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

1. 0:00 – 1:13

   Why most people age poorly: reactive medicine vs proactive “health creation”

   1. RCDr. Rangan Chatterjee0:00

      Staying youthful, strong, and mentally sharp as you age is the most important investment you can make in yourself and for the people you love. Yet so many accept physical and cognitive decline as unavoidable, doing little to interrupt the hallmarks of aging. If this is the most important investment we can make, why are so few people making it?

   2. FCDr. Florence Comite0:29

      I think we don't know enough, and there's nothing in the medical world that actually treats you proactively. It's all about you getting sick, and it's a reactive healthcare system in most places in the world, certainly in the US, and presumably in the UK. So there's no real basis for understanding what you're looking for, what you need to do, not just to prevent disease, but actually proactively reverse it and own your own health destiny.

   3. RCDr. Rangan Chatterjee0:56

      Yeah. In your book and your wider work, you talk a lot about this concept of healthy aging. What do you mean or what should we be thinking of as individuals when we think about that term aging?

2. 1:13 – 5:29

   “Pro-aging” in fantastic health: living longer without chronic disease

   1. FCDr. Florence Comite1:13

      I think we should be grateful for aging, because if we're not aging, then we've died young. And so I'm not in favor of the term necessarily anti-aging. I'm pro-aging, but pro-aging in fantastic health, so you can live life to the fullest and be vital to the very last moment. More and more of us are living beyond 100. Antibiotics brought that to the 20th century. This century, equivalent to that is GLP-1s, I believe, and we are gonna be living to beyond 100, beyond 122, I believe. But without investing in keeping our body strong, healthy, without heart disease, stroke, dementia, cancer, we're not gonna enjoy those years. So living long without health may not be as much fun as we have had the rest of our lives.

   2. RCDr. Rangan Chatterjee2:02

      Yeah. In that same section of the book, you basically reference what you have just been talking about, the kind of aliveness we all want. We want to be biologically youthful, engaged, and healthy, no matter how many candles adorn our birthday cake, which I, I really like, but I wanna talk to you about this concept of biologically youthful because I'm trying to sort of understand in my head the tension that some people may have between growing old gracefully and accepting the aging process at the same time whilst trying to stay biologically youthful. Are those two things in opposition to each other, or is it possible to do both?

   3. FCDr. Florence Comite2:48

      Well, my career has been built on it's possible to do exactly that because you do chronologically age. You do get a candle every year. But we allow our bodies to decline because life expectancy before antibiotics was much younger than it is today, and we don't invest in our health in the way we invest in finances to stay a- well and to be able to live well, right? But how-- where do you live? In your body. If you're gonna age, don't you wanna be in charge of all your facilities? Don't you wanna be able to play paddle ball, tennis-

   4. RCDr. Rangan Chatterjee3:21

      Mm-hmm

   5. FCDr. Florence Comite3:22

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

   6. RCDr. Rangan Chatterjee3:57

      What would you say are some of the most prevalent myths that exist in society or beliefs that exist out there about the aging process?

   7. FCDr. Florence Comite4:06

      The biggest myth is that you can wait. You can wait until you're sick, because we tend to reinforce that. When do we see a physician?

   8. RCDr. Rangan Chatterjee4:13

      Mm-hmm.

   9. FCDr. Florence Comite4:13

      When does a physician actually start exploring? A lot of physicians feel that by looking at your tests, by understanding what's going on at the cellular level, we can just keep an eye on it, or it's all in the normal range, and both of those statements are outrageously wrong.

   10. RCDr. Rangan Chatterjee4:27

       Yeah. The way you write and the things you talk about in terms of how you've practiced for many years resonated so deeply with me, this idea of every patient being an individual, and actually, we need to find the right approach for them, what you, you know, the term you coined, N equals one medicine, right? So I, I really enjoyed that. I enjoyed this idea that there are seven aging patterns that you have recognized, which I'd love to talk about, but also this idea that whatever we're doing, whatever we want in health, ultimately, you've identified five key biomarkers that can give us a representation of how well we're doing. I very much like that approach because I think these days there's so much data out there, and I think it can become very overwhelming. So we'll definitely get to those five key biomarkers shortly. But this idea about aging, you mentioned Michael Schneider's work and what happens

3. 5:29 – 7:41

   Aging accelerations: why decline becomes noticeable in the 30s–40s (and again in the 60s)

   1. RCDr. Rangan Chatterjee5:29

      at 40 and at 60. I've heard you talk before about this idea that it's in your 30s where people suddenly start to feel things going wrong. Can you elaborate on that a little bit?

   2. FCDr. Florence Comite5:42

      Yes. So Abbie Hoffman, I don't know if you recall who he was, uh, it ends at 30, and that's because in our 20s I think we can compensate well. We can burn the candle at both ends. We can ski all day, party all night, and still get up the next day and ski, and we don't pay a huge price for it. But as we enter our 30s, biologically, metabolically, hormonally, our system is changing. It may not change in a way that's palpable. It may not change in a way where symptoms have emerged, but we know that because we know men begin to get heart disease in their late 30s. We know women begin to put on a few pounds around their waist, and we know hormonally it's driven even if you're trying to do everything perfectly. Let's rule out the fact that in our 30s, which u- is used as excuses for the most part, real excuses, we're raising children, we have a busy career, we may have aging parents. We're coping with things, and we c- may not get into the gym. We may not eat correctly. We may not be able to get enough sleep. But if you do all of that, you are still aging, and you're aging in a way metabolically that undermines your health for the future. And by thinking that way, that's the way I began, and looking at where peak health happens, and we know that because of athletes. We know that 27 or 25 to 30 is a perfect time to have children. We're supposed to be optimal. You can still see disease, and you can still assess it in the 20s, even in the teens, and even in children, but where it begins to matter is our 30s because that's when hormones really start to decline, and that's when metabolism changes because hormones are declining, and you can't maintain muscle in the same way even if you do everything you've done before.

   3. RCDr. Rangan Chatterjee7:29

      Yeah. This is really interesting that by the time modern medicine gets involved, you are way down the road to getting sick.

4. 7:41 – 8:49

   Chronic disease doesn’t start suddenly: decades-long runway to diabetes, heart attacks, and dementia

   1. FCDr. Florence Comite7:41

      Absolutely. In fact, diabetes, heart disease, dementia, that's not overnight. It's not what happens from one week to the next. Your heart attack has been brewing generally under the surface for decades. Insulin resistance is seen decades before florid signs of diabetes-

   2. RCDr. Rangan Chatterjee7:59

      Mm

   3. FCDr. Florence Comite7:59

      ... whether it's tingling in the feet and hands, whether it's eye disease, kidney disease, any number of issues, and yet we don't look for it until we're aggressively active, we have symptoms, and they've emerged. Because medicine, the way we practice it today, is about disease. It's reactive. So we're 10, 20, 30 years down the line already, and we've been dealing with these conditions under the surface.

   4. RCDr. Rangan Chatterjee8:22

      Yeah. Here in the UK, we have the National Health Service, and that has been fantastic for many years, and elements of it continue to be fantastic, but what I don't think there has been is a recognition of what it actually is. It is a disease management service.

   5. FCDr. Florence Comite8:48

      Exactly.

5. 8:49 – 14:54

   Why ‘normal ranges’ can mislead: population averages vs individual trends

   1. RCDr. Rangan Chatterjee8:49

      And sometimes it can do that exceptionally well. It is not a health creation service, but also this idea that actually it does prevention is, is unfortunately very, very misplaced because the current NHS's idea of prevention, and I, and I get- I'd love to get your take on this, is once you hit 40, you will be invited in for a very basic blood panel, so lipids, you know, fasting glucose, um, maybe an A1c, an average blood sugar, and a blood pressure reading. If it's deemed normal, not optimal, normal, that's it. You, you just... You, and you have a blood pressure reading. You, you crack on with your life. That, that's prevention done, and if there's a issue there that they pick up, yeah, they might see you again. But I feel it's so dated, but of course, you've been practicing a true preventive model, a true health creation model for several decades now. So firstly, what is your take on what I just said in terms of what you are offered currently in the UK on the National Health Service?

   2. FCDr. Florence Comite9:56

      I can't speak intimately to the UK-

   3. RCDr. Rangan Chatterjee9:59

      Sure

   4. FCDr. Florence Comite9:59

      ... because I'm not as closely knowledgeable as you are with how they operate. I will tell you I've had patients in the UK, and I've had interactions even this week alone as I talk about Invincible and the book that I hope to get in everybody's hands because people have complained to me and said they have symptoms. They have vague symptoms. They're in their 40s, and they're not getting any direction. They've gone to five or more doctors, and no one can help them both figure it out and also put in place ways to stop the diabetes their mother had or the heart attack their father or dementia in their grandfather. And so to me, what I think about is proactive prevention, not just reactive prevention, which is what you described. And a one-time measurement is meaningless because what you have to do is look at trends.

   5. RCDr. Rangan Chatterjee10:50

      Yeah.

   6. FCDr. Florence Comite10:50

      You're told you're normal, but that normalcy, what so-called normal, is based on a derivative of average of one size fits all in a sick population because there's no telling where those blood results have come from. They're measuring a thousand, even a million people, and the ranges are broad, and you fall anywhere. It's population dynamics. It's not about you, distinctly you, and it's not about the ins and outs of where you go as you travel-

   7. RCDr. Rangan Chatterjee11:17

      Mm

   8. FCDr. Florence Comite11:17

      ... as you travel in life. And so it is similar in the US. We probably have a little more access. We've lost the art of family medicine-

   9. RCDr. Rangan Chatterjee11:27

      Yeah

   10. FCDr. Florence Comite11:27

       ... because it's gone. Most people use urgent care. But in the UK, from what I've seen, and I've counseled people about even getting an appointment based on symptoms. I tell them I, I had a young woman in her 20s who worked for me, and she looked incredibly pale. Um, it might have been her complexion, but she was feeling weak and not so well. She could not get an appointment, and I said to her, "Listen, you might wanna tell whoever you need to tell to get an appointment that you feel faint when you get up, when you go from sitting to rising. You feel weak. You feel like, um, you're, um, losing weight, and you need a workup." And so she got an appointment, and the workup consisted of a stethoscope on her chest, and she was told she was fine, and two weeks later she was hospitalized because she was profoundly anemic. And so nobody looked at... I told her the options are anemia, thyroid disease. She was only in her 20s. And so I think less is more in medicine. Like, it is not about searching for abnormalities. It's about looking for how an individual is evolving and particularly looking at an individual, not at the population.

   11. RCDr. Rangan Chatterjee12:37

       Yeah. I think the, the problem is, is that the medical system is a massive institution that has been set up a certain way, and certainly what I've seen in the UK is that when the NHS was set up, you know, many decades ago now, the health landscape was completely different.

   12. FCDr. Florence Comite12:55

       Mm-hmm.

   13. RCDr. Rangan Chatterjee12:55

       I think back in its inception days, people would generally go to their doctors with an acute problem.

   14. FCDr. Florence Comite13:03

       Exactly. In the days wh- we were taught medicine, it was a chief complaint. You come in with a chief complaint.

   15. RCDr. Rangan Chatterjee13:09

       Yeah.

   16. FCDr. Florence Comite13:10

       Now, if you're lucky enough to go once a year, you get seven minutes even in the US. What can you learn in seven minutes about a human being? So to me, a chief complaint was mostly outdated, and I don't know when the inception was of NHS. I'm, I'm sure you can enlighten me.

   17. RCDr. Rangan Chatterjee13:25

       I think, I think it was around, uh, late '40s.

   18. FCDr. Florence Comite13:28

       Okay.

   19. RCDr. Rangan Chatterjee13:28

       Uh, late 1940s.

   20. FCDr. Florence Comite13:29

       So right just after that is when antibiotics became available. Life expectancy did not incorporate chronic disease 'cause we didn't live long enough to make it a burden, to make it difficult on the individual, on the family, on the country, and so we've completely changed how we've evolved and where we're going. We're living longer but not better. So the first generation that lived longer was the Great Generation, the generation born before the baby boomers. Uh, from the baby boomers are '46 to '64. This was the generation just before that. They're living longer, but they're sick, and that has put another burden on the healthcare system. And as a result of that, we're seeing that we're waiting way too long to intervene in when someb- to, to figure out what your health, where it's going. What does your-

   21. RCDr. Rangan Chatterjee14:16

       Mm

   22. FCDr. Florence Comite14:16

       ... future health trajectory actually look like? You know, what diseases are brewing under the surface? Because to me it's like a crystal ball. You look at certain numbers. You do, um, you wear a few wearables, and certainly a continuous glucose monitor will tell you what your glucose is doing in your body based on your genetics and your heritage, which is very different maybe between-

   23. RCDr. Rangan Chatterjee14:39

       Hmm

   24. FCDr. Florence Comite14:39

       ... you and I-

   25. RCDr. Rangan Chatterjee14:39

       Yeah

   26. FCDr. Florence Comite14:40

       ... and certainly other people. Um, and so if you get that data, you can begin to invest in your own health and do it in such a way that hopefully ultimately will align with the healthcare sy- a true healthcare system.

   27. RCDr. Rangan Chatterjee14:53

       Yeah.

   28. FCDr. Florence Comite14:53

       Yeah.

6. 14:54 – 16:42

   The 5 biomarkers of “True Health”: simplifying what to track

   1. RCDr. Rangan Chatterjee14:54

      Let's talk about these five biomarkers of True Health, as you call them. I'm interested as to how you came up with these five, what these five actually represent for us, and then we can go through them one by one and sort of try and figure out what are the levels we should be looking for.

   2. FCDr. Florence Comite15:14

      Sure. Love to. So let me be clear. When I set up what I did, and I set it up as real-world data, my background is as a clinical scientist. I trained at Yale and the National Institutes of Health in Bethesda, Maryland, and there I, I was guided by brilliant mentors that actually helped me design protocols and understand clinical research in people 'cause we as people-

   3. RCDr. Rangan Chatterjee15:38

      Hmm

   4. FCDr. Florence Comite15:38

      ... are very complex. How do we figure out what's going on? In general, research is done in people where you have exclusion and inclusion criteria, even if it's 1,000 people. So you're ruling out all the, um, anomalies and issues that may complicate findings and outcomes because we are so complicated.

   5. RCDr. Rangan Chatterjee15:57

      Hmm.

   6. FCDr. Florence Comite15:57

      Right? We simplify it. So the five markers that I came to believe in were out of the work I did and the research I did, and they include looking deeply at carbohydrate metabolism, which is fasting sugar; hemoglobin A1c, which is an average of 100 days; fasting insulin, which almost nobody measures; cholesterol risk ratio, which takes the standard lipid test, but you're looking at the average of total cholesterol divided by HDL or high density lipoprotein; and the final one, which is almost never looked at, even by people knowledgeable in the field, of male hormones and female hormones, and that's free testosterone, not total testosterone, but free testosterone.

7. 16:42 – 25:00

   Carbohydrate metabolism triad: fasting glucose, HbA1c, and fasting insulin

   1. RCDr. Rangan Chatterjee16:42

      Yeah. Before we go into them in detail, one of those that people in the UK really will struggle to get on the NHS is fasting insulin, and, you know, I don't mean to get into it now, but one of the reasons I created Due Health, uh, this preventative model of healthcare in the UK, is to ensure that people do have access to fasting insulin 'cause I think it's very important. Let me put it to you, Florence, why do you think fasting insulin is such an important biomarker to check?

   2. FCDr. Florence Comite17:16

      As an endocrinologist, and when I was at Yale, I was in trip- I had a triple appointment in adult endocrine, which as you know is diabetes, thyroid, osteoporosis-

   3. RCDr. Rangan Chatterjee17:25

      Hmm

   4. FCDr. Florence Comite17:25

      ... lipids, um, and children, so I, I took care of children. I worked in peptides for both children and adults, pediatric endocrine growth-

   5. RCDr. Rangan Chatterjee17:33

      Hmm

   6. FCDr. Florence Comite17:33

      ... and development. I was fortunate enough to see every decade of life. Beyond that, I was trained in reproductive endocrine, which is the way the brain engages with the gonads, the testicles in men and the ovaries in women, and the adrenal glands. And so I felt that the reason why fasting insulin was so critical is it changes decades before we get diabetes.

   7. RCDr. Rangan Chatterjee17:55

      Yeah.

   8. FCDr. Florence Comite17:55

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

   9. RCDr. Rangan Chatterjee18:22

      Exactly

   10. FCDr. Florence Comite18:23

       ... we weren't gonna survive. Now we have Uber Eats. We can have processed food and ultra-processed food, and we're doing our body a disservice, and therefore by not looking at insulin, we're giving diabetes a chance to grow for decades-

   11. RCDr. Rangan Chatterjee18:35

       Yeah

   12. FCDr. Florence Comite18:35

       ... before we're symptomatic.

   13. RCDr. Rangan Chatterjee18:37

       I mean, I, I just wanna highlight what you just said 'cause I think it's such an important point. We've already spoken about this idea that- Modern medicine, the way it is currently practiced, is reactive.

   14. FCDr. Florence Comite18:49

       Mm-hmm.

   15. RCDr. Rangan Chatterjee18:50

       It waits until you get sick or very close to getting sick before it tends to get involved. That's the whole model. And people will have heard of type 2 diabetes. They will have heard me talk about this idea that in the UK, and I know it's subtly different in America, but the HbA1c, your average blood sugar, you know, when it's 6.5 or above, that's type 2 diabetes. That's the same in America as it is here. In the UK, once you hit, uh, 6.0, it's called prediabetes. So in the US, you hit prediabetes at 5.7, I believe.

   16. FCDr. Florence Comite19:27

       Exactly.

   17. RCDr. Rangan Chatterjee19:28

       Right? Which means, and this may surprise you, uh, worry you [laughs] I don't know until I say it to you, but there will be patients today in the UK who have had an HbA1c done, and it will come back as 5.9, and they will be told it's normal.

   18. FCDr. Florence Comite19:47

       So I think of normal as a bad word because-

   19. RCDr. Rangan Chatterjee19:50

       Yeah

   20. FCDr. Florence Comite19:50

       ... there's nothing that's normal, and it's certainly the next 1/10 of a point, which is going to happen, is almost inevitable unless there's some kind of intervention that's specific for that human being. It could be sleep. It could be food. It could be exercise. It could be testosterone. And all of those variables are so simple that, in fact, when I've treated thousands of people over the years, I have never prescribed insulin because I reverse disease even if they come in with a hemoglobin A1c of 7.9.

   21. RCDr. Rangan Chatterjee20:22

       Yeah. And also, I wanna say this 'cause I think it really frames the rest of our discussion today, you write about this in your book that as of yet you have not had a patient experience a heart attack when they are continuing on your program. That is staggering. That is the kind of thing that most clinicians would want to be able to say. And of course, you have a specific type of practice, which not everyone has. I get all those things, but nonetheless, that is very impressive to hear. 5.9, the reason why I brought that up is because it goes back to the fasting insulin point that we're making, which is, A, I think it is wrong to call an A1c of 5.9 normal, right? Because it is... You are so far on the continuum to getting type 2 diabetes. It, you know, yes, in the UK, you're not prediabetic yet, but you're, you're, you're as close as you can be.

   22. FCDr. Florence Comite21:20

       But that... What you're saying is that it's a false standard, and it is.

   23. RCDr. Rangan Chatterjee21:23

       It is a false standard.

   24. FCDr. Florence Comite21:24

       Because we're not looking at a human being as where are they trending. We're looking at a human be- being as if one number defines them, and that number is actually telling us that you are unhealthy. You're just not quite unhealthy. Do you know that the reason why 6.5 was picked as the diabetic framework was based on the fact that they found eye disease-

   25. RCDr. Rangan Chatterjee21:45

       Yeah

   26. FCDr. Florence Comite21:45

       ... very prevalent at 6.4? And even in the US today, when you hear commercials about, uh, GLP-1s, you're looking at let's make it below seven, and below seven, as we just pointed out in both of our countries, is still diabetes.

   27. RCDr. Rangan Chatterjee22:00

       Yeah.

   28. FCDr. Florence Comite22:00

       So we're willing to live as a sick community and deal with it instead of having people own their own health trajectory, make decisions so that they can use changes in the way they live life, maybe medication, maybe supplement, maybe exercise, food, sleep, to actually alter their path and own their health for life.

   29. RCDr. Rangan Chatterjee22:20

       Yeah. Fasting insulin, I agree with you, is critically important because that HbA1c marker, and I'm... I know you know this. I'm just spelling it out so that everyone listening or watching gets this as well. It's this idea that that is quite late, or it can be quite late, and fasting insulin will likely in many people go up, as you said, decades earlier, way earlier when your body is having to work a little bit harder to maintain your blood sugar, and that's why I find it staggering that we don't offer fasting insulin here in the UK.

   30. FCDr. Florence Comite22:56

       The reason it's doing that is it's actually called insulin resistance. Our body and our cells are not responding to insulin. And so it's critical to think of that. Here's where a human being could make a change by knowing what their sugars are doing because you can have a perfect A1c, to set this up as a devil's advocate, which I do. I have had it for years below five, and yet if sugars vacillate high and low, both of which is not acceptable, the average can look beautiful.
8. 25:00 – 25:58

   How often to test—and why feedback loops matter

   1. RCDr. Rangan Chatterjee25:00

      You mentioned before that a one-off biomarker reading is limited in the sense that it gives you an idea of where you are, but what you're really looking for are trends over time. From your experience, in an ideal world, how often would you track these five biomarkers in an individual?

   2. FCDr. Florence Comite25:27

      If you're talking about number of times a year, I think that the ideal would be at least twice a year and maybe three to four times, depending on your makeup. And when I say makeup, I mean your health story. How are you living life beyond a chief complaint? Let's put aside the chief complaint of old-fashioned conventional medicine-

   3. RCDr. Rangan Chatterjee25:48

      Mm

   4. FCDr. Florence Comite25:48

      ... where we're treating disease, and usually acute disease, although chronic disease has now taken, um, it has now taken place in, in a way that takes much more attention and costs us trillions-

   5. RCDr. Rangan Chatterjee25:58

      Mm

9. 25:58 – 45:06

   Continuous glucose monitors (CGMs): turning invisible physiology into daily insight

   1. FCDr. Florence Comite25:58

      ... of dollars. And so I believe, though, there's a far better way to do it. You should get biomarkers on some kind of regular basis, but ideally you can manage your own sugar fluctuations. You can see if a banana raises your sugar or a cookie does, because each of us, as that N of one, is unique. And there's research out of Weizmann Institute from a few years ago that has shown two different individuals, one whose sugar can go up to 150 with a banana because of the fructose, and the other one, the banana doesn't move the needle at all. The sugar stays about 85. The other person who's, the, where the banana triggers it, a cookie does not. And the reverse is true-

   2. RCDr. Rangan Chatterjee26:40

      Mm

   3. FCDr. Florence Comite26:41

      ... of the person who a banana has nothing to do with, uh-

   4. RCDr. Rangan Chatterjee26:44

      Yeah

   5. FCDr. Florence Comite26:44

      ... you know, with their sugar. And so when you look at it that way, having the, uh, knowledge within your own system, within your own hands, so that's why I'm a strong advocate for the continuous glucose monitors, because instead of just arbitrarily getting blood and then waiting a few weeks and being told, "Oh, you're in the normal range or just about, or maybe it's a little high, you better get to the gym, you better eat better," you're gonna be able to tie exactly the way you live life to the fluctuations in sugar.

   6. RCDr. Rangan Chatterjee27:12

      I agree that CGMs can be really powerful if you use them in the right way, and there's a really nice section in your book actually where you explain to people how to use CGMs, which I, which I thought was very valuable. But I just wanna get back to this point of how often to check these biomarkers. And when I was creating Do Health and I was chatting in the, in the clinical meetings, a lot of people were saying, "No, no, w- let's just check once a year." I said, "No, guys, you cannot check these biomarkers once a year, and I'll tell you why." In my view, because some of the biomarkers we're checking that overlap with yours are amenable to lifestyle change. So the problem is, is if you only check it 12 months afterwards, you don't remember what you were eating or how you were working out 11 months ago or nine months ago. We have chosen initially at least to check every four months. Now, I suspect over time if someone is in really good shape, we could probably reduce it to twice a year. Some people we might need to raise it to four times a year because you wanna know, let's say your fasting insulin is high and your HbA1c is high, so you know that there's an issue here with my, you know, I, I may have a degree of insulin resistance. You wanna then make some changes, and relatively soon after [laughs] that, see has this made a difference.

   7. FCDr. Florence Comite28:33

      And that's the most important piece to me, because I absolutely agree that, you know, four times, three times a year to get a sense of are you making a change and what is the consequence-

   8. RCDr. Rangan Chatterjee28:43

      Exactly

   9. FCDr. Florence Comite28:43

      ... of that change. And if you can't get that feedback, what's gonna have you stick to that change? If you don't know what's happening, you're not gonna st- stick with it-

   10. RCDr. Rangan Chatterjee28:52

       You just don't

   11. FCDr. Florence Comite28:52

       ... because there's no... Right. There's no positive result from it. And yet if you know that you're defining yourself and your CGM 24/7 allows you to actually make the connection and connect the dots between the way you eat, for example, as just one example, or the way you sleep or drink alcohol, or how close to bedtime are you eating, because you wanna stop eating about two hours before bedtime to allow your body to clear me- metabolic waste from your brain and your body. And by wearing a CGM, you take control into your own hands. There's, in fact, many doctors in the United States and some very brilliant people that I've worked with, before they started working with me, tried the CGMs 'cause they were f- a fun tool.

   12. RCDr. Rangan Chatterjee29:35

       Mm.

   13. FCDr. Florence Comite29:35

       They looked like they'd be helpful. Completely confusing to them. So I think part of the issue here, too, is how we give clarity-

   14. RCDr. Rangan Chatterjee29:42

       Yeah

   15. FCDr. Florence Comite29:42

       ... to each person about what that number actually means. For some people, having wine at dinner, a couple glasses of wine, their sugar will go up high, but then in the middle of the night they'll have insomnia. That's a way of just seeing why you're not sleeping through the night.

   16. RCDr. Rangan Chatterjee29:56

       'Cause the blood sugar's dropping.

   17. FCDr. Florence Comite29:56

       The blood sugar's dropping.

   18. RCDr. Rangan Chatterjee29:57

       Yeah.

   19. FCDr. Florence Comite29:58

       And so it is life-changing for people. So while habits make a difference, lifestyle makes a difference, in, in a vacuum it really doesn't. It really can't because you don't-

   20. RCDr. Rangan Chatterjee30:09

       What do you mean by that, in a vacuum?

   21. FCDr. Florence Comite30:10

       Meaning without knowing what's really going on inside your body, you don't know that you're heading in the right direction.

   22. RCDr. Rangan Chatterjee30:16

       Yeah.

   23. FCDr. Florence Comite30:16

       You may feel better, which is great. You may get more energy if you've learned to control sleep and you're not waking up at night and you're getting adequate deep sleep. Lots of us sleep through the night and don't get adequate deep sleep. If you do get good deep sleep, even if you have only a few hours, let's say four or five to sleep or less than six, then, and you feel great, it usually means you're getting adequate deep sleep. When you get less than adequate deep sleep, less than an hour, even if you sleep long, a long period of time like 10 hours, you may not feel so well. And so there's a... We're very complex human beings.

   24. RCDr. Rangan Chatterjee30:53

       Mm.

   25. FCDr. Florence Comite30:53

       To figure out what's going on, the wearables also beyond continuous glucose monitors, for example, the Apple Watch or the Oura or the Whoop, will give us insight into your own daily patterns.

   26. RCDr. Rangan Chatterjee31:05

       Yeah.

   27. FCDr. Florence Comite31:05

       And I think that's a very valuable thing to own.

   28. RCDr. Rangan Chatterjee31:09

       I'm delighted to announce that AG1, the daily health drink that has been in my own life for over six years now, have updated and improved their formulation based upon the latest science, and to celebrate by giving my audience a very special offer. Some of the upgrades include more magnesium, which supports muscle function and improves the ability of your nervous system to relax, and also five strains of bacteria instead of just two to reflect the latest advances in microbiome science. It also contains key nutrients like vitamin C, biotin, niacin, vitamin B6, riboflavin, thiamine, zinc, and folate in bioavailable forms the body can easily and readily utilize, maximizing their potential benefits. Nutrition can often seem really complicated. What diet should we be following? What supplements should we be taking? And I think that's one of the main reasons I really like AG1. They make it really simple for you to be the best version of you. Over 70 ingredients, one scoop once a day for less than a cup of coffee. So if you wanna support your health seven mornings a week, get started with AG1, and right now we have a very special limited time offer. Your first month subscription will be only £59, saving you £20 off the regular price. On top of that, you'll get a free welcome kit, a shaker bottle, a scoop, five travel packs, and a bottle of vitamin D3 and K2 drops. To claim this limited time offer, head to drinkag1.com/livemore. What are some of the key things you learned about yourself from wearing a CGM?

   29. FCDr. Florence Comite32:58

       So one of the things I learned is despite my optimal hemoglobin A1C, again, the average sugar over 100 days, um, my sugars could go very high and very low, and when I'm sick and just a little sick, my sugar's high.

   30. RCDr. Rangan Chatterjee33:12

       Mm.
10. 45:06 – 55:04

    Testosterone as an aging biomarker: metabolism, muscle, brain, and bone (not just libido)

    1. RCDr. Rangan Chatterjee45:06

       Yeah. Okay. I w- I wanna get to testosterone because I think it may well be one of the most misunderstood hormones. So I would say that most people, or many people, think about it as a male hormone, and they think about things like muscle, aggression, sex drive. But in your book, you very powerfully link it to insulin resistance, heart health, visceral fat, brain fog, loss of motivation. So Dr. Comite-

    2. FCDr. Florence Comite45:39

       [laughs]

    3. RCDr. Rangan Chatterjee45:39

       ... talk to us about testosterone. What do we misunderstand about it, and why do you think it's so important for men and women?

    4. FCDr. Florence Comite45:46

       Okay, I'm happy to do so. I have, myself have been on testosterone for 30 years because of a high risk of osteoporosis inherited both on my mother and my father's side. I had an aunt in, a maternal aunt and a paternal aunt who had osteoporosis, and I knew that one of the ways I can strengthen bone was with testosterone.

    5. RCDr. Rangan Chatterjee46:06

       So 30 years means probably somewhere in the mid-'90s you were starting this. Were there many people taking testosterone in this way?

    6. FCDr. Florence Comite46:17

       No, I can pretty much assure you that if it was 5%, that was a lot. And also, in this day, there aren't many because there isn't a deep knowledge of the fact that in women, testosterone is low. We lose it just like men do. It's critical for bone health, memory, cognition, muscle. And most of the men I treat, when they use testosterone and they get it into the optimal range, their sugar naturally drops, their hemoglobin A1c naturally drops, and we use testosterone, but we also use peptide agents that actually stimulate your own testosterone. So testosterone is really a critical hormone for me, and I'll tell you where the data came out for me. So I mentioned having an identical twin.

    7. RCDr. Rangan Chatterjee46:59

       Mm-hmm.

    8. FCDr. Florence Comite47:00

       We get bone densitometries pretty much yearly. I knew I had osteopenia 30 years ago, as did my twin sister. I started then. She started about 15 years ago, and she has early osteoporosis, and I still have the same bones that I had 30 years ago, osteopenia. So now we're gonna treat her for the osteoporosis, but had she been on it as long as I do, I would venture to say that she would not have osteoporosis at this point in time. So we know, for example, just to carry that a little further, that women get Colles fractures of the wrist beginning in the 40s and 50s because the wrist is more vulnerable. We don't walk on our hands, and we don't reinforce bone there, and as hormones shift. And then about 10, 20 years later, it's fractures of the hip and then shrinking spine and shrinking, uh, kyphosis-

    9. RCDr. Rangan Chatterjee47:52

       Hmm

    10. FCDr. Florence Comite47:52

        ... and buffalo hump. In men, osteoporosis occurs at the same, in the same numbers. 25% of all men, 25% of all women will become osteo product. That one disease alone can destroy your life, can, you can die when you break your hip. Um, you don't live alone afterwards of the people who remain. 50% of them can't live alone, so they move their family members. And so you want to start young so that you could sustain bone turnover, and I saw that because men had stronger bones and don't start losing bone, it's about 10 years later, it made sense to me that testosterone would help prevent bone loss and would keep my bones strong. So that was for me to test and for me to find out that my twin sister, because she wasn't on it as long, had developed more bone loss than I did at that stage.

    11. RCDr. Rangan Chatterjee48:44

        This is so interesting. So people who regularly listen to this show will know, because we've spoken about it on numerous occasions, that after the age of 30, we start to lose muscle mass each year unless we do something about it. Now, as I think about what I've read from you and what I've just heard you say, it begs the question, given that we're losing testosterone, I think you, you write, is it 1 to 3% a year?

    12. FCDr. Florence Comite49:15

        1 to 3% a year.

    13. RCDr. Rangan Chatterjee49:16

        After the age of 30.

    14. FCDr. Florence Comite49:17

        Mm-hmm.

    15. RCDr. Rangan Chatterjee49:19

        Is the muscle loss that we all experience, unless we do something about it, massively or largely influenced by the fact that our testosterone is dropping?

    16. FCDr. Florence Comite49:30

        I think there's a direct impact. I don't think it's the only factor, but it's the main factor. I think if you don't eat enough protein, one to two grams a day per kilogram of body weight, if you don't work out and do resistance exercises, you are going to lose muscle as well, but testosterone is the driving factor, as well as sugar management.

    17. RCDr. Rangan Chatterjee49:50

        So if we broaden this out beyond the patients in your practice, do you think that if a society wants to age well, then most men in that society would benefit from having some form of testosterone replacement, whether it's HCG or testosterone once they hit middle age

    18. FCDr. Florence Comite50:17

        So let me just tweak that a little.

    19. RCDr. Rangan Chatterjee50:18

        Please.

    20. FCDr. Florence Comite50:18

        Most men and women would be better off with optimizing testosterone beginning in their 30s. As a scientist and a physician, I'd like to see a measurement or two to see where we're at, particularly free testosterone, not total. As a explanation, total testosterone is caught up and bound in proteins like sex steroid binding globulin. Um, and so when that happens, the testosterone isn't free to act on your cells. And so that's a critical piece of understanding why it's misleading to use total testosterone as the point of reference, that free testosterone is, is the active hormone that you need to understand. It affects sugar, it affects memory, it affects cognition, it affects heart, it affects bone. It affects every cell in the body. And so I can point to patient after patient, and that surprised me. I have patients, I'll speak of one, who was ripped. He was in amazing shape, and he was in his 40s, close to 50s when he came to me, and yet he shared a... He worked very, very hard. He's actually in the news world. And yet he came to me and he said his memory was definitely slipping, and it, he, it was affecting his profession and what he needed to do. He f- would forget people's names. He couldn't report on that, and he couldn't talk about, uh, things that he loved that he was very into because he was forgetting the details. After a few months on testosterone, 'cause he was doing mostly everything as well as you could.

    21. RCDr. Rangan Chatterjee51:50

        Mm.

    22. FCDr. Florence Comite51:50

        Eating well, working out, sleeping. Um, and after a few months on testosterone, his memory started returning, and for the last 15 years he's been fine. And this is a man where Alzheimer's also runs in the family, and so his fear of going down that path contributed to his memory loss. But I've had other patients who I couldn't even take initially alone. I would have to have a loved one on the phone with them, because I do a fair amount of telemedicine in introducing the ideas and what we explain. And within a few months, largely about three months, they were acting like their memory was repaired. So the role that testosterone and estrogen play on memory is vital, and I was surprised by that. I didn't-

    23. RCDr. Rangan Chatterjee52:36

        Yeah

    24. FCDr. Florence Comite52:36

        ... the data wasn't really there. What is there, and you will find those papers, is low testosterone is associated with every disorder of aging, too, uh, in some ways like sugar.

    25. RCDr. Rangan Chatterjee52:49

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

    26. FCDr. Florence Comite53:26

        I ask if it's common for people, um, to age and stay strong, or do they get weak and frail? Do they need to depend on others-

    27. RCDr. Rangan Chatterjee53:36

        Yeah

    28. FCDr. Florence Comite53:36

        ... to care for themselves? Are they enjoying life? Do they wanna live a long life because they're not in good shape? If you ask people, most people don't wanna live way beyond 90, and even short of that, because they see illness.

    29. RCDr. Rangan Chatterjee53:47

        Yeah.

    30. FCDr. Florence Comite53:48

        And so the whole question to me is the quality of your life. It's not really about longevity. I take that for granted if we keep people healthy and strong. And the natural indication is to decline. Our genes don't usually dictate living forever, although there's a group of people who do have genes that let them live for a very long life, the oldest old-
11. 55:04 – 1:06:25

    Lifestyle vs hormones: can you raise testosterone naturally—and what is hCG?

    1. RCDr. Rangan Chatterjee55:04

       So I have two follow-ups, I think, okay? Number one is related to lifestyle. Can a man bring up their testosterone using their lifestyle? I guess that would be my first question. And the second question I think we need to cover at some point is, are there risks to taking testosterone, and side effects that we need to be aware of?

    2. FCDr. Florence Comite55:29

       So the answer to lifestyle is essentially no. You cannot work out harder, do more, eat more protein, and raise your te- raise your testosterone with any supplement that I've ever tested.

    3. RCDr. Rangan Chatterjee55:42

       But hold on. Let's, let's... This is a really important point. We do know, for example, that people who sleep less, like men who maybe sleep five hours a night compared to eight hours, will have lower testosterone.

    4. FCDr. Florence Comite55:52

       Yes, but that's lower testosterone, not increasing testosterone. That's not optimal. If you sleep well, yes, so sleep will... It's a different question than you just asked.

    5. RCDr. Rangan Chatterjee56:01

       Okay. I got it. This is a really important-

    6. FCDr. Florence Comite56:02

       Right

    7. RCDr. Rangan Chatterjee56:02

       ... so go for it.

    8. FCDr. Florence Comite56:03

       You cannot-- Let's say you're doing everything right, um, and you make no changes in your lifestyle because you're sleeping well. You're sleeping maybe six to eight hours, maybe 10, but getting over an hour of deep sleep, over an hour of REM, and you're able to do that pretty regularly. Your testosterone is going to be low, but the reason your testosterone is low is because you are getting older, and your body isn't listening and making enough testosterone. I've read over and over again in Men's Health and elsewhere that working out increases testosterone. What working out does is increase growth hormone, which is a peptide hormone that's synergistic with testosterone, works together with testosterone, but doesn't increase testosterone. Now, if you aren't sleeping, your-- or you have a newborn baby, or they have issues, your testosterone can fall because your body isn't in its prime. It isn't doing what it... It isn't being given-

    9. RCDr. Rangan Chatterjee56:55

       And, and, and when you address those things, it will go up.

    10. FCDr. Florence Comite56:57

        Yes, but that is presuming you're in your twenties or your thirties or your forties, but it's not gonna go to optimal.

    11. RCDr. Rangan Chatterjee57:05

        Okay, so this is... Let, let me just make sure I've got this point, right? So if you're, uh, whatever your age is, let's say you're in your forties, and your lifestyle has slipped because of life situations, young kids, elderly parents, too much work, not sleeping, you know, whatever it might be. If you then address those factors and are able to, yeah, your free testosterone, again, may increase, but there's a ceiling on that.

    12. FCDr. Florence Comite57:34

        Yes.

    13. RCDr. Rangan Chatterjee57:35

        And you're saying that, sure, optimize your lifestyle as much as you can-

    14. FCDr. Florence Comite57:38

        Yeah, that's the low-hanging fruit

    15. RCDr. Rangan Chatterjee57:39

        ... and that will help.

    16. FCDr. Florence Comite57:40

        Yeah.

    17. RCDr. Rangan Chatterjee57:40

        But for some people, that will not get you to optimal free testosterone levels.

    18. FCDr. Florence Comite57:46

        Exactly.

    19. RCDr. Rangan Chatterjee57:46

        Okay, so that's really interesting because if that's the case then, as you said with that patient, he was doing, from what I recall, everything right.

    20. FCDr. Florence Comite57:56

        Mm-hmm.

    21. RCDr. Rangan Chatterjee57:56

        Like, he was following all the lifestyle advice, but when you added in test- was it testosterone or hCG? And maybe-

    22. FCDr. Florence Comite58:02

        Actually-

    23. RCDr. Rangan Chatterjee58:02

        ... you should explain the difference to people.

    24. FCDr. Florence Comite58:03

        Sure. Uh, it was hCG. We tend to default to that because it's a peptide hormone that allows a man, not a woman, just a man, to produce their own testosterone. It stimulates the testicles in a way that creates, uh, more production of testosterone because what's failing in men decade to decade is stimulation of the testes. So there are particular hormones that are just not paying, the brain isn't paying attention to what's going on in your body, and there are fewer rises in something called LH, which then leads to increasing testosterone directly for the testes. So you are making your own testosterone, and particularly someone in your area of life is very likely to need that, and there are ways to tell by measuring those other horm- they're pituitary hormones, LH and FSH. If you can raise LH, which is what hCG is in effect, it acts like LH. It's a, it's a natural peptide. It's actually used in women to ovulate women because at that point-

    25. RCDr. Rangan Chatterjee59:01

        Mm

    26. FCDr. Florence Comite59:01

        ... in the cycle, we use LH if you're undergoing IVF, or you need, uh-

    27. RCDr. Rangan Chatterjee59:06

        Mm

    28. FCDr. Florence Comite59:06

        ... to be, you, you've been stimulated. That will release the eggs from the ovaries.

    29. RCDr. Rangan Chatterjee59:12

        And so is hCG in some way a more optimal way of-

    30. FCDr. Florence Comite59:16

        To me it is, and here's why
12. 1:06:25 – 1:09:21

    Safety considerations: monitoring, dosing, and the polycythemia risk

    1. RCDr. Rangan Chatterjee1:06:25

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

    2. FCDr. Florence Comite1:06:53

       Well, Father Time takes over-

    3. RCDr. Rangan Chatterjee1:06:55

       [laughs]

    4. FCDr. Florence Comite1:06:55

       ... and actually declines what Mother Nature has done so well, and we can talk about that with reference to women because it is an interesting way to think about it. And so it's really up to the individual, and doctors should be comfortable keeping people healthy for life as opposed to watching them decline, and I think testosterone plays a major role-

    5. RCDr. Rangan Chatterjee1:07:16

       Mm

    6. FCDr. Florence Comite1:07:16

       ... that way. As far as side effects, if we're not managing people effectively, testosterone at too high doses, and again, there's variation in how much is absorbed, how much is stimulated. It's affected by the food you eat, the alcohol you drink, because it's metabolized also in the liver, and so, um, you want... and it's metabolized at different rates, so it can vary. It's not gonna stay in one number the whole time. It's gonna go up and down within a range that is in the sweet spot. Um, you can have a issue where you create, um, erythrocytosis or increased polycythemia, specifically red cells, but I'm gonna use polycythemia, which means that your blood becomes a little, uh, s- uh, increased blood amounts, which can cause sluggishness-

    7. RCDr. Rangan Chatterjee1:08:04

       Mm

    8. FCDr. Florence Comite1:08:04

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

    9. RCDr. Rangan Chatterjee1:08:32

       Mm

    10. FCDr. Florence Comite1:08:33

        ... actually less than the Endocrine Society-

    11. RCDr. Rangan Chatterjee1:08:35

        Mm

    12. FCDr. Florence Comite1:08:35

        ... which says your hemoglobin should be 20. I actually don't like it if it comes close to 18. I see where a person starts.

    13. RCDr. Rangan Chatterjee1:08:42

        Mm.

    14. FCDr. Florence Comite1:08:42

        And we, we take some, we do what we call a therapeutic phlebotomy, unless a man could donate blood. So that is the one side effect-

    15. RCDr. Rangan Chatterjee1:08:49

        Mm

    16. FCDr. Florence Comite1:08:49

        ... I've seen happen that is a side effect of- ris- uh, reaction because, um, men who grow up in mountainous areas are gonna do the best they can with generating red blood cells.

    17. RCDr. Rangan Chatterjee1:09:01

        Mm.

    18. FCDr. Florence Comite1:09:01

        That's why Lance Armstrong and others train in tents that have less oxygen, 'cause when you go to higher altitudes, you want, you know, more red blood cells-

    19. RCDr. Rangan Chatterjee1:09:10

        Mm

    20. FCDr. Florence Comite1:09:10

        ... to release more oxygen, right? So polycythemia, or erythrocytem-emia, which is more specific, is caused by too high testosterone for that human being.

13. 1:09:21 – 1:17:52

    Women and testosterone: weight, bone, libido, and menopause complexity

    1. RCDr. Rangan Chatterjee1:09:21

       Yeah. Let's talk about women and testosterone. Why should we be thinking about that as a woman as well?

    2. FCDr. Florence Comite1:09:29

       We women have brains, muscles, hearts, bones, um, [laughs] and libido and sexual function in a slightly different way as manifested than in men, and we start losing testosterone the same way, in the s- in the 30s. Testosterone's produced in the adrenal glands and the ovaries. Some natural tests of it are young women in their 20s who actually start gaining weight on birth control pills. So they're given birth control pills, which has estrogen and progesterone, but no testosterone. It's not even approved for use in the States, and they start gaining weight. They blame the birth control pill, but what's really happening is that they're reducing testosterone, even at a younger age, and they gain weight. They gain, uh, truncal weight. Their bones are not as supportive. There's data that shows on birth control pills-

    3. RCDr. Rangan Chatterjee1:10:16

       Mm

    4. FCDr. Florence Comite1:10:16

       ... that you are more likely to become osteopenic if you're on it for 10, 20, 30 years, even though they're also protective of cancers of the reproductive system-

    5. RCDr. Rangan Chatterjee1:10:25

       Yeah

    6. FCDr. Florence Comite1:10:25

       ... 'cause you're lowering hormones. So women really need this as an essential hormone. It's part of the reason we women put on weight around our trunk in our 30s quicker than men do, 'cause you have more testosterone as a male. So testosterone also is vital. I set up a protocol when I was at Yale, when I started women's health in the early '90s, where I had a protocol for women who had breast cancer and were, had undergone mastectomies, tried to block all the estrogen in their body. They were miserable and really didn't wanna live.

    7. RCDr. Rangan Chatterjee1:10:56

       Mm.

    8. FCDr. Florence Comite1:10:56

       They lost their jobs. They didn't feel well. They didn't think they looked well. They, they didn't have any sexual function. So I set up a protocol to use testosterone and block the conversion to estrogen, which turns out to be not that big a deal in women.

    9. RCDr. Rangan Chatterjee1:11:10

       Mm-hmm.

    10. FCDr. Florence Comite1:11:11

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

    11. RCDr. Rangan Chatterjee1:11:45

        Mm.

    12. FCDr. Florence Comite1:11:45

        So there's data in the book that people can read and find. And so women, we women need it. Now, we women hit a wall when we go through menopause-

    13. RCDr. Rangan Chatterjee1:11:54

        Mm

    14. FCDr. Florence Comite1:11:54

        ... because we used up all the eggs. Unlike men, we are very complex, each one of us. I think all men would agree. And each one of us, when I'm stopped at a meeting, at a convention, and somebody in the field is trying to learn what this is all about, and they'll say, "Can you just give me something about women?" And I'll say, "Yes. Unlike men, each woman is different. You cannot judge each woman by the next woman." Some women go into menopause overnight in their late 30s. Other women, I've had sisters, where one has gotten pregnant in their 50s, and the other one's in menopause in her 30s.

    15. RCDr. Rangan Chatterjee1:12:27

        Wow.

    16. FCDr. Florence Comite1:12:27

        And so there's a variety of the way we express genes. It is not, uh, like, set in stone from our DNA, but because of epigenetics, the way we live life, the choices we make, and our genes, we may express them in different ways.

    17. RCDr. Rangan Chatterjee1:12:42

        Yeah.

    18. FCDr. Florence Comite1:12:42

        So when women, they need to take estrogen, progesterone, and testosterone, and in fact, in the perimenopause, more women than not have irregular menses. You have to be careful with that because sometimes it's only estrogen that they're seeing. They're not seeing progesterone. You wanna protect the endometrium to avoid endometrial cancer, and I've had sad stories of women who aren't seen because the doctor says, "Well, it's, it's perfectly fine having irregular cycles. You're not ovulating. Don't worry about it." But in fact, with unopposed estrogen for more than three months, there's data that shows that you can get more likely to get endometrial cancer, which is curable-

    19. RCDr. Rangan Chatterjee1:13:20

        Mm

    20. FCDr. Florence Comite1:13:20

        ... if you find it early enough, but then you need a hysterectomy.

    21. RCDr. Rangan Chatterjee1:13:23

        Mm.

    22. FCDr. Florence Comite1:13:24

        So testosterone for women does exactly what we want it to do for men. We increase endurance. VO2, uh, uh, increases. Your heart performs better. You lose visceral fat. You lose truncal fat. So all of that leads to chronic diseases of aging. And so why wouldn't women be on testosterone? And yet even in the States, it's not approved formally. A doctor can use it if they have a reason, a category, and they justify it. And as an endocrinologist and a reproductive endocrinologist, I've been lucky enough to be exposed to all of that, so I think slightly differently than most physicians. What's actually taught is sad because the group of people who really know about women, gynecologists, some of them even go on and train as infertility/fertility experts.

    23. RCDr. Rangan Chatterjee1:14:12

        Mm.

    24. FCDr. Florence Comite1:14:12

        But they don't really train in menopause and change of hormones. That's just beginning in the last, maybe, decade.

    25. RCDr. Rangan Chatterjee1:14:18

        Mm.

    26. FCDr. Florence Comite1:14:18

        And so I'm thrilled to see that. I'd like to see the same happen for men because I think men are underserved in terms of all their hormones. It's not just testosterone for men, either.

    27. RCDr. Rangan Chatterjee1:14:27

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

    28. FCDr. Florence Comite1:15:00

        Yes, that's gonna happen. I'm predicting it, that w- Do men have hormones or not?

    29. RCDr. Rangan Chatterjee1:15:04

        Well, I guess it's because maybe for men it's less obvious in the sense-

    30. FCDr. Florence Comite1:15:09

        Yes, yes
14. 1:17:52 – 1:33:33

    Defying genetic destiny at scale: N-of-1 medicine, apps, and “Who do you want to be at 100?”

    1. RCDr. Rangan Chatterjee1:17:52

       Yeah, and what I'm, I guess what I'm, what I'm trying to sort of bring in here is this idea that if we understood that modern medicine is primarily a disease management system, then we go, okay, great. Let it do that. Okay. But we need to also make sure that we are, um, part of a health creation system, right? A proactive aging system.

    2. FCDr. Florence Comite1:18:16

       I love that, that term, health creation, because I think we want to create health in people who, as we age, are bound to decline based on our genetic makeup, which drives a lot more than we actually thought. We actually put way too much emphasis on lifestyle and habits, and we've kind of ignored, for lack of knowledge, what is going on in our genes and what our genes, which is translated by family history, because family history is expression of genes. If you have dementia in your family, if you have osteoporosis like I knew I had, if you have heart attack and stroke, um, you are at risk if your genes express themselves. So what can we do as both an individual and a society to change that-

    3. RCDr. Rangan Chatterjee1:18:59

       Yeah

    4. FCDr. Florence Comite1:18:59

       ... paradigm, to have people own their future health by understanding they are at risk?

    5. RCDr. Rangan Chatterjee1:19:04

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

    6. FCDr. Florence Comite1:19:30

       Mm.

    7. RCDr. Rangan Chatterjee1:19:32

       Well, if you owned your own health data and you could see, hey, wait a minute, why was it that two years ago my HbA1c was 5.1 and now it's 5.6? What... You know, if you can see that and you have a nice graph or something showing you, suddenly I think that will land in people's head a bit differently that, oh, I might need to do something. Or, you know, your, your fifth biomarker is the free testosterone. If you suddenly, if you saw that year on year starting to plummet and drop, you might be triggered earlier to say, "Actually, I need to see someone. I need to see a healthcare professional who can help me. Is this an issue? Do I need to do something about it? Is it okay?" So I think that whole model needs to change, but I, I really want to touch on what you said about genetics here. I've heard... What have you previously said? Is it a po-

    8. FCDr. Florence Comite1:20:22

       Can I comment on what you just said there?

    9. RCDr. Rangan Chatterjee1:20:24

       Please, please.

    10. FCDr. Florence Comite1:20:24

        So in the States, and I don't know if it's really available here, you can get biomarkers almost anywhere now. What's missing is that interpretation-

    11. RCDr. Rangan Chatterjee1:20:33

        Exactly

    12. FCDr. Florence Comite1:20:33

        ... from knowledge to wisdom. So absolutely agree with you. If you can see those biomarkers, if you know... I have a, a perfect example. I'll, I'll call him Max, real patient. He was part of the app I was developing to give the information into the hands of an individual-

    13. RCDr. Rangan Chatterjee1:20:49

        Yeah

    14. FCDr. Florence Comite1:20:49

        ... to practice virtual medicine, which I believe is absolutely the way we need to go for health creation, a term I'm gonna steal from you and use. And when I looked, I did-- I made it a point, unlike the center where people come in, and it was part-- like, more of the old-fashioned family medicine meets futuristic medicine-

    15. RCDr. Rangan Chatterjee1:21:08

        Yeah

    16. FCDr. Florence Comite1:21:08

        ... 'cause I see the patient. Um, and I made it a point of not getting a story, but rather just asking a series of limited questions, which was limited from the usual questionnaire, but what I thought was critical. His biomarkers were terrible. His testosterone was fifty-two, not even ninety, as you mentioned, and he was only 30. He had recently married, and his libido was decreased, not because he married, but because he saw that it was decreasing from his 20s. He was putting on a little weight, even though he was really active, but he was putting weight around the middle, and he didn't feel great. When I looked at the history, his family history, his father had had multiple heart attacks and strokes beginning in the 40s. I didn't ask if his father was alive-

    17. RCDr. Rangan Chatterjee1:21:50

        Mm-hmm

    18. FCDr. Florence Comite1:21:50

        ... or not. I didn't know-- He didn't put anything in about his mother, which is kind of interesting, 'cause he actually lived with his mother. He had a sister from another mother who was only five months difference in age.

    19. RCDr. Rangan Chatterjee1:22:01

        Mm.

    20. FCDr. Florence Comite1:22:01

        And he had a certain makeup where his father was Ashkenazi Jewish, his mother was Puerto Rican, and I looked at the pattern. I went to see him. I asked to see him, and I said, "How's your father doing?" Well, his father died of a massive heart attack at 60. This man, in his biomarkers, was showing changes that you typically see in a man 10 or 20 years older.

    21. RCDr. Rangan Chatterjee1:22:22

        Mm.

    22. FCDr. Florence Comite1:22:22

        His numbers and his combina- His hemoglobin A1C was perfect. It was 4.9, but his fasting sugar ranged from, like, 75 to 95.

    23. RCDr. Rangan Chatterjee1:22:30

        Wow.

    24. FCDr. Florence Comite1:22:31

        And his testosterone was 52. His cholesterol risk ratio was 5.8, as opposed to being-

    25. RCDr. Rangan Chatterjee1:22:38

        You want under two

    26. FCDr. Florence Comite1:22:38

        ... ideal at under two. And so you put that all together, and you saw a man who was actually aging exactly as his father was, which is a syndrome we learned about, I learned about in medical school. When you have early heart disease in a family, it's hereditary. We just didn't understand the factors around it.

    27. RCDr. Rangan Chatterjee1:22:56

        Mm.

    28. FCDr. Florence Comite1:22:56

        And so we completely reversed that. This, this gentleman is, like, in amazing shape. We increased his testosterone with HCG. He was able to come off of it, b- because by triggering in a younger man, and I have a set of those, um, for other reasons, for lots of other reasons, we can actually get function back, and they can take off on their own. You can actually-- Once you hit the 40s, it's much harder. I've had a handful of men in their 40s-

    29. RCDr. Rangan Chatterjee1:23:22

        Mm

    30. FCDr. Florence Comite1:23:22

        ... where I could stop using, um, HCG.

Episode duration: 1:33:33