Buck: Welcome back to the show, everyone, today. My guest on Wealth Formula Podcast, he’s one of us. He is Dr. Rob Hamilton, a guy who is part of our wealth formula community. He is a physician with a medical degree from the University of Colorado. He’s board certified in emergency medicine. But more importantly, in my view, he’s one of the smartest guys I know when it comes to this whole longevity medicine movement. And and for those of you who came to our last event, you were probably completely blown away by his talk as you gave this, you know, tremendous overview of longevity and the literature. And basically it was stuff that I kind of find more interesting than even money right now. So, Rob, welcome. Welcome to the show.
Rob: Thank you. But very happy to be here.
Buck: Yeah. So first of all, let’s talk a little bit about what got you interested in, you know, because you were practicing emergency medicine. You were doing this kind of thing. How did you get into this wellness and longevity space And, you know, and what what continues to interest you about that?
Rob: Well, you know, mortality.
Buck: Yes, you’re right.
Rob: One of the things that happens in emergency medicine is, you know, we see the worst of the worst, right? Yeah. But one one corollary to that is most of the worst of the things you see are more or less preventable or at least delay. Right. You see a lot of heart attacks and strokes and things like that. And you realize after a period of time that chronic disease is killing all of us one way or the other and the chronic diseases of kind of modern civilization, things like hypertension and, you know, dyslipidemia, high lipids, strokes, heart disease, as the end result. I mean, not all of what we do in the E.R. is gunshots and trauma. A lot of it is just dealing with the the ravages of daily life. So I you know, I turned 40. That’s when you you know, the night shifts get longer and harder and your mortality starts to creep up on you. I started noticing some abnormalities in my own personal lab work that hadn’t been there before. And I said, Well, what’s going on? Why is my CRB so high? And that’s sort of sent me down some some rabbit holes into, you know, looking online and reading and learning things that I never learned in medical school, things about diet and exercise and nutrition and sunlight and circadian biology. And then sadly, my, you know, a number of things converged. My father got cancer and I started to realize, gosh, we’re all mortal here. And I looked at the struggles he went through, and then some of my colleagues were starting to get into this anti-aging and regenerative medicine period. So I went some formal education.
Buck: Yeah. And that’s great. So, you know, let me let me just jump right into it, because one of the, you know, in your talk was very popular. And I was and again, I’m not just trying to pull your chain here. I just I was really impressed, like with, you know, your your presentation. You sort of body of knowledge in this space. So, you know, the problem with the space right now is it’s all over the place, right? Like, there’s no well, there’s no protocol at all. There is no you know, there’s there’s not a lot of you don’t have like randomized control studies. You’re never going to do that if you’re trying to get into longevity space because you’ll die by the time it’s over. But you put it, you kind of created a little bit of an infrastructure to explain this. Do you want to do you want to kind of dive into that a little bit?
Rob: Sure. So, you know, like you say, there is so much information out there, it’s overwhelming. It’s literally you could you can spend hours. And in fact, I have and probably continue to do so reading and tracking down stuff. But as I started to get out of my emergency medicine practice and get more into a wellness and preventative practice, I realized that what people need is, number one, education. And number two, direction. And I try to distill that information on some various trainings I went to. I came up with what I call the four pillars, or maybe the five pillars actually, of anti-aging medicine. And so one of the things I did when I put together that talk at the Wealth Formula Network conference was just to try to distill it down into these are the five things to look at that.
As of now, we have either good solid clinical evidence or at least directional evidence telling us this is the right approach. And of course I’m always looking at this stuff, constantly reading all the latest stuff that I can find and trying to understand how to do it better. But, you know, I feel like I’m directionally accurate on these five pillars. Yeah, so the five pillars, because I know that’ll be your next question.
Buck: Yeah. What are those five pillars?
Rob: Our number one chronobiology. So yeah, if you want to dive into that a little bit, you know what it boils down to is circadian rhythms, okay? Things are driven by the clock, right? And not the clocks because it’s early, but by the natural rhythms of our planet, by the sun and the moon and the tidal cycles and things like that. But for most people, it’s really daylight and darkness.
Buck: Mm hmm. And sleep and sleep would be in there, too, presumably is huge.
Rob: And, you know, there are guys like Matthew Walker out there that are getting real popular in the sleep space, talking about what you can do to improve your sleep. And I’ve read a bunch of his stuff, look through his stuff. But yeah, I mean, the bottom line is we all are biologically meant to be awake during a certain part of the day and asleep during a certain part of the day.
And if you look at the literature in medicine, you realize that for example, night shift workers have a much higher rate of the diseases that kill all of us eventually. Yes. Their disease and. And such cancer. Sure. And why is that? It’s because we’re messing with our circadian rhythms. So, you know, the corollary to that is if you want to be healthy, you’ve got to pay attention to your circadian rhythms, right? The circadian rhythms we were all designed to have.
Buck: Are those associated I mean, it’s getting a little technical, but with with cortisone levels, like in.
Rob: Absolutely, yeah. Cortisol. In fact, if you measure cortisol, cortisol is is a is one of the hormones that’s very strong, what we call a diurnal rhythm. It’s got a rhythm of the day. In fact, one of the things if you look at one of the things that we think helps wake you up in the morning is your cortisol starts to rise. So in a “normal person” who is sleeping normally and has a normal schedule, whatever that means in this modern world, you know, right around 5 a.m. quarters, all starts to rise, raises your blood pressure and there’s a bunch of molecular confirmation changes that happen in the brain is your cortisol rises. And in fact, one of the things I used to see in the air is, you know, one of the most common times of day for a heart attack is that first few minutes. It’s early in the morning. Yeah, I as part of our shift, you know.
Buck: Yeah, we’re talking about cortisol leads to not only, you know, increase increasing arms and all that that in the morning that you talked about, but also from a chronic perspective, you know insulin resistance more likely heard of, you know, becoming a diabetic and all those kinds of things and it’s all ultimately kind of related to something that in modern society we’ve not really taken very seriously, which is sleep. Right. And just to I think that’s like a very good place to just focus on for this part. And one question I have for you is, you know, having read that literature, having read, you know, Matt Walker’s books, what are just a couple of things that maybe you feel like people don’t know that would be useful to know about sleep?
Rob: So probably I mean, you could go I go on for a long time about the importance of sleep in different phases of sleep and so many people complain of difficulty sleeping. And I think one of as I mentioned, from the circadian biology standpoint, one of the most important things you can do to protect your sleep is protect your eyes and by extension, your brain from blue light after sundown, or at least as you get ready to go to bed.
And the reason for that is because light in the blue end of the spectrum produces or suppresses the production of a really important sleep hormone called melatonin. And melatonin is produced in the pineal gland and helps put you to sleep. So one of the simple, cheap tricks that you can use is to wear, for example, blue light blocking glasses as the sun goes down. And people I tell a lot of people that a lot of patients notice that when they start to get more and more sleep at night now it’s hard to stay up til 3 a.m. and watch Netflix if you’re falling asleep with your glasses. But guess what? You shouldn’t be doing that anyway for your health.
Buck: Blue light. Is that just screens or is that even just like, you know, ambient light from your light bulbs and that kind of thing.
So sadly Buck, it’s everywhere I the screens is huge. In fact you notice Apple has come up with night shift for their phones. There’s a number of applications for computer. One is called flux that will temper the blue light. But most of us have gone to indoor lighting. Now that’s produced by LEDs because they’re cheap, they’re energy efficient, they last forever as opposed to the old incandescent light bulbs. But the spectrum of LED lighting, the so-called white light coming from LEDs usually has a huge spike in the blue range. And so unfortunately, I think as we transition more to LEDs for our indoor lighting, we’re finding we’re going to find more and more trouble sleeping. Yeah.
Buck: The incandescent the incandescent light bulbs are those safe, so to speak, or they’re going to have some level of blue light as well.
Rob: They’re safer. They’re not entirely safe. And I have a tremendous graphic I can probably pull up and send to you or emailed to you that shows the light spectrum from different bulbs. Yeah, but incandescents are very energy efficient, right? They get hot. A lot of the light comes off in the red and the yellow end of the spectrum and less in the blue, right?
And then halogens are different. They have a different spectrum. But LEDs typically come up with a lot of energy. In the blue. They don’t get hot. That’s another great thing about them. You’ll never start your house on fire with the label bulb. But the sad thing is you’ve got a lot of blue light exposure there.
Buck: Let’s move on to the next pillar.
Rob: Yeah, you’re right next to our diet, nutrition and supplements. I put all these together because, you know, everybody knows that what you eat is really important for your health. And if you look at historically, what the rates of chronic disease and obesity and things like that in the US are, you’ll find that prior to 1980 they were a lot lower than they are now. And that’s despite a deluge of information about, you know what you should eat low fat, low cholesterol, low carb, gluten free. And it’s a very confusing space. And I’m always looking for a better way to recommend what people eat to enhance longevity. And the other thing that’s important about diet is what you don’t eat or when you eat in fact, almost weekly now, you’ll see in major news sources things published on intermittent fasting.
You know, our bodies were not designed to be fed small amounts of high calorie density, low nutrient density foods. 24 seven And so going through the drive thru at your local fast food restaurant at 2 a.m. is terrible for your health. Sadly, sign your body is not meant to eat and particularly the kind of stuff you get there. So pillar two is really focused around what you eat and when you eat.
Buck: So it’s interesting to me about this topic is that, you know, in medicine, we, you know, we’ve been giving people not yummy, but medical world has been giving people a very different story for for years and years. And they, you know, the food pyramid and there was obviously some you know, some reports about how that food pyramid was really affected by, you know, the sugar industry and that kind of thing I’ve seen. But, you know, it’s funny because I remember being in I think it was like third or fourth grade. And the the teacher, my teacher said we were doing this thing on food pyramid. And he’s like, can anybody think of the, you know, the perfect food And based on this? And and he said, well, it’s pizza, of course pizza’s got everything here and that.
Rob: Oh, yeah, exactly the same, the same thought.
Buck: So I think the thing to focus on there Right. Is in tell me if you agree with this. But I think the biggest difference in terms of, you know, what we used to say and what we know I think is true right now is that sugar is bad. I mean, sugar is kind of the devil. Correct?
Rob: Correct. And many of the foods that have been regarded as, quote, healthy, unquote, for many years basically break down to sugar. So it comes down to carbohydrate consumption and whether simple sugars like sugar, like sucrose, you know, table sugar or really complicated but relatively simple sugars like high fructose corn sirup, which I can’t imagine who would argue that’s good for you at this point.
There’s data or even just these really complicated carbohydrates, sugars like bagels, you know, for example, I mean, and they’re extremely high in caloric density, but they have almost none of the nutrients that your body really needs. And so overconsumption of those is very bad.
Buck: So the you know, it’s funny, even even a few years ago, like I’m talking about maybe three or four years ago, I was talking to my physician at the time. He since retired and he was a good guy. And I, you know, wasn’t really into all this stuff. And I brought up this concept of intermittent fasting or or intermittent feeding or whatever you want to call it, you know, time restricted feeding. And he said, Well, you can do it if you want, But, you know, it’s really at the end of the day, it’s calories in, calories out ends up that that’s probably not true. Zap, is that right?
Rob: Yeah, I agree. I mean, the data, again, there’s so much good stuff both in the medical literature. If you look and now in the literature about fasting and time restricted feeding, I mean, when you’re fasting, your body is undergoing a process called autophagy. Autophagy is basically recycling your body’s says there’s no new energy coming in. I got to figure out what to do with the garbage in the system and recycle as much of that as I can for energy.
And so if you never fast, you never undergo autophagy in your mitochondria, those little batteries in your cells, those little power plants, your cells, you know, you think of fasting as calling the herd of bad mitochondria, right? So when your bad mitochondria aren’t, when there’s a lot of energy to feed everything in the body, the bad side is the body breaks down, the bad mitochondria and recycles the components to make new and good mitochondria. The problem is if you never fast, if you’re never without food for a period of time, you will find that those little bad mitochondria just kind of hang around and they just may never be, you know, the herd gets weaker by the weaker parts of it.
Buck: The concept is sort of it’s almost Darwinian, right? Like, I mean, you think about this concept of what what we call forms is comes up a lot, which is you know, challenging the body to a certain degree, but not too much where you get, you know, you get killed by it. So being hungry sometimes is a good thing because your body needs needs to be hungry in order to process some of these things. And for sure that’s the concept. So intermittent fasting versus time restricted feeding, I mean, really is there and I know I hate to put you on the spot because you’re just talking to me, but is there any difference in terms of the effectiveness? Yes, because when you talk about intermittent fasting, it’s sometimes it’s like people fasting for like a day, full day or like two days of the week versus restricted time feeding, which is more what I do, which is like I basically eat between, you know, one in, you know, eight and no calories other than that.
Rob: You know, I think so. That’s a good question. The challenge with fasting is we know there’s great things it does for the body. We don’t know what the right dose is. Think of it as a drug. It’s a very, very powerful drug. It does all kinds of amazing things for the body. We don’t know the right dose or the right strength to give you. So, you know, there are clinics where you can go back and you can pay them to give you a pitcher of water every day and monitor your vital signs. And after three weeks, you know, your high blood pressure might be all better, for example. Yeah, not specifically, but as as a patient. But this is so there’s a spectrum from what you’re describing time restricted feeding, say eating for a 6 to 8 hour window a day to, you know, maybe fasting for 24 to 36 hours once or twice a week to, you know, some people recommend a, you know, five or seven day fast quarterly.
There’s a really interesting product at all by a longevity scientist named Valter Longo at UCLA called Prolong. It’s what they call a fasting mimicking diet. And he claims to have created the same effects of fasting while eating small amounts of certain macronutrient foods. And I use that with some patients who’ve had tremendous success, although.
Buck: That diet itself is it’s you might as well be fasting. Right?
Rob: Yeah, it’s, it’s pretty awful. But in some people it works better for than others. But yeah he’s got data on this just showing people do better with cancer. They tolerate chemotherapy better after three months of doing this for five days a month. So 15 days total in three months. Now it’s not really aimed at weight loss. So people generally there’s a little bit weight, but they’re their C-reactive protein, which is an inflammatory marker goes down, their lipid profile tends to normalize. I mean, just five days, once a month of this time restore or this this calorie restricted diet they call the fasting mimicking diet does really amazing things for people. Okay.
Buck: So this this is not something you have to keep doing, like every day for good. It’s it’s like five days per month.
Rob: That’s the fasting mimicking diet.
Buck: That’s interesting. Okay.
Rob: But then I think the idea of time restricted eating daily makes a lot of sense because if you look at the and this is why it’s so hard to get data because their studies are all over. But if you look at the alternative, which is you eat constantly all day long, we know that’s bad for you. That’s what’s leading us to so many problems. So if you can restrict your feeding to 4 to 6 hours a day, then your body’s essentially fasting or, you know, for the other say, 20 or 16 to 20 hours, whatever it ends up being, that’s it. We think that’s a good thing. Again, to be.
Buck: The complicating factor. Not complicated, but the confusing thing about this to a lot of people is, again, this is really kind of different from what I grew up believing to be healthy, really be like take eat several times a day, small amounts. And that’s how you keep your weight down all that but it’s it’s it’s the opposite. So it’s like, man, I hope this doesn’t change again. You know what I mean.
Rob: You’re right. But also think of how things have changed since you grow up. I don’t know. When I grew up, you know, when we we generally had three meals a day. Yeah. And there wasn’t all this snacking built into every day. I mean, now when you take your kids to soccer, you know, the parents draw lots to see who’s bringing the the snack for the soccer game. You know, like at school, they have nutrition breaks, you know, halfway between breakfast and lunch. And so a lot of things have changed since the seventies. In the eighties, you know, people eat more frequently. There’s a much higher availability of really equal quality food. We also live in a very different environment. Our environment is, you know, you also weren’t staying up till 2 a.m. on Instagram, and I hope you’re not now, but I that stuff all plays in.
You know, if you talk about circadian biology and then you talk about eating all this stuff all day long, then you start to wonder why now like 30% of kids are now obese. In fact, I think just the other day, the American Academy of Pediatrics says that something like 30% of kids are obese and they’re starting to recommend bariatric surgery at age 13 and GLP one and yeah. The world has changed a lot in the last 50 years. Yeah.
Buck: Okay, so let’s go to the next pillar.
Rob: Sure. Exercise. So, you know, like fasting exercise. You almost need to consider a drug to the point where it almost is a necessity. A prescription should be given. And then people say, well, what and how much? And, you know, there’s a huge range of what exercise is from, you know, walking your 10,000 steps a day to running a marathon.
Buck: Is there any data that certain kinds I know we often hear these days about high intensity type workouts and that kind of thing that might be better than others?
Rob: Well, one thing is very clear from the data is, number one, the higher your VO2 max, which is your aerobics capacity, your ability to do kind of aerobic exercise. And that’s a test that, you know, they hook you up with a mask on your face and measure your oxygen inspired in your carbon dioxide output. One thing that’s clear is the higher your VO2 max, the better your ultimate longevity will be.
So we think based on that, that some level of cardiovascular exercise, aerobic exercise that helps to maintain and increase your VO2 max is very valuable and required. Know whether that’s high intensity interval training. And that seems to be all the rage right now. And I think the reason for that is it’s efficient, right? Everybody’s pressed for time. If you can go in the gym and get a good workout and 20 minutes of intervals, that fits most people’s schedules.
But you know, you also find that people who are out doing stuff at a lower intensity all day long, like walking or doing physical jobs, can also get good aerobic fitness. But the pushing you’re pushing into high intensity is good periodically for sure, because you do want to keep that VO2 max up. The other thing that’s really clear is resistance. Exercise or some kind of weight training is absolutely critical as people age good muscle mass helps with keeping your metabolism where it needs to be. It also is really important for mobility as people get older, like it’s fine to be 90, but if you can stand up and you’re in a wheelchair and you fall over and you break your hip, the first time you try to transfer from the chair to a bed, then what does it matter? Right? So you want to be able to get up and walk and then go upstairs and things. So resistance training is so critical as people age for longevity.
Buck: And that’s a good point you bring up too, just to circle back to that a little bit, which is, you know, people if you if you go in a room and you ask a bunch of people if they want to live to be 110, actually not as many people would raise your hand as you would think. And I think it’s because people are imagining what you would be like at 110. Yeah, and that’s not what we’re after when we’re talking about longevity. We’re talking about this concept, this potential that through behavior, through exercise and ultimately pharmaceuticals, that we may be able to say, you know, 100 years old is the new 70 or something like that, and live like a 70 year old for a period of time. Right.
Rob: Right. Well, what we really want to do and this is where it’s this is kind of where I fall with most of our patients is we can’t prove that anything we do increases your lifespan yet, and maybe we never will. Let you say the controlled studies are not there and it’s going to be really hard to do that.
Humans are too complicated. But what we’re trying to do is increase what we call your health span, right? I want you to live the most vital life doing the things you want to do, whatever those are, as long as you can and then die quietly in your sleep, you know, or at least not have a prolonged period of disability because of aging. So you’re right. Nobody wants to live to 110, probably if they’re told, well, you’re going to be in a nursing home bed with Cuba, this all serves a feeding tube. But if I could be 110 and, you know, taking a walk every day and going to dinner with some loved ones, then you sign me up.
Buck: Yeah, for sure. Exactly. Yeah.
Rob: It’s health span of most Everybody’s looking for more so than lifespan.
Buck: So let’s move on to the next pillar.
Rob: Sure. Next pillar is this is where we start to get out of the lifestyle sort of interventions. You know, the chronobiology, the diet exercise and into something where I think a medical doctor or some kind of a practitioner can be helpful and is hormone replacement therapy. So, you know, men and women both are programed, if you will, to lose our hormones as we age.
So women go through a period of time called menopause, which, you know, they refer to as the change of life. And if you talk to a lot of women about it who’ve been through menopause, they’ll tell you it’s like falling off a hormonal cliff. You know, everything changes almost overnight. You know, usually it’s within a six months or a year period of time.
Rob: And that’s when women lose the important what we call sex, steroid hormones, things like testosterone, progesterone and estradiol. And once that happens, their risk of heart disease goes way up. Their risk of osteoporosis goes way up. You know, that’s when women really start to age quickly. Now, men have a different thing. We go through what we now call and pause, which is a generally a very slow decline over time.
And there are a lot of hormones involved. But the key one in men is testosterone. And as a man’s testosterone starts to decline, all kinds of things start to happen. And, you know, things like loss of energy and sleep and inability to gain muscle and worsening body composition and mood instability and inability to concentrate and focus and decrease libido and all kinds of things that never are things you want to have happen.
But the challenge in men is they happen so slowly over time, sort of starting in our forties and continuing for the rest of your life that we’re just told by our doctors, Hey, you’re just getting older, you know, just live with it. That’s what happens when you get older. It turns out that we can very safely replace hormones in both men and women in a medical monitor fashion and restore a lot of that vitality. And by extension, most of the studies show and and what seems to be happening is we can put off some of those chronic diseases, things like osteoporosis, you know, like that.
Buck: I’m curious. So one thing I would I want to just kind of drill down on a little bit is this idea of hormone replacement therapy in women. Again, this was something I remember gosh, I remember in high school and maybe it was college or something. It was college. And I hear about people trying to decide whether or not like parents, whether or not they were going to have that kind of treatment or not. It was really not clear. Like doctors, a lot of doctors were telling women not to do this. And it seems to me like this is probably one of the biggest mistakes we’ve made in the last, you know, 20, 30 years.
Rob: I think that’s very true. So the back story that I can give you pretty quickly is that there was a big study back in the early 2000 called the Women’s Health Initiative, and they looked at hormone replacement in women and essentially the hormones that they used were drugs, not what we call bioidentical hormones. So not to sound, again, too conspiratorial, but there’s not any money in marketing testosterone, ultraviolent progesterone. Those are biologically available compounds and there’s no patents. You can’t patent them. But what you can do is you can take, for example, estradiol and tweak it chemically and now it’s a drug and you can patented and instead of being $0.10 a dose, it’s $2 or $10 or $100 a dose and then you can market. And so this Women’s Health Initiative study used these synthetic hormones to investigate whether or not the symptoms of menopause could be improved in women.
And they found, in fact, that they decreased their risk of cardiovascular disease and stroke and some other things, and they got better. Some of those perimenopausal symptoms, like night or night sweats and hot flashes got better. Unfortunately, they also found that a lot of those women got breast cancer. And so what happened is the newspapers published big headlines. You know, hormones cause cancer in women. And so whole generation of doctors and women said, well, I’m not prescribing those things. Yeah, but, you know, if you drill down and look at the bioidentical hormones, in other words, the same compound that the body makes and expects to see and the ones that we give and most of the people that are doing hormone replacement now give, there’s no data showing increased risk of cancer and there’s a ton of data showing good things happen. And more important to me than the data is the experience. I mean, I have patients coming in literally every week or two saying, you’ve totally changed my life, you know, thank you. And I’m telling my sister and my friend and my daughter and my, you know, coworkers about it.
Buck: On the men’s side of that is there and, you know, obviously this is not as well studied, but is there any evidence that testosterone replacement actually helps with some of the chronic disease issues like, you know, cardiovascular disease?
Rob: Oh, yeah. There’s there’s a lot of there are lots and lots of studies on this. And, you know, of course, like any study you can find a counter study, right, that says the opposite. So but but men with low testosterone are much more likely to die sooner of cardiovascular disease. They’re much more likely to get osteoporosis, you know, much more likely to suffer from mood disorders and depression and and things like that.
Obviously, libido and sexual function are issues that diabetes is way more likely in men with low testosterone. And in fact, almost every diabetic you’ll ever meet has low testosterone. And maybe as a corollary to this disease, not as the cause, but dyslipidemia or, you know, the type of cholesterol findings we don’t want, our blood panel is way more common with testosterone.
And in fact, testosterone helps treat all of those things. The big thing that men worry about with testosterone is prostate cancer. And that’s based on some very sketchy anecdotal stuff from 100 years ago where we discovered that men with really bad prostate cancer, we could put it into remission by castrating them, which doesn’t sound like much fun. Yeah, but, you know, since then that’s been looked at extensively and it’s actually been discovered that, first of all, testosterone doesn’t cause prostate cancer.
Men who have very low testosterone have a higher likelihood of high grade prostate cancer when they have prostate cancer. And the current consensus that most urologists agree with is if you have low testosterone, get it treated. If you have prostate cancer, get it treated. But, you know, testosterone doesn’t cause it or it worse. There are some very advanced cases where we will, you know, essentially destroy a man’s testosterone production with drugs like Lupron. Those men are miserable. Most of them, if they don’t die within a couple of years from their cancer, would like to die anyway because they’re so miserable about their testosterone, so low. So I think it’s very safe. And it’s and, you know, doctors think it’s surprising. And we’re seeing this every day in my practice is young men, you know, used to be testosterone replacement.
You know, we when I started doing this, I mean, I’ve been doing this for that long, but, you know, ten, 15 years, 12 years, ten years, I guess now, you know, it was 45, 50 year old guys. Now we’re seeing 30, 35 year old guys coming in.
Buck: Now, is that does work? Do you think that that’s a change in in demographics of who’s got this or do you think this is just about self-reporting?
Rob: It’s a little bit of both. I mean, I think demographics and, I think it’s awareness. Right. And but I do think there are more I mean, gosh, there was just something published not long ago about sperm counts going down in men and multifactorial stuff that’s leading to that. You know, plastics in the environment and BPA in your bottle. And so I think I think we’re seeing more and more men who are probably having lower testosterone at a younger age. And also they’re more aware because there’s more information out there on the Internet. I mean, I just had my assistant call me yesterday and say, hey, I got a 27 year old here who has low testosterone. Can we treat him?
And I’m like, oh, my goodness, Yeah. You know, it used to be that was a rare thing. And that was something send to an endocrinologist and we probably will still send them to an endocrinologist because there’s there are other things that need to be worked up in someone that age. But I’m not surprised anymore to see a 35 year old come in with testosterone of a total testosterone of 300, whereas it should be, you know, 800 or 900.
Buck: What do you what do you treat it? I’m curious. You know, there’s probably a lot of guys who are aware of what their testosterone levels are generally. I think that these step medical established and still has a pretty pretty high threshold for for actually doing hormone replacement. You know, I think it’s like below 300 or something like that. Right. Isn’t what they typically have been have been taught. Yep. But what is what’s what’s your threshold and why.
Rob: Well so we don’t look at the range itself. So the range for example at the lab we use is 250 to 1100 and I think it’s nanograms per deciliter. And so most doctors will look at that and say, well yours is too 61. It’s higher than 250, don’t worry about it. Because like you say, the medical establishment has long said, hey, you know, as long as you’re in the normal range or in the normal range. Well, those of us in the anti-aging field believe there is an optimal range. And it’s not just a belief. There’s a lot of studies showing that men do best in what we would call the top quartile of that. So most men feel best their risk of disease, you know, those those immediate and chronic diseases is lower when their testosterone is in the top quartile. So that’s somewhere between, say, 9100.
And then the other thing that we do, which is different than a of practices, is we measure actually the free or the bioavailable testosterone because total testosterone can be, say 800. But if most of a man’s testosterone is bound to something called sex hormone binding globulin, which is a common protein found in everybody’s blood and goes up as we age and goes up with exposure to various toxins and estrogenic substances and this, that and the other, Your total testosterone might look fine. It might look like it’s 800. And your doctor might say, hey, that’s great. But if you were bioavailable or your free testosterone is in the bottom part of that range, if I can bring it back to the top of that range, you’ll feel better. And again, I have people, patients, men coming in very frequently saying, hey, you know, now I finally feel like I did five years ago and now I have their motivation to go to the gym and work out or the energy or now when I get home from work, I don’t just crash on the couch and, you know, go to bed at 8:00 or whatever.
Buck: I’ve heard some people worried, like younger men who who have it for infertility. Yeah. And is that is that permanent in fertility just while they’re on testosterone?
Rob: It is typically well, they’re on testosterone. So when we give a man exogenous testosterone, essentially the brain shuts down the production of testosterone and by extension, also can it doesn’t always decrease a man’s sperm count. And so we want you know, we tend not to like treating younger patients for that reason. But then there are alternatives that can help maintain their fertility.
But typically, when a man goes off testosterone, their body doesn’t forget how to make it. It doesn’t forget they need it. It just takes about 2 to 3 months to return them back to kind of close to where they were.
Buck: Got it.
Rob: So I have patients they do I need to be on this for life. And I say no, as long as you want, you can be on it. You can get off at any time. You’ll just go back to feeling how you did.
Buck: There you go. Yeah.
Rob: Fertility is an issue in younger men. And there are there are other medications and hormones that are used to to, you know, mitigate that problem when it’s an issue. But I also I mean, guess what? So strong is not birth control just because I’m giving you testosterone. Now. That’s a good point. Make sure you take adequate precautions if that’s not your goal.
Buck: That’s right. There’s one more pillar, right?
Rob: One more pillar is and this is kind of the new one. This is the drugs. This is where we start to get into the the real potential medical interventions for so-called anti-aging. And, you know, this is a tough one because most of these drugs are repurposed drugs for other diseases. You know, interestingly, if you go talk to the FDA, they don’t regard aging as a disease.
You know, there’s all these diseases that sort of come with aging, but nobody has sort of or I won’t say nobody, but overall, nobody’s come up with a drug that treats the so-called disease of aging. But the most prominent drugs in that space that are being studied currently and I think are really worth considering, depending on where you are in your life span and health span are one called metformin.
I know people who are familiar with medications may say, well, that’s a drug for diabetes. But it’s interesting, diabetics have been taking metformin for many years. It’s a very inexpensive drug. I mean, you can get a month’s supply for three or $4. It’s crazy cheap. And yet there is some pretty compelling data that shows diabetics who are on metformin actually die less frequently of some of the diseases of aging than non diabetics and diabetes. And yet diabetes is a known risk factors just say cardiovascular disease. If you put a big group and this has been showing a big group of diabetics on metformin versus an age matched population of controls, we know diabetes leads to cardiovascular disease. And if you’re not treating those diabetics with metformin, they die off a lot faster from cardiovascular disease.
But if they’re on metformin, they live longer than the people who aren’t on metformin who don’t have diabetes. And so that’s led to looking more carefully at what metformin does. And it turns out it has a bunch of different mechanisms and it looks like it it does have some compelling data suggesting that it potentially can extend life and sort of earthworms and, you know, rats and things like that.
The game is hard to get on humans, but it makes a pretty compelling case for metformin being an anti-aging drug. Now, here’s the problem. It’s cheap. It’s off patent for the last 25 years. So very few drug companies are going to want to put, you know, the half a billion dollars into studying it for that new quote indication. But there are studies going on on metformin for anti-aging.
Buck: Another one I think you’re probably going to get to is rapamycin.
Rob: Yep. Rapamycin is another interesting drug. And this is probably the one that is in some ways the most compelling. It’s a it’s used currently as an immunosuppressant drug. So people who have organ transplants. The interesting thing is if you look at rapamycin, it works directly on a really important protein in the cells called mTOR. In fact, it’s pretty funny. They used rapamycin in the to discover how your body’s cells actually how the metabolism works. So there is a protein in every cell, in every biological being from an earthworm to a human being. Now it has a protein called immature and it stands for mitochondrial target of rapamycin. So rapamycin works at this extremely targeted cellular level on a biological.
And what it does is it inhibits this tau protein. And what that does is that basically that protein controls energy balance in the body and it controls about 50 different pathways that tell the body or the cell how to use energy and how much energy is coming in and how much should be extended. And interestingly, again, it’s showing that to increase longevity in mice, rats, dogs, earthworms, a variety of primates, monkeys, great apes. We just don’t have good longevity data in human beings. Now, again, it’s used for immunosuppression in organ transplant patients. It’s off patent, so it’s relatively you know, you can get off that inversions and there’s some pretty compelling data on human beings or at least anecdotal data. There’s not going to only good long term studies, but I think rapamycin.
And then the other thing is it’s very well tolerated, doesn’t have a lot of side effects. People say, well, what about immunosuppression? I mean, that’s what it’s used for. Well, we we can prescribe it in different dosage protocols for anti-aging, and then we can then we do for immunosuppression for, say, kidney transplants. And yeah, I mean, this it’s not sort of widely accepted yet as an anti-aging drug, but there are some doctors that think it is the anti-aging drug of the future.
Buck: And that is the of the one potentially that may have the most actual research behind it, at least in, you know, maybe not human, but other mammalian or, you know, lesser animal models.
Yeah, but pretty well studied.
Buck: To your point though about, you know, rapamycin, again, this is this is a cheap drug and it’s remarkable how little you hear about it from, you know, in the longevity ecosystem compared to something like an omen or, you know in a right. Do you want to talk a little bit about those and if you think that there’s real validity to, you know, or reason to consider taking those things.
Rob: Sure. So the things you mentioned in a man and animals, nicotine, as I would say, nicotinamide minus nuclear riboside or so is ice.
Buck: You’re a bit bigger, bigger man than me trying to remember what that stuff is.
Rob: These are variants of niacin, basically, which is a B vitamin. And so the reason we think those drugs have some value is there was a paper by a longevity scientist, I believe, Harvard named David Sinclair, who realized that as organisms age the the the intracellular components illegal nad decreases and it is nicotinamide adenine di nucleotide is one of the components that is used in the Krebs cycle, which is the energy production part of a cell anyway.
So the theory is, is if we know aging is related to decreasing MTD, if we can get extra energy into the cell, it will hopefully reduce reverse aging. And so again, there’s studies in in earthworms and and they use earthworms a lot because they have a quick lifecycle and you can control all the variables. But in mice and things showing using these man and NMR products, when they can get into the cells they might raise the need levels enough to potentially prevent aging.
The reason you hear more about those, I think in the anti-aging space is because there are supplements right now. And so most of the time when you go online and you you look around for supplements, you know, there’s a lot of people out there that’ll make money selling those supplement s to you. And so you can buy these supplements.
There’s a number of companies that make them, and some of them have some pretty compelling data. One of them is, you know, founded by Doctor Sinclair and I think if I were inclined, I’d be go in that direction, for example. And I do take one of those supplements because they’re safe, they’re relatively cheap, they’re nontoxic, but we don’t have as good a data on them yet.
I think we will eventually have more data. You know, you hear more about those, I think then you hear about things like metformin and rapamycin, because those are drugs that have to be expensive in the US anyway. And a lot of doctors don’t kind of look at this space because it’s a it’s not their thing, right? I mean, they’re too busy doing surgery or prescribing blood pressure medications and but I think we’re going to see more and more on this as time goes on, as people are more interested in the longer health span.
Buck: I don’t know if you have any other major medications, but one thing I do want to touch on, because I think this, you know, just way underutilized is the thing that was known as a skin nine inhibitor. Do you want to explain what that is?
Rob: Sure. You’re going to make me remember what PCSK9 is.
Buck: So basically know but PCSK9 inhibitor, basically you don’t you don’t have to use the long.
Rob: For this right. I just trying to think of the name of the enzyme.
Buck: It’s a monoclonal antibody. Yeah.
Rob: One of the drugs, the prototype drug is called Repatha. And this is in some ways also a miraculous drug. This is a genetically engineered product. So it’s one of those drugs that came about with the advent of genetic engineering. And it’s an it’s an antibody to this protein in the liver that processes cholesterol and it lowers people’s LDL cholesterol by a huge amount with almost no side effects. And they’ve been around for about seven or eight years. So we’ve got pretty good data on safety. But the theory here is that it is almost possible at this point to certainly prevent and maybe to an extent reverse atherosclerotic cardiovascular disease using these PCSK9 inhibitor drugs. And, you know, up till now, the best way to do this has been the statins and statin drugs, although I’m sure that, you know, there’s there’s good data for various things on them and they’ve saved a lot of lives, come with a lot of their dirty they come with a lot of downsides. There are a lot of people who have side effects from statins. There are, you know, a lot of issues with statins, whereas PCSK9 inhibitors are extremely clean. They target this one protein in the liver. They can drop someone’s LDL from, say, 130 to 30 in a couple of months. And, you know, there’s actually some studies showing reversal of coronary plaques, which is pretty amazing..
Buck: If here’s a number, there’s a threshold. Typically. What is that? Is that below below 50 or below? What is that number where I’m trying to remember? Do you remember what what the number LDL number is that way if you get below that, there seems to be some reversal.
Rob: You know, I’m not sure. I don’t do primarily cardiovascular.
Buck: So that’s fine, of course, and I don’t expect you to do it. But the concept though, in and I and the reason one of the reasons I ask others because I am on a PSA nine inhibitor and you might ask, well, gosh, why are you on a PSA nine and ability of hypercholesterolemia? DNA Sure is. You know, I never, never really did have high cholesterol. I was my history of heart disease on my mom’s side. And I got paranoid in my forties and somebody put me on a statin and a statin. I didn’t feel great with the statin. And so I just kind of got off of it over time. Then I did a big story. Yeah, cardio cardiac study. I did. I did a great big, you know, thing just again, you know, for because I’m, you know, getting older and just the same reason you went into longevity medicine and just and the cardiologist introduced me this this whole PCSK9 inhibitor and the idea again being, okay, you don’t have disease and but we can artificially, in your case, suppress your LDL to such a degree that presumably you may never have to worry about dying of cardiovascular disease. And that to me is astounding, given the fact that cardiovascular disease is the number one cause of death in the United States. But but I am absolutely floored by the number of people that I know who have high cholesterol, not even like mine, pretty normal high cholesterol. And their primaries are like, it’s fine. It’s that bad. You know, a diet exercise and. Right. And completely ignore this. Peter Attia actually, who I think is brilliant, he’s he’s a podcaster, he’s a physician. And the drive I think his podcast is called he he estimates aided and I don’t know how I got this, but that cardiovascular disease would go from, you know, the first leading cause of death to probably under ten if people routinely began using PCSK9 inhibitors, which is just again, crazy to me.
Rob: Yeah, I know. I mean, I’ve heard it theorized that we could essentially eliminate cardiovascular disease. I think they’re great drugs. I mean, they they seem to have very few side effects. Most of the people that take them do really well. The big problem right now to, the center is they’re very expensive. You know, you’re looking at 500 to $600 a month and most of the insurance companies will not even allow you to get them unless you proven that you failed a statin and you’ve got documented coronary disease or this, that or the other. And so I think part of the issue is just going to be awareness. And I think as we see more evidence that perhaps we turn around some disease, that maybe the indications will widen.
Buck: Well, you would think the insurance companies at some point might feel like it’s more cost effective to prevent the disease.
Rob: And pay for a bypass.
Buck: Surgery or bypass surgery.
Rob: Or a stent or, you know, and, you know, another potential anti-aging drug I just heard it proposed the other day on another podcast by another physician I know is the new is the GOP one agonist drugs, the semaglutide and things like that as a potential anti-aging drug you know.
Buck: Which is then another diabetes drug.
Rob: Yeah, they’re diabetes drugs and they’re all the rage right now for weight loss in Hollywood and places like this because you there was a study showing you could lose 20% of your body weight. I think it was over 70, 72 weeks using Semaglutide and it alters appetite and glucose metabolism. And again, it’s this question. You know, you if you look at obesity as a potential cause of heart disease and all these other things, you think the insurance companies would be wanting you to get on this stuff so they could prevent further disease. And I’m sure at some level the actuaries will figure that out. That right, if we pay for this 500 or 800 or $1,000 drug now, we can put 100,000 in hospital costs down the line.
Buck: This one has some bad side effects, too, though, doesn’t it?
Rob: They do. They’re not super clean. I mean, people oftentimes get nausea and vomiting and reflux and and such.
Buck: Basically slows your gut down.
Rob: Makes you feel so you feel full all the time. You don’t want to eat, you feel a little, you know. But but again, for people that have been struggling for weeks, some years and have no other way to lose weight, it helps. It seems to help. And they start you know, you started a low dose and you titrate people, they They seem to be working. Yeah. I don’t know that I’d want to be on that forever. And there was also a black box warning on those for thyroid cancer. So that’s sort of. 911 for three years. So we don’t we don’t know. There’s no reported cases in people yet, but we’re waiting to see. Right. But they were, you know, on the other hand, you have people as they change their lives. So yeah, yeah, there was some really neat stuff in this field, in this place. And again, what you see, what we’re doing now for this longevity, we’re taking drugs used for a specific purpose, like these pills and arbiters, and we’re saying, well, maybe that’s going to help extend life span if we can prevent some of the diseases of aging. Right. You know, from treatment.
Buck: I want to. Yeah. If people want to come out and see you to tell us, but where your office is and stuff.
Rob: Oh, wow, we’re in far northern California, a place called Redding, the little town up near Lake Shasta. Our practice is called Prestige Regenerative medicine. Because of the type of economy in the area, we mostly focus on hormone replacement and some sexual wellness services and also some regenerative orthopedics. So things like PRP injections into joints and things like that. But, you know, we do do some of the you know, when we get somebody who really wants to dive into the anti-aging type stuff, we certainly can support that. I’ve got a couple one practitioner working with me and we we try our best to help people live the best life they can now. And hopefully with the longest, best health span, they can have been tastic.
Buck: Rob, it’s always a pleasure. I’m always texting you or emailing you my own question, so I appreciate your time today. And people people just love, you know, love what you have to say. So thanks. Thanks for that. My pleasure, Brooke. Thanks for having me.
Buck: I’ll have it. Let’s talk again soon. We’ll be right back.