah, that's one of the things that I think some of my fellow geriatricians often teach about because they will show that someone may get referred to them say maybe age 82 and it's just slowing down in so many ways physically, cognitively, and maybe like their own expectations. It's time to go into the sunset. But then they also knew them when they were 75 and they did all these things that they were so active with. So they were just wanting a second opinion and so just a simple review of the med list and the indications and then uh tweaking the medications they can become a completely different person. Are there any classes of of drugs that you would say are more commonly overprescribed than others that you find yourself kind of deprescribing more often? I think sleeping aids are a big one because they're all a lot of the sleeping aids are meant to be short-term. They all say it, but then
people want to sleep and so they end up longterm and those are often benzoazipines and benzoidazipines can affect one's thinking and risk for falls. So that I'm seeing that less now, but that was big one. The other one in the 1990s, proton pump inhibitors became over - the-counter. So a lot of people would be on the first one was a merazole and they would be on that for a long long time for reflux. So some people do need it for reflux but there have been since studies that have um associated long-term use with worsening cognition, worsening kidney function, um worsening fractures and bone. So they can affect nutrient absorption. Right. So they decrease the pH um balance in the acidity of the stomach which can affect absorption. Yeah. You mentioned nutrition before. Without us going into a two-hour episode on on nutrition here, and I'm not a nutritionist, by the way, but what would you say are the biggest challenges that this population has when it comes to eating a healthy diet, getting the nutrients that they need to support that goal of functional independence? Well, that again depends. what I'm seeing in the veterans actually if they still have a partner they're eating pretty healthy because I asked them what they're eating and they're like, "Oh yeah, vegetables. Yeah, he hated them." But they usually can find some some vegetable that they'll eat. So it's not just meat and potatoes. Women do better than men when their partner passes away. I think that's been the lore. Yeah. But like my 100-year - old vet, his wife died of Alzheimer's, right? So there's exceptions to that rule. Oh, for sure. But on the whole, are there certain aspects of nutrition that you tend to focus on more or emphasize with with the patients? Oh, for sure. So, minimally processed
foods, things that don't last on your shelf for more than, you know, a few months. I think when you say what are the biggest challenges I think and I don't I'm from Pelto so we don't we're pretty lucky up there but I think access is a huge aspect and and if you're more homebound it's harder to get fresh fruits and vegetables but in general if that's the case because I did when I was at UCLA I'd had some fixed income patients where we would talk about healthy fast food choices relative to others like well I don't want to name names but just different colors on the plate. And also instead of canned fruits and vegetables, canned have a lot of sweets or a lot of salt. Better to do frozen if possible if if you have limited means. And are you finding that you're it's more common you're worried about patients being overweight and consuming too much energy or is this a population where consuming not enough energy becomes more prevalent? It's so interesting you asked that question because I haven't been asked in a while, but even when I was at UCS, uh, UCLA, I think especially for women, there's this idea you get post-menopausal weight gain and then you never get it off and you're 65, 70, and you just feel like I can't wear those clothes I used to wear. And I tell them, are you kidding? That's your insurance policy. If you end up in the hospital, they never let you eat. And being skinny is actually a risk factor for doing poorly. So, I have never really focused on BMI or body mass index and saying, "Oh my gosh." In fact, if you look at large observational studies, the optimal BMI for an older adult is probably 27 men and women, and that's more than I am. And if you get lower, like less than 22, that's a risk factor, broadly speaking. So, I think it's more about function. I don't. It's like,
can you get up from the floor? If you if you're on the floor and you find yourself, can you get up by yourself? I don't care what weight you are. I mean, you could be pretty heavy. And if you get up from the floor and you're super heavy, I'm doubly impressed. So, if it's hard on the joints and their other aspects metabolically, they're not healthy. They have diabetes. That's a different subject. But just weight in of of itself, I'm not concerned. So, interesting thing to think about then is the emergence of GLP1s now. Oh, yeah. Clearly, there's there's going to be some benefits from long-term health with if you take someone who was obese and and get rid of the metabolic consequences of that or reduce them. But there's equally there's a conversation to be had about what about long-term body weight for that person and is there potential for increased frailty later in life. So, G GLP1's for diabetes and and that I think we have good long-term data. We should feel reassured by that. Um, we just don't have the long-term data to know for sure. We have we I think the people who work in this field have reason to be optimistic, but we just don't know. While we're on nutrition, I found it interesting that you've you've also studied the the microbiome and nutrient status as well as microbiome and sleep. So, how how does a a geriatrician end up doing a microbiome study or microbiome studies? That's called opportunity. I also was uh getting to know doc uh professor Rob Knight who is a leader in the field of the gut microbiome. microbiome gut project I think he led. Yeah, the American gut project. It was his work actually that and some of the regular listeners will have heard this research discussed where he looked at what predicted the greatest diversity in the microbiome and it wasn't someone's specific dietary label. It was
like how many unique plants they had in their diet across 40. 40 a week. And then when he when I saw that from the American Gut Project, I was like, can I even name 40 different fruits and vegetables? But then he said, you can put in spices, herbs and spices. Yeah. And then I realized actually I am hitting 40. Yeah, it's pretty good going. Yeah. So the research that you did, what did it reveal? Firstly, let's let's zoom in on on the vitamin D side of that research because I thought that was quite interesting. Oh, yeah. That blew my mind. So basically at UCSD I was seeing my patients in the bone clinic and so many would come in pretty educated and they'd say well I know that I need my I need vitamin D to absorb my calcium in my gut so how much should I take of each? And so I thought oh yeah I remember hearing another lecture that they're vitamin D receptors everywhere in our body and they're really prevalent in the gut. So maybe I can propose to Eric Orwell that we should measure vitamin D levels because they had stored serum. And then I'll get Rob Knight to help do the analysis of the gut microbiome. And we got the study approved. And what we found was uh Eric brought in the ex world expert in vitamin not the world expert but a very wellrespected scientist in vitamin D measurements from Belgium University of Leven. And so he did the measurements but not just of the 25 hydroxy vitamin D level which is the storage form that your clinician doctor will measure but also the 125 dihydroxy vitamin D which is the active hormone and then the metabolites of the vitamin D as well downstream. And what we found was that the actual storage form the 25 hydroxyd had nothing to do with the gut microbiome. there was a flat line, but those men who had more diversity within the bacteria of their guts tended to have um better active vitamin D hormones
and more evidence of vitamin D flux suggesting like flexibility of the system. So that's an association, but is a hypothesis that the microbiome is directly affecting like the activation of of vitamin D from a storage to an active form? So it's a great question. And so when we figured out how to write this paper, since they were both measured at the same time, you really can't talk about cause and effect. And so it's that chicken and the egg problem. But what we know is that they are very closely related. And that was very exciting. And these men, by the way, were from six areas ac across the United States. Portland, Oregon, UC San Diego, Palo Alto, actually, which was lucky because then when I moved to Stanford, I'm still involved with study. and then University of Minnesota, University of uh Alabama and University of Pittsburgh. So from six areas across the country. So we could really look at sunlight for example because that was one of the things I wanted to see. And certainly the people who lived in the sunny more sunny days per year by the weather maps they had higher levels of 25 hydroxy vitamin D just as one would expect. But um in terms of 125 across the board there were no differences by latitude. So what it taught me was that our biology is smart. So it's going to figure out what it needs and the men were equal across the ways. And so um I I think vitamin D metabolism is super important for bone. Um but um yeah, that we we're we're using a clinical marker that works, but there's still a lot more research that needs to be done. the people in that study who had more diversity and had higher levels of the active vitamin D, was that level considered was that clinically better, clinically meaningful? That's a good question. So, we couldn't look at that directly in this study. An interesting study, like an an add-on study to that that I'm thinking
could be to take a group of men that are supplementing with vitamin D and then randomize half of them to eating more plants to increase the diversity of the microbiome and see if that increases their active vitamin D levels versus the placebo. Yeah, that would be interesting. Actually, a good number of these Mr. Ross men were already taking vitamin D. of course they were pop uh they were participating in a an osteoporosis study so they were already kind of educated to think about their bones so we have a I we did um adjust for vitamin D's use and actually a lot of the men were very few of them were deficient um so what's your at this stage even though it's an association what's what's your kind of clinical takeaway or how how does that affect you clinically so for bone health actually I I it's Not just these data. I think I'm using data from the UK bio bank where they've really tried to figure out there's so much on vitamin D. What is it actually doing? And and then the randomized controls trials that showed no benefit in terms of cardiovascular disease or cancer or falls or fractures and everybody's like oh it's the wrong study just like the WHI for hormones. It's the wrong study. But I think that vitamin D is very important and in certain scenarios if you look at the the some of the work that's come out of the UK it does seem that it's important for bone health for sure. We already know that but you it's really for those people who are deficient and um that was a big um a complaint regarding the vital trial the big one but they did measure vitamin D in 12, 000 people. It wasn't like they I think so they did measure it. Maybe it wasn't 12, 000. I I think it was some subset of the 25, 000. And when they subseted into the people who were deficient to see if there was a difference between 2, 000 versus nothing or placebo, there wasn't a a benefit for
fracture. But I think most endocrinologists are like, well, scratching their heads, we know vitamin D is important for bone. So we still check it. And if they're deficient, we try to replete to 30 to 50 nanograms per deciliter. But apart from bone, the UK has it convinced me it is important in immunity. So it's not a bad thing. There's as long as you don't get toxic because you can have toxic effects, some level of vitamin D supplementation is probably safe. So if if not all men are converting the same amount of the inactive stored form to the active and we're measuring the stored form, how do you actually know clinically if they have enough active? Exactly. And we don't and the thing the whole reason why physicians measure the storage form is because it's stable. And the 125 will be measured by kidney specialists when they because most of the 125 comes from the kidney in the conversion in the kidney from a non-active form to an active form. So they'll measure it. But this this kind of work really is harder to do in individuals as opposed to populations where you get kind of an average um reading. What were the findings uh in that kind of body of research on on gut health that were related to sleep that Yeah, that was another fun one. So, uh these men uh wore armbands for a week, which is not the gold standard for sleep, but um they we also had in a subset uh the wrist activity, which in the sleep world was considered more of the gold standard for objective measures of sleep. But we had both the questionnaire, a validated questionnaire of sleep, self-reported sleep and aspects about their sleep habits as well as this armband measure for seven days. And what we found was it was the men who had the most regular sleep patterns, meaning they tended to go to bed at the same time and wake up at the same time every day had the most diverse gut
microbiomes. And what I didn't mention and don't want to emphasize too much, but there are certain bacteria that considered kind of more favorable to gut health and those are the butyrate or short - chain fatty acid producing bacteria and we found the pattern in both studies, the vitamin D study as well as the sleep studies. Interesting. what are the most common neurological conditions that that you you would be treating or or kind of helping patients manage that that's affecting their cognition. So that would be in the broadest class called a neurodeenerative disease of which probably the most famous is Alzheimer's disease. So definitely Alzheimer's but then there's also um what we call mixed dementia. So a lot of the people who develop dementia will have underlying cardiovascular disease as well. And when you do neuroiming, you can see evidence of small vessel disease that would be consistent with a vascular pattern. And I really think it's more and I'm not a dementia expert, but I think it's more of a continuum that you could see. So there are kind of classic Alzheimer's um but I think there is definitely a vascular component throughout. I would say that the manifestations of how people present with a dementia are very variable. What are the most effective kind of tools in your toolkit that you have to to help someone's cognition improve if they have mild cognitive impairment or Alzheimer's? Is that even possible? So, let's just start with mild cognitive impairment, meaning that their 01: 25: 44. 790 - - > 01: 25: 44. 800 align: start position: 0% 01: 25: 44. 800 - - > 01: 25: 48. 709 align: start position: 0% their function is pretty much conserved. So, by that I mean maybe before they could keep a list of 10 things they need to get done in a day and it's all in their head, but now they realize they should write down the 10 things or they
may get to number five and they'll never remember what 6 7 8 9 and 10 were. So if someone's in that form where they're still functioning because they're making accommodations to whatever it is that's bothering them, then I ask them and I do this even advanced dementia is to ask them to challenge their brain. So even with advanced dementia, are you speaking directly with the patient or are you speaking to a caregiver or how does that look? It depends. So sometime so often times there better be a caregiver because a dementia patient will not reliably remember but I speak to the patient first even if I know that they're not going to remember because they are my patient. The caregiver is the caregiver. So I will tell them what I think might help them. I will also give them the possibility that some of their function could improve by participating in certain behaviors. And a lot of times that's just taking a walk, you know, maybe it's getting off out of the couch. Maybe they tell me, "Oh, I read." And I say, "Great. What did you read?" In fact, I this happened last week when my um 79year-old with a knee replacement who played tennis. A lot of times people get very vague, but because I said, "Well, now you can't play tennis, so what do you like to do?" And he said, "I like to read." And I said, "Okay, great. what do you read? He he looks at his wife and the wife is, by the way, 14 years older than he is and she's still working and his caregiver. And she he says, "Well, I like to read two magazines. I don't want to name them for patient privacy reasons, but then I asked, okay, well, I used to read these magazines, so I knew the two of them." And then I asked him, "So, what what was on who was on the cover of the last magazine?" He named it and he talked about it. And so I was really imp impressed because the wife was very concerned about his cognition in the past two months and basically he's had a
knee replacement that's gone bad and this is something a geriatrician would think he's not just has dementia he might just actually have a smoldering infection in that knee. It was swollen and maybe we need to take care of the infection because maybe if we treated that his thinking would get better. And by me asking just those very specific questions made me have faith like their neurons are still working in there. He's pretty precise. He remembers what the the magazine cover was for this last and I actually went back after because I don't read this magazine anymore. What is the latest? I checked it. He was right and he knew what it was. He knew the person. Sometimes the the presentation of mild cognitive impairment or dementia could be something else. Yeah. That's what we have to rule out. What other things like hearing loss or Yeah, it goes hand in hand. So sometimes, yeah, sometimes some people are just not social. So that it's a good protection to being not social. It's just not to hear. So is that dementia? Hard to know. But um mood mood is a big one. Delirium is another big one. So medication over medication is a big one. Yeah. Do those brain exercises do they just slow progression of disease if someone does have mild cognitive impairment or they do have Alzheimer's? Is there evidence looking at, you know, doing certain exercises, stimulating your brain in a certain way, whether it's recalling certain words or doing a crossword, does it can it reverse pathology at any stage? Yeah. So that's a great question and this is what I I actually think nutrition physical intervention activity intervention trials and then these ones that try to look at change in cognition they're really technically difficult studies because for a geriatrician
I want to care about the endgame like are they actually better I don't care if they get two points better on some scale out of five skills that they've done it's more like how is their function improved and so I think they're probably are studies that show some benefit. I would say just anecdotally, and this is how we used to practice medicine back in the 1960s just by patient experience is is that they're kind of two factors, right? It's like I can see learning happen uh from visit to visit and but maybe what's more important is the patients perception of how they're doing because that's what really I'm only there forever at VA. We're lucky we get like an hour, hour and a half. But for shorter patient visits, it's hard to really get a full snapshot of what someone's life is really like. Why is that more important? The perception. Like what does that mean to them? Fundamentally, that means uh that they feel better. And isn't that what a doctor's job is? Is to make people feel better and they feel more hopeful probably. Yeah. For the the 50-year - old listener who is fearful of developing dementia, perhaps their mother or father has it. What do you think are the most effective things that someone can do in midlife to to help lower their risk of experiencing that later? Probably to believe that that's not necessarily their destiny. What I found a lot is people if they've lost a parent, whatever age that parent died, if they pass that age, I mean, it's like a big deal because they're like, that's kind of when I expect that I might not live because that's when my parent died. So, same thing with kind of dementia is that we don't fully understand all of its causes for sure, but we do know that
there are behaviors, namely number one is still physical activity, getting the blood circulating. The other thing is really believing treating your brain like a muscle, you know, in that you've got to exercise it in challenging you to build new neural pathways. And I think the research has shown that we can do that and we can do it at a very old age. So it's really engaging the brain and not just becoming a robot doing the things that you do all along because that I think leads to constriction and then eventual loss of function faster. So to a 50-year - old, it's really engaging, living in the moment, not thinking in the future and the past, not getting overly anxious about that's that's my destiny, but saying what can I do and believing that if you do it, you could actually change your destiny to something that you want. What do you do in the circumstance where you and I have to believe that this this happens inevitably. You're you're dealing with an an elderly person and perhaps they think their best years are past them and they don't really have a lot of purpose and and joy and so maybe it's difficult to find a concrete answer to kind of what matters most to to that person. How do you work work with that person? You know, it's hard to write a prescription for purpose. It's it's different to writing a prescription for a medication for bone or telling someone to do a balance exercise. But when someone's lost the joy for living, I think the best thing that people can do in that case, if that's really like it's not a mood disorder, there's not something that can be fixed like chronic pain that can be addressed, social isolation, if it's really something where the core is and this happens like I am ready like I don't even know why
I'm on this earth anymore, then it's from a practitioner standpoint an acceptance of that that's where they are and um giving them the validation that if that's where they are, I'm not going to change that. All right, let's land this plane. What's what's one thing you want to leave the listener with today from from our conversation? If one thing was going to land, I think if one thing is going to land, it's I think um just being self-aware of who you are. So, I'm going to go digress a little bit, but there's a a married couple from Harvard. One of them, Jerome Groupman, wrote for The New Yorker, wrote a book, and Pam Hartzman was is his wife who's an endocrinologist also at Harvard. And they went around the circuit around the early 2000s talking about a medical mind and how they they compared and contrasted their experiences. So for Jerome Groupman he said I grew up in a family where there was already early cardiovascular disease and I saw how the latest in inventions of the time stints literally saved my parents' lives and so I'm in for the latest the newest the greatest medical inventions because we are at the precipice of continuing greatness and precision now we're precision medicine precision health. So that's really exciting. And then Pam was like, "Well, my parents lived well into their 90s and our thing was stay away from doctors and I would rather uh you know, grad um kind of go towards more just natural healing, not not supplements, but you know, just natural healing, letting the body, believing the biology, doing the healthy health behaviors and things like that." And so I think people have to find their comfort zone of where they are. And a
lot of the PhD scientists now in the longevity space, I mean, they really believe. So I've been on other podcasts saying I don't I wouldn't do NAD, but you know, really smart scientists not only believe it that it's going to work, they are ingesting it or injecting it or whatever and selling it and making a profit. So we're not talking about conflict of interest in terms of profit, but I mean I think they believe it. So at least they're doing what they're saying and they're selling and getting rich off of. But I think because of my 30 plus year and seeing in medicine and being in the aging space with Roy Walford who believed in caloric restriction and watching kind of the iterations and then it's rveratrol and then it's this and that and the other rapid mice that biology and aging is just so complex. um we want to distill it in to easy bins and what can we do but really I know people are looking for something sexy but if they're really looking towards a long healthy life I can't I I would say figure out who you are and maybe if that makes you happy like injecting that stuff and you have that wills to do it fine would I as a treating physician ever recommend it no well thank you Deborah this has I think great and and I really I value your your voice in this conversation around longevity and healthy longevity as you put it and certainly that distinction between health span and and healthy longevity is something I'm going to walk away from this conversation with. Well, thank you for putting on such a thoughtful podcast. Uh I'm I'm learning more about the field now. There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify. Finally, thank you for showing up and the effort that you're making to
take control of your health. I look forward to hanging out with you again in the next episode.
Transcript auto-generated by YouTube. Verbatim — duplicates intentionally preserved.
Her work in geriatrics is a reminder that aging well is not a single intervention. It is a practice of preserving capacity. The strongest protocols are often quiet ones: movement that protects bone, sleep that steadies the brain, relationships that create meaning, and medical decisions made with enough context to avoid both fear and excess.
Kado makes a precise distinction. A chronic condition does not end the possibility of a healthy life. Healthy longevity asks a better question than whether every marker is ideal. It asks whether you can stay engaged, independent, and connected while working honestly with the body you have.
That shift matters. It turns longevity from a performance metric into a durable practice. The goal is not to avoid every sign of age. The goal is to build enough resilience that age does not take more function than it has to.
One of the most striking ideas in the conversation is the link between how people think about aging and how they age. A more constructive view of later life has been associated with a substantially lower risk of dementia decades later.
The mechanism is not magic. Beliefs influence behavior, stress physiology, social connection, and whether someone keeps participating in life. A person who expects decline may move less, withdraw earlier, and stop practicing the very capacities that protect independence.
Healthy longevity is not the absence of challenge. It is the preservation of agency inside challenge.
Strength matters. Power matters in a different way. Power is the ability to produce force quickly, and it is central to catching yourself when you trip, climbing stairs with confidence, and moving through the world without hesitation.
This is where exercise becomes more than fitness. Balance drills, resistance training, dance, and movements that ask the body to respond in real time all train the nervous system. They preserve the conversation between brain, muscle, bone, and environment.
Bone is living tissue. It responds to load, hormones, nutrition, inflammation, and medication decisions. Kado's discussion of fracture risk and osteoporosis treatment points to a broader principle: fear should not make medical choices for us.
Rare risks deserve respect. So do common risks. A fall, a vertebral fracture, or a hip fracture can change the course of later life. The most careful path is informed, individualized, and guided by a clinician who understands both benefit and risk.
Geriatrics often uses the 4 Ms: what matters, medication, mentation, and mobility. The framework is simple because it needs to be useful. It keeps care focused on the person, not just the condition.
For anyone building a longevity practice, the same frame applies. Know what you are preserving. Review what you are taking. Protect your mind. Train your ability to move. The details can be sophisticated, but the foundation remains beautifully clear.
A chronic condition does not mean your healthy life is over. — Dr. Deborah Kado
Train the capacities you want to keep. Balance, power, attention, and purpose all respond to practice.
Practice balance before you need it. Use simple progressions, stable support nearby, and consistency over intensity.
Add power thoughtfully. Fast sit-to-stands, stair work, dancing, or supervised resistance training can help preserve real-world function.
Make medical decisions in context. Bone medication, vitamin D, sleep concerns, and deprescribing all deserve individualized clinical guidance.
