What does longevity medicine actually mean?

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So...what is longevity medicine?

With all the conversations surrounding longevity medicine, I thought it would be fun to talk with a doctor that actually works in the space. Today we have a conversation with Dr. Anant Vinjamoori, a practicing doc in longevity medicine.

We go through a bunch of topics, including:

• What the difference is between a primary care visit and longevity medicine visit
• Some tests and biomarkers that might be more interesting in longevity vs. traditional practice
• Criticisms about the space like overtesting
• Lessons from Modern Age
• What societal changes happen if people live to 100
• And more!

[Memes and commentary are from me]

NK: Background, current role and latest cool project?

Anant: I’m a primary care doctor by training, and have worked in both product and medical leadership roles at leading healthtech ventures. I was previously Director of Product at Virta Health and most recently Chief Medical Officer at Modern Age.
I’ve recently started Next Generation Medicine, a new venture focused on helping clinics and businesses seamlessly build longevity medicine into what they do.

Concretely, what I provide is a suite of best-in-class medical education and technology to help make it easy to learn, implement, and scale longevity medicine. I’m already partnered with a number of really exciting, innovative companies, including Superpower and Midi Health.

PS- if you are a clinician looking to get into longevity medicine, or if you are looking to build a longevity business, please reach out to me!

I also maintain a small clinical practice where I deliver in-depth longevity-focused care to a handful of individuals.

NK: Let’s start with Virta. What are the pros and cons for patients considering the ketogenic diet to manage something like diabetes? Why does it seem to work from a medical perspective?

Anant: At this point, I would say there is quite a bit of clinical evidence that indicates that carbohydrate restriction (which is the focus of the Virta intervention) can be very beneficial for individuals with diabetes. There’s also good evidence at this point that the Virta intervention in particular is successful at doing this in the real world.

At a scientific level, I believe that a major reason that the ketogenic diet works has to do with ketones themselves, which are the molecules that are produced by the body when fat is burned as fuel instead of carbohydrate. Our understanding here is rapidly evolving, but it appears that Ketones favorably promote gene transcription and have a variety of anti-inflammatory effects that help address diabetes at the root-cause level.

That is not to say that the ketogenic diet is for everyone. There can be some undesirable effects if it’s not implemented in the right context or in the right way. I do think medical supervision is necessary. While I was at Virta we used to frame our intervention as akin to a pharmaceutical, and my time in longevity medicine has reinforced that.
(In the interest of full disclosure, I will note that I am a shareholder in Virta.)

NK: Everyone who promotes longevity medicine seems to say something different. What do you personally believe will help us live longer? How does it differ from what others in the space believe? 

Anant: Let me first say that I wish we had a better term for this field than “longevity medicine,” as I don’t think that describes why people come to us. Most people simply want to feel better today and have a good quality of life as they get older. Almost no one is coming to us saying “I want to live to 100.” Nonetheless, “longevity medicine” is the term that’s emerged to describe the type of personalized, data-driven medicine that we practice.

I think one thing everyone in the field can agree on is that healthy foundational behaviors- nutrition, exercise, and sleep- are essential to longevity.

I personally think that of those three, exercise is the most important as it has the capacity to influence the other two, and has a whole host of other benefits that are not replicable by any diet or drug. I think exercise, at least in 2024, is the most powerful intervention we have to promote a healthy life. I think I might differ from some people with regard to this particular belief.

NK: Let’s cut to the chase, what do you think about Bryan Johnson.

Anant: I think what Bryan is doing is overall a positive for our field. I know people are drawn to the headlines about how many millions of dollars he spends, or how “out there” some of the treatments he is doing are. It creates controversy and polarization to an extent, but the net effect is that more people are now thinking about longevity and proactive health much more than they were a few years ago. And I think that’s a good thing.

[NK note: “Out there” is one way to put it. Would you rather do 50 pushups or…]

NK: If I compare longevity medicine to a regular primary care visit, what do you think the biggest differences are between the two. What tests/recommendations do you think are regular in longevity clinics that should be in primary care but aren’t?

Anant: In many respects, I think longevity medicine is what primary care should have been. The most striking difference between the two today is in how they typically begin visits. In a primary care visit, you usually begin by trying to understand what disease or disorder someone has. If no diseases are evident, you might screen for others that we know about. If none of these are present, we send you on your way.

At a longevity medicine visit, we start by understanding what your goals are. This seemingly small difference takes you to very different places with the patient. People share things like “I wish I had more energy after work” or “I wish I could focus better in the middle of the day”- things that they would generally not mention to their primary care doctor because they don’t seem like diseases, which tend to be the focus of primary care. In longevity medicine we think about preventing and addressing disease too, but there is more attention given to what's important to the individual and how we can use our medical toolkit to make that happen.

One common misconception about longevity medicine is that it always involves expensive, high-tech tests and treatments. While these can be part of the practice, they're not the core of what we do.

In my view, the essence of longevity medicine is personalization and education. We draw from a broad playbook of tests and interventions, and aim to align our approach with each individual's values, beliefs, risk tolerance, economic situation, and other personal factors. We do our best to educate people on what they are about to sign up for.

With all that said, there are markers tested by longevity physicians that I think merit consideration for conventional practitioners to order as well. Some of the most obvious ones relate to cardiovascular disease. Despite abundant evidence, most conventional practitioners are ordering standard lipid panels alone, and not ordering ApoB and Lp(a), which are actually much more informative when it comes to cardiovascular risk. Other markers that I think are worth considering given their broad relevance to health are sex hormones (testosterone and estrogen) and inflammatory markers (C-reactive protein).

[NK note: ApoB seems to be more accurate than just traditional cholesterol measures because it reflects the number of particles that can actually cause damage].

For example - imagine a man in his mid-40s who has a family history of heart disease, and who struggles with bouts of low energy at the end of the day and poor recovery from his workouts.

We’d start by doing a comprehensive blood biomarker assessment to understand key drivers of the aging process- hormones, metabolism, inflammation, nutrients, and more. This testing alone gives us quite a bit of information to begin to implement a plan. It generally costs a few hundred dollars - not cheap by any means, but it's much more accessible than people imagine about longevity medicine.

If we find high markers of cardiovascular risk, we might proceed to advanced tests like a coronary CTA from Cleerly (which can often be covered by insurance) to get a better picture of the patient's actual plaque burden. If we discover suboptimal testosterone levels (which we often do), we might have a conversation about how to support these levels through a combination of resistance training, sleep optimization, as well as certain supplements and even TRT if appropriate.

NK: Are there particular papers or areas of study within longevity medicine that you’re particularly interested in? 

Anant: I’m particularly interested in biomarkers and measuring the impact of what we do in longevity medicine.

I think we’re at the doorstep of a paradigm shift in medicine where we move from thinking about things in terms of body parts and organs to thinking in terms of cells and signaling pathways. The processes that drive aging and disease ultimately happen at the level of the cell.

We’ve used largely the same set of biomarkers for the last half-century- the complete blood count, comprehensive metabolic panel, C-reactive protein, and so on. But these markers are actually several levels removed from what’s actually happening at the level of the cell.

We need a new generation of biomarkers that describe what is happening at the cellular level. Much of this- proteomics, metabolomics, genomics- has been largely the domain of basic research, but it’s increasingly now possible to use it in clinical medicine too.

One biomarker I'm particularly excited about are DNA methylation patterns, also known as biological age. DNA methylation patterns have shown strong correlations with how our cells and bodies are aging, and can be a great surrogate marker to determine whether the interventions we implement are moving things in the right direction. These markers are far from perfect, but they are a useful tool.

I think GLP-1 agonists represent the importance of achieving this level of understanding. The reason these drugs have positive impacts on so many different parts of the body- the brain, the gut, the liver, the kidneys- is because they work on signaling pathways, like the AMP-K pathway, that are fundamental to cells in many organs in the body.

[NK note: There seems to be a bunch of longevity biomarker papers that have come out in the last year. Here’s one that looked at a bunch of different -omics from 108 participants over several years and found a bunch of dysregulation that causes aging in two distinct ages, at 44 and 60. Aging will probably not be one singular biomarker, and a composite of many.]

NK: Longevity medicine still seems a bit fringe compared to other specialties - what do you think it would take for longevity as a specialty to become more legitimized?

Anant: I would challenge this a bit and say that longevity medicine appears “fringe” through the lens of conventional medicine. I think this is mostly because the paradigm and approach is so different. But in fact, there are many people who want this type of care, so in that regard it’s hardly fringe.

A good example is that longevity practitioners will use a much broader toolkit of interventions and tailor our use of them to the individual. We of course consider FDA approved-options and guidance from specialty societies, but we don’t stop there. We understand evidence exists on a spectrum. We also understand further that every individual is unique in ways that are not captured in research studies. We use all of the data in front of us to make the best possible decision for each patient we take care of.

Conventional medicine is primarily focused on population-based approaches and standard guidance issued by government bodies and other clinical organizations. It has value to be sure, but it is generally institutionally driven and can feel very “one-size-fits-all” to patients. 

So for people steeped in this system (and I was once of them), longevity medicine looks different - and it’s why you’ll hear terms like “unproven” “untested” at times in reference to this field. There are bad actors in the space to be sure, but a lot of this comes from a first principles philosophical difference.

There are some people who are trying to make longevity medicine “look” more like the rest of conventional medicine. I personally think that we are in the midst of a paradigm shift from population based medicine to personalized medicine- and longevity medicine is in the vanguard of this shift. So, I’d argue the inverse is more likely to happen.

NK: A lot of the criticism around longevity medicine stems from overtesting or interventions that are clinically dubious (blood boys, stem cell interventions). How would you respond to the idea that these might actually be net negative?

Anant: Setting aside the extreme examples, the primary problem derives from the notion that any of these intensive interventions you mention are things that every person should consider getting. True longevity medicine is all about personalization, and so I don’t think any good practitioner would ever arrive at that conclusion.

I think this speaks to one of the bigger problems in the field right now, which is that actual longevity physicians don’t have enough of a voice in the field. Through the lens of the consumer, the most prominent voices today are testing/supplement/therapeutic companies and their sponsors who are very often not practicing longevity clinicians themselves. 

I would actually agree with you that if we don’t strike a better balance, there is a real possibility of some of these things having a net negative impact. A good example of this might be the mass usage of CGMs without the right guidance. I believe that CGMs are extremely powerful tools, but there are a lot of people out there who are drawing the wrong conclusions and believing that they have “prediabetes” because “oatmeal spiked them,” when in fact what they are seeing is completely physiologic and normal.

NK: You were the CMO of Modern Age, which recently went under. What lessons would you give from that experience for anyone thinking about starting a longevity clinic/startup?

Anant: I think one lesson I would share is to be very humble and honest about how your customers will actually think about your business. You might have a really ambitious multifaceted vision for how your venture will transform medicine, but customers will see it in very simplistic terms- like “botox place” “medspa” or “lab testing company.” Develop that understanding as early as possible and use it to communicate what you do as simply as possible to find traction with your initial audience. You can then evolve how you communicate what you do there, but traction has to come first. 

The second would be to engage the right clinical expertise and find the right clinical tools as early as possible. The clinical component of a longevity business is the lifeblood. Too often founders try to define this without having any clinical input at all. Or, they might engage a handful of academic or scientific experts who have no idea how to give guidance that can be useful to a business. I genuinely believe it's critical, I’ve seen it throw off many businesses. 

NK Bonus: What do you think the weird second order effects of a population with life expectancy of 100 are?

Anant: I love this question! Probably the one I am most interested in are the implications to how we think about education and career. If people are able to not just live longer, but be functional for longer, they should be able to navigate multiple career changes throughout their extended lifespans. In that world education really should be an ongoing thing and not just an investment made primarily in childhood and adolescence. What if we had “mid-life schools” where 40 year olds spent a few years together to intensely learn new skills and refresh social connections? Maybe I’m describing executive MBA- lol.

Another one to consider is how longer productive lifespans might actually lead to reduced upward mobility in the professional world. If people in positions of influence are able to continue working for longer, what will the implications be for everyone else? Could this lead to a slower infusion of fresh ideas and innovation? Or will we benefit from greater stability and accumulated wisdom in our leaders? How will everyone, especially younger people, experience this?

[NK note: Curriculum for a “mid-life school” of 40 year olds:

• How to use the interface of whatever the dominant social network at that time is.
• Normal vs. abnormal joint sounds
• Faking interest in other people’s kids and their activities
• Gardening basics and why it’s not worth it
• Modern slang and what it means
• Tea?

IMO In a world where people live long, healthy lives - the big issue is going to be dealing with a society where people form their opinions about how the world should work by age 40 and then basically remain unchanged for 60+ years as the world changes around them. 

How do we retain plasticity around thinking, that’s something that goes beyond just making our bodies work for long periods of time. Or put age maximums on literally all positions of power.]

Thinkboi out,

Nikhil aka. “🖖”

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

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