[43:20:31.980] - Dr. Lemanne
I do have that talk with patients that I tell them that if I were an Eastern medicine practitioner, I might be talking about qi life energy. But since I'm not, I'm going to be talking about dopamine and other neurotransmitters, which I consider life energy. And dopamine is not the only neurotransmitter and it's not the only important one. But what dopamine, why it's got my interest and why I put it up in the front is because it directs goal seeking behavior. And if you want to have as your goal regaining health or maintaining health, you have to have a why 

 [43:21:32.670] - Dr. Gordon
In today's episode, we talk about a shift in medical terminology that is both obvious and subtle. Two phrases, healthspan and lifespan, have become increasingly common as we think about how we approach our health goals, both as patient and as healthcare provider. When you consult your physician or your healthcare practitioner, you want your immediate concern to receive its due attention, but increasingly so you also want the quality of your overall life to be preserved and hopefully even enhanced. We want not only a longer life lifespan, but we also want a better one, now referred to as health health span. How do we think about what it means to not just have your problem fixed, but to actually be healthier? And what are some of the tools you and your doctor might use to enhance a broader concept of health? And when we talk about longevity, I think what we really are intending to talk about is healthevity, which of course there's no such word, right? But that we're healthy longer, not just living longer. Wouldn't you agree?

[43:23:03.230] - Dr. Lemanne
Absolutely.

[43:23:04.310] - Dr. Gordon
Absolutely.

[43:23:04.940] - Dr. Lemanne
And I think, you know, healthspan is really, really important. And I really want to impress upon my patients that it's not just about and the elderly age group either. Healthspan matters. Even if you're 25, if you have long Covid or lupus or some other terrible autoimmune disease like multiple sclerosis or rheumatoid arthritis, or you are depressed and anxious all the time, your health span has been reduced. It doesn't matter whether you're 25 or you're 75. So yes, I think health span Is is something that very much needs to be centered and brought into the conversation. And who wants to live a long time if you're sick?

[43:23:54.770] - Dr. Gordon
Nobody.

 [43:23:55.220] - Dr. Lemanne
And who wants to live? Even young people don't want to live if they're sick. It's not an age related issue.

[43:24:02.040] - Dr. Gordon
I think you and I have both incorporated this a little bit in our practice. 

And if I may, I'd like to share with you and our listeners a nice compliment. I heard about you from one of our mutual patients. So she's a patient who is. And I do not know the details of the cancer and it doesn't matter because that would probably not be HIPAA compliant. But she has a cancer that is challenging. And when she got diagnosed with a cancer, her friend said, are you gonna fight it? You're gonna conquer this cancer? You're gonna beat it? And she always knew there was something wrong with that. And she's adopted a different attitude. A little bit like what you and I talked about when you were talking about the management, long term management of prostate cancer. She considers herself someone who's dancing around the cancer, quiets it down, and then can go on and live her life and she'll dance around it again if it ever comes back. She's found this so much more compatible with her mental health and well being than the attitude of fighting and beating, which felt like going to war, which she would never do.

[43:25:11.840] - Dr. Lemanne
That's a really, really interesting point of view and one that I can very much espouse. I think fighting a cancer, I mean, that's a stance that people take. I mean, we use all sorts of metaphors in our lives to get through various obstacles and we describe them as something else like cancer and getting well. Is fighting a war a battle. But boy, battles can be exhausting if they never stop. And I do think that one of the things that I like to emphasize with my patients is that all of us are fighting or dealing with or living with or dancing with cancer our entire lives. From conception.

[43:25:58.630] - Dr. Gordon
From conception.

 [43:25:59.500] - Dr. Lemanne
From conception. Yes. I think it's either a quarter or a half of all of our somatic or new mutations that we're going to develop in life. A quarter to a half we acquire between conception and birth.

 [43:26:15.630] - Dr. Gordon
Oh my goodness.

 [43:26:16.700] - Dr. Lemanne
Okay. And I think we acquire another quarter or so between birth and age of 20. And then the rate of mutation actually slows down during adulthood because we don't have as many dividing cells. It's stochastic or statistical process, and it happens just at a certain rate. And you know, if you think about cancer. And we're going to talk about all sorts of diseases today. I think not just cancer, but, you know, if you think about cancer and health span. Yes, our bodies are dancing with cancer and usually most of the time are able to kind of keep it quiet.

 [43:26:56.660] - Dr. Gordon
And not let it come to our attention.

 [43:27:00.290] - Dr. Lemanne
Not let it come to our attention. Wow.

 [43:27:03.240] - Dr. Gordon
 think I told you a story once of having a mammogram and the radiologist called me and all in a fluff because he said, who read yours last year? And I told him, and he said, I would have told you you had breast cancer, but you don't have it this year. And what he just really meant was indicators that could have been breast cancer, you know, calcifications or something. And the mammogram read. But I've always kind of, you know, taken that to heart in a loving sort of way that maybe something was going askew in my body and it very wisely, without me paying attention to it, took care of it.

 [43:27:41.000] - Dr. Lemanne
Well, it could be. There's, you know. Have you heard of Dr. Laura Esserman at the University of California, San Francisco?

 [43:27:51.660] - Dr. Gordon
Boy, I should have.

 [43:27:55.100] - Dr. Lemanne
You don't want to have to think about this all day long. But she's a very brilliant breast surgeon and she's dedicated her career to decreasing the amount of treatment that breast cancer patients undergo. So things like the sentinel lymph node evaluation rather than just removing all of the lymph nodes under the arm, we can thank her for developing that.

 [43:28:18.550] - Dr. Gordon
That has made a huge difference. It has in side effects. And I don't know if all our listeners know what.

[43:28:24.350] - Dr. Lemanne
Well, so sentinel lymph node evaluation involves taking out just one or two lymph nodes that are drained by the tumor. So a little dye or tracer is injected, or maybe both is injected into the tumor at surgery, and the dye or tracer will then flow to the nearest lymph node from the tumor. And the surgeon can then detect that lymph node by looking at the dye or detecting the tracer and remove that lymph node. And so you can just remove, you know, one to three lymph nodes. That's how many are usually removed, that are specifically drained by the tumor and look for cancer cells in those lymph nodes Rather than removing all of the lymph nodes en bloc, which used to be done in the axilla. The whole axilla was kind of carved out in one piece, sort of like with the lymph nodes in it, sort of like peas in jello. I describe it and it sa the patient from a higher risk of bad outcomes, like specifically lymphedema or permanent swelling of that arm. So that has almost gone away. Used to be a big problem. There were whole careers built on dealing with lymphedema.

 [43:29:40.790] - Dr. Lemanne
Physical therapists would specialize in this, and there would be special garments made by special factories to compress the arm and yada, yada, yada. We don't need that really anymore because those people will have to retrain because this new surgery, which is about 20 years old now and promulgated by many people but Laura Esserman prominently, has become the standard of care.

 [43:30:06.160] - Dr. Gordon
And that practice, that approach to lymph node biopsies, has spread to other tissues besides breast.

 [43:30:12.810] - Dr. Lemanne
Breasts too, yes. So melanoma, anything where there's a chance of spread to lymph nodes and that's part of the staging or prognostication process, will have a sentinel lymph node option these days. But I brought up Laura Esserman in regards to your story about the mammogram and perhaps things reversing. She has been developing a vaccine for DCIS and it has been helpful. I've sent patients to her who have DCIS, and she gives them her vaccine and the DCIS goes away. So it's what it tells me is that, yes, with certain types of immune activation, which you may have produced naturally in your own body, since you are very, very careful with your health, likely does play a major role in reduction of risk of cancer. Now, DCIS, which does show up on a mammogram, is not considered cancer. And this is another Laura Esserman story. I'm a big fan. Can you tell?

 [43:31:12.740] - Dr. Gordon
 can tell.

 [43:31:13.370] - Dr. Lemanne
Yeah. She's been working to change the. The name of ductal carcinoma in situ, or DCIS, or in situ, as they say on the east coast, to a term that doesn't contain the word carcinoma. And I can't recall what the actual new term is. I better look that up. But I think that's really interesting. She does not consider it cancer. She considers it a precancerous condition, and it can be reversed either naturally or with with some help in some cases.

 [43:31:43.590] - Dr. Gordon
Which I hold that awareness close at hand when I'm meeting older patients because one of the pillars of good elder health is restoring one of the tendencies of aging, which is loss of hormonal vitality. So as we've talked about before, I see a lot of patients where I'm going to suggest for them, particularly for women, that they Replace their hormones and. And they say, oh no, I've had breast cancer. And we get the details. And it's ductal carcinoma in situ. And I believe I talked about this with you the first time it came up. And for this person in particular, it had been 10 years. So I think even without talking to you, I would have felt comfortable prescribing hormones for her, which she's now been on for five or six years and of course, with no problem. But hormone hormones, I think are an important pillar of creating health. And hats off to Dr. Esserman for changing the terminology of that. I can't wait to hear the new word because I'm going to go back and take all my. I hope she gets a new ICD10 coding for it, because I want to go back and change all my charting where I've ever said DCIS and take the cancer word out of it.

 [43:33:06.340] - Dr. Lemanne

Well, you know, I think work like Dr. Esserman's and yours really allows treatment of patients in a truly personalized way. And I completely agree that hormones are vital for health and hormonal balance. Now, some cancers are hormone sensitive. In other words, they tend to grow and use hormones to help that growth. In that case, it still is. And I think this will be the future of oncology. It still is important to toggle hormone use and balance with periods of hormone deprivation to keep the cancer in control. And I've been privileged to work with a new field of oncology called mathematical oncology. And there are people who are called mathematical oncologists and they tend not to be MDs, but they are working and they help oncologists like me actually precisely toggle the dose of hormones and anti hormone treatment in a very defined and personalized way. So we will use tumor markers like in prostate cancer, which of course, as you know, is sensitive to androgens or male hormones. And in we use the psa, the prostate specific antigen, which is a blood test. And we get that very often in those patients weekly. And we toggle the treatments on and off.

 [43:34:47.100] - Dr. Lemanne
And we do alternate it with actual testosterone injections with good effect. And that is very investigational. We're also moving into doing this with breast specific and very carefully selected breast cancer patients in a clinical way, in an empirical way. And this is really exciting to me. And it allows the patients to have their cancers treated and controlled. We're not trying to wipe out the cancer, we're trying to keep it in an preclinical or asymptomatic state. In other Words, the cancer is there, but the patients feel well. And then we also allow them then access to the health that comes from.

 [43:35:33.530] - Dr. Gordon
Proper hormonal balance, even if it's intermittent for them, it's going to be better than total deprivation.

 [43:35:42.350] - Dr. Lemanne
Yes. And I want to point out though that it's not just, oh, I'm going to take my hormones for a while and then, oh, I'm going to take the cancer medication for a while. This is very precise work that has to do with mathematical modeling. Just doing a calendar based on off or what we used to call metronomic treatment will not work in most cases unless your tumor happens at the moment to be following a weekly or monthly or three weekly schedule, which is possible over the larger population, but is statistically unlikely in one person's case.

 [43:36:20.900] - Dr. Gordon
I think everyone can kind of grasp the valuable insight in approaching cancer that way and developing skills that enable you to do it safely. I want to back up just a second to talk about. I've used the term health span and longer healthy life a little bit casually and I want to just give deference to the fact that has arisen out of some very specific medical observations or statistical observations kind of like your. So this is mathematical medical insights that medicine has really advanced since I was born and a lot of things are more easily treated. And one of the time periods that's compared in this paradigm that I'm going to introduce is that in 1990 we had a certain lifespan and it would differ depending on your gender, where you lived, your social, economic status. But in general, there was kind of a General lifespan in 1990. And if you fast forward to 2020, it was quite a bit longer than it was in 1990. But here's what differed. In 1990, people who died averaged less than 11 years of disability, of compromised quality of life prior to their life's ending. Now that number is more than 13 years of debility.

 [43:37:57.990] - Dr. Gordon
So the observation came that we are better at keeping people alive rather than over giving them quality of life. And that disparity, if we don't pay attention to it, is just going to get worse over the next 30 years. They expect three times as great a proportion of our population to live past 80. And if they are living in more than 13 with more than 13 years of debility, we're going to have some pretty unhappy seniors. I won't be around in 2050, but I want to have a quality of life past the age of 80.

 [43:38:33.910] - Dr. Lemanne
Well, do you have. You may not have this at your fingertips, but you might. What Was the life expectancy in 1990 and what is it now?

 [43:38:42.930] - Dr. Gordon
Well, now I do know what it is now and I don't have it for 1990, and I can look that up and see if I can find it. But the average age of life in general in the US right now is 74.8 years for men and 80 for women.

 [43:39:01.320] - Dr. Lemanne
78 and 80.

 [43:39:03.150] - Dr. Gordon
75.

[43:39:03.880] - Dr. Lemanne
75 and 80.

 [43:39:05.880] - Dr. Gordon

So if you consider that they are going to have more than 13 years of disability, I'm well into where I should be disabled, and I will. So disability is different at different ages. One of the things you talked about was, gee, maybe you have cancer when you could. You have cancer tendencies in your genetic mutations when you're very young, but you actually don't suffer with cancer. What young people suffer from is really primarily more as they get a little older than infancy and childhood is more mental health issues and as they a little older, substance abuse. But at my age, a great proportion of my colleagues are suffering from neurological degeneration. Musculoskeletal problems is high on the list of things that older people's lives are ruined by. And that one is so much in all of these can be talked about because they can be handled so differently. Cardiovascular disease and diabetes. Cancer isn't even up there as one of the causes of chronic debility because most people do not have your attitude of treating cancer like a chronic disease rather than an acute one.

 [43:40:35.620] - Dr. Lemanne
Yeah, I think I completely agree. And what are some of the things that you've been trying to impress upon your patients in order to deal with this and to work with trying to increase the health span? Now I'm trying to do some back of the envelope calculations here, and it looks like the health span is kind of keeping pace with the increase in lifespan. It's not really too much different. It's just the fact that we're living a little bit longer. That's the reason for the increase, the decrease in the health span rather than an actual increase overall. Meaning that we are living longer, but our health is staying the same. Is that what your take is?

 [43:41:25.460] - Dr. Gordon
Kind of, yes. And in particular, some of the diseases that we're looking at are actually beginning to decrease a little bit. You know, even before the GLP1 drugs, which are the magical diabetesweight loss drugs, we're doing a little bit better with preventing these diseases because this concept. So I think maybe a couple of our listeners also listen to Peter Attia. Dr. Peter Attia's podcast, the Drive. And he's the one who coined a shorthand phrase for what we're doing, which is medicine 3.0, to be distinguished from medicine 2.0, which is the salvation of 20th century medicine, and medicine 1.0, which was the herbs of 19th century and prior medicine, the herbs and bleeding and some things which should go unnamed, but we've progressed. He would like, he's coined the term medicine 3.0 to describe really hoping that people have. Paying attention to people having a longer time of healthy, really vital life. And he has a lot of tools and if you haven't looked at his book, outlive. It's a good outline of this. But what I'd say I start with my patients is really, from the very first understanding that, yes, if your Chief complaint is 1, 2, 3, I still want to know where you live, what you eat for breakfast, who's in your life.

 [43:43:04.870] - Dr. Gordon
Because these essentials of our daily life offer us some of the most simple and effective fixes to any threatened disability. And that would be diet, exercise, sleep. And then the term used connection is meant to cover several areas. Some of the connection is emotional. Some of the connection is thought of as, are you driven? Do you embrace a purpose in your life that you feel rewarding? And here's another connection I learned about this week. So I was chatting with a colleague of mine, Dr. Tommy Wood, about a book he's writing about preventing neurodegenerative disease or Alzheimer's. And he asked me kind of what the things I've noticed that were common threads in people who had cognitive decline. And I said, you know, retirement is not all it's cracked up to be. And I'd say several people I've talked to really decline when they retire. And he shared a newer insight with me that I'd never heard before, but it makes a lot of sense. The more intellectually demanding our work happens to be, Dr. Lemanne, the more we will suffer should we ever decide to retire. So I marched out and told my office staff, take retirement off my future plans.

[43:44:45.410] - Dr. Lemanne
Well, you know, that's the first time I'm hearing this. And I'm, I'm actually, I'm so happy to hear that. I really have been dreading the day that you leave the field of medicine. And so. Well, personally, that's wonderful. I'm really, really happy to hear that. And I, as you were. Yeah, yeah. And as you were talking, I, you know, I was thinking, you mentioned diet, exercise, sleep, and then you mentioned purpose. And I have been. I'm going to change my practice right here. See what. Yes, so you've talked me into changing my practice. I rank these items for patients in terms of importance and here's my ranking. Okay, number one, sleep. Yeah. Number two, diet. Number three, exercise. And then there are various types of exercise that I consider more or less important. But number four is going to move to number one, which is the purpose. And the reason is that I realized in my discussion with patients, I often don't make it to number four. We get to the first three and in that order. And I truly believe that that's the order in which they have to be tackled with without having sleep in place.

 [43:46:02.310] - Dr. Lemanne
And you will not have good metabolic health no matter what you do with diet or exercise. It doesn't matter.

 [43:46:08.140] - Dr. Gordon
Do you remember when you first learned CPR in medical school and they said, and particularly if you're dealing with a young person, you can't call a code considering them dead until they're warm and dead. Do you remember that aphorism as part of CPR training?

 [43:46:28.100] - Dr. Lemanne
I don't.

 [43:46:28.940] - Dr. Gordon
Somebody's not dead till they're warm and dead. And I would say somebody's not fat, diabetic or has dementia until they're sleeping and they still have those problems. Okay, so that's a good point that I'm going to move sleep up in my list.

 [43:46:44.340] - Dr. Lemanne
Well, you know, I'm going to move, I'm moving the purpose part of things up. Yes, I do have that talk with patients and I tell them that if I were Eastern medicine practitioner, I might be talking about qi, life energy. But since I'm not, I'm going to be talking about dopamine and other neurotransmitters which I consider life energy. And you know, dopamine is not the only neurotransmitter and it's not, you know, the only important one. But what dopamine, why it's got my interest and why I put it up in the front is because it directs goal seeking behavior. And if you want to have as your goal regaining health or maintaining health, you have to have a why. And so I think, you know, what you've just enlightened me about is that that has to be first. The person has to consider and figure out why. Why do they want health? And you know, because only then will you have the energy, the mental, emotional and even physical energy to tackle any problems with sleep, diet, exercise, et cetera.

 [43:47:52.870] - Dr. Gordon
Absolutely. And I guess I've looked at it as goals when people come to me with complaints where I know I'm going to, number one, draw a lot of tubes of blood from them, more than they've ever seen taken out of their body. And number two, give them a long list of suggestions. When all the results come in, I ask them what their goals are and how important they are. But I think you're right, particularly when they are retired or withdrawn or moved here without friends or anything that has shrunken their life's circle to talk to them about purpose, I'm going to rephrase my goals, word to purpose and connection.

 [43:48:41.270] - Dr. Lemanne
Do you know, you probably do know of a doctor named Tirone Low Dog, and if you don't, you'll remember her name because it's unusual. Yes, but she's a mentor of mine and I took a course, as you know, at the University of Arizona Integrative Medicine Fellowship a long time now. And one of the last lectures we had There was by Dr. Low Dog. And I didn't know it at the time, but she had recently been diagnosed with advanced metastatic breast cancer. She's still alive, so that's a number of years. Yes, we ought to take some advice from her. But what she said in this lecture, and I didn't know where it was coming from, was health is not really the important thing in life. And we were all there in this integrative medicine fellowship, you know, trying to figure out, seeking health. She said, what you're going to do with your health is what's most important, and you have to figure that out. And then she ended up writing a book a few years later called, I think it's called life is your best medicine or something like that, Life is the best medicine. Anyway, I think that that particular sentiment, she expressed that.

 [43:49:55.850] - Dr. Lemanne
But I don't think it really sank in until you just said that. Now, I did notice it, though, when she said that, it really struck me and it must have been coming from her heart because she had recently gotten this diagnosis, I believe, and she's very public about it. So I think, yes, I'm going to move that up to the very top. It's going above sleep.

 [43:50:20.370] - Dr. Gordon
And I'm going to rephrase it because if we're going to be on this journey together and this kind of medicine 3.0 is a journey because you, you. I'm just. I think everybody knows the conventional paradigm for dementia with, if you see a neurologist, they do about four blood tests. And when I say four, I don't mean, oh, one of them is the thyroid panel. I mean, no, two of them are thyroid tests. One of them is B12. And then they do one other test, which I don't know what it is.

 [43:50:57.830] - Dr. Lemanne
But really that was what we learned in. Which was, well, for me, decades ago.

 [43:51:02.530] - Dr. Gordon
Decades ago. Yeah, that's what they do. And then they write out a life plan and say, you know, your next markers are when you can't do this anymore and we'll start the medication. And then when you can't do that anymore, we'll take away your license. And then when you can't do this anymore, you'll be put into a home.

 [43:51:20.980] - Dr. Lemanne
Is that medicine 2.0?

 [43:51:22.630] - Dr. Gordon
That's medicine 2.0.

 [43:51:24.100] - Dr. Lemanne
Okay. Yeah, let's retire that.

[43:51:25.650] - Dr. Gordon
Let's retire that.

 [43:51:27.700] - Dr. Lemanne
That's. That's actually kind of hilarious in a morbid way.

 [43:51:32.830] - Dr. Gordon
And I will say in a. I.

 [43:51:34.690] - Dr. Lemanne
Would go for that. I mean, unless you're so demented you can't figure out what the doctor's saying, who's going to go for that?

 [43:51:42.110] - Dr. Gordon
Anybody whose sister in law also went to the doctor and heard the same thing and they think that's it. And they haven't been paying attention to the new and hopefully more widely publicized information about. It's more complicated than that. You know, we're, it's so much so getting way more detailed about this conversation. What's your purpose and what's your goals? And I'm going to rewrite my intake interview to start talking about that, and particularly with family members too, because family members, if you are completely independent and I'm working with somebody, whether it's about their weight, their blood sugar, their blood pressure or their brain, and it's all about. And they're still very healthy and competent, the primary relationship is going to be between me and that patient. But if that patient has cognitive impairment, they need to have a buddy at home. They need to have a buddy of some sort. So I'm going to involve the significant other in this. But you know, after we do these, they can even fix their connection purpose. Sleep, diet and exercise, or exercise and diet. And we can still have a lot of things we have to work with, you know, as they know, you know, I've never seen so many vials of blood tests.

 [43:53:13.310] - Dr. Gordon
And I said, yeah, and we haven't even gotten to the stool tests, the urine tests, the mri. And you're gonna. It's an ongoing relationship because I don't do all these tests right out of the gate at the first visit. But I know that there's gonna be different pathways through the forest that we're gonna pursue. Active leads. Kind of like a detective novel.

 [43:53:36.120] - Dr. Lemanne

Very nice. You like those?

[43:53:37.200] - Dr. Gordon
I do. I do like those.

 [43:53:38.770] - Dr. Lemanne
Yeah. Yeah. You know, that makes me think. I just realized as. As you were talking about that the culture in medicine that we've practiced on in past decades was to limit the number of tests. And the reason was very clearly, because, you know, have you ever played Dual N Back, this online game where you try to remember a sound and a position of a dot over and over again going 1, 2, or 3?

 [43:54:12.430] - Dr. Gordon
I want the name of this game.

 [43:54:14.210] - Dr. Lemanne
It's called Dual N Back. And if you play it for 20 minutes a day for eight weeks or something, supposedly it improves your IQ five or eight points or something. What it does is it improves your working memory so you can hold things in your mind as you manipulate them. So more than one or two things, you know, it can hold four, five, six. Apparently most of us can hold about seven. That's why phone numbers are seven digits long, for instance.

 [43:54:38.650] - Dr. Gordon
Oh, no, now they're 10.

 [43:54:42.950] - Dr. Lemanne
But the reason that medicine discourages there are financial reasons. We don't want you doing 20 vials of blood because it's going to be expensive. The insurance companies say, et cetera. I'm sure the blood test companies are happy about that, though. But the reason was, is that you couldn't manipulate with the human mind more than three to seven things at once and figure out the relationship between them. By the time you get to seven things, the number of relationships is seven factorial or something like that. It's just, you know, huge, huge number, and you can't make much sense of it. However, we have invented this thing called the computer. And now we've trained the computers to think. We call it artificial intelligence. And we are now able to use those tools to manipulate and find patterns in very large numbers of items that before just looked like, you know, this big hurricane of, of data points. So now we will see, you know, doctors doing many more, many, many more tests, and we'll be using, you know, I'm already using and you are, too, devices such as sleep monitors that you wear on your wrist and activity monitors that you also wear on your wrist, et cetera, like I like whoop, and you like Oura ring.

 [43:56:00.280] - Dr. Lemanne
And then there's Fitbit, and there's Y things. There's a whole garment. There are a lot of them, and they give us a lot of data, and we can crunch that now and really help patients. So I've been telling patients, you know, if you really want to improve your sleep, for instance, you have to measure it. You have to. There's no other way to do it. Otherwise, you're, you know, stepping up to the, you know, putting a bow and arrow in your hand, pulling back and covering your eyes. You just kind of sort of know the direction of the target. You can shoot 100 million arrows at the target, and you're not going to improve because you don't have any feedback. You have to take off the blinders and look at the effect of each shot and then consciously improve it. And that's what these devices allow you to do with sleep, with exercise. Oh, my goodness. When I have these patients who tell me, oh, I exercise so much, blah, blah, blah, you put on Fitbit. Oh, not so much, huh?

 [43:57:01.600] - Dr. Gordon
Not so much. So I want to say something about sleep because I think it's important. The second the actual phrase you ended up with in your talk then just was that you have to look at your sleep and there is some data. And then I recently heard a cognitive behavioral therapy therapist talk about it. You have to look at it, but you actually don't need a device. There's pretty good if you know the details to write down and you remember how to write with an. You know, they have these writing implement things that I, you and I both love called nice pens.

 [43:57:39.830] - Dr. Lemanne
Oh, I do like a good pen.

 [43:57:41.710] - Dr. Gordon
So you have a nice pen and a good notebook and you ask the proper questions.

You can learn a lot from attending to your sleep with your own memory recall and keeping notes of it and keeping yourself honest. Oh, how many drinks did I have last night before bed, you know, and how many times did I get up and how well did I go back to sleep? You can do it without a device. Except there's one thing I think you absolutely need a device for.

 [43:58:16.750] - Dr. Lemanne
Oh, now you've got my hanging on.

 [43:58:19.730] - Dr. Gordon
A cliff, wondering what it is.

 [43:58:21.470] - Dr. Lemanne
I do. I am. I'm on your cliff.

 [43:58:24.130] - Dr. Gordon
All my patients know if they're. If you have had any sleep trouble, you deserve to be checked for sleep apnea. The archetype. That's not the stereotype. That's the word I'm looking for. The stereotype of a sleep apnea patient is a heavy, overweight, loudly snoring.

 [43:58:44.800] - Dr. Lemanne
Yes, we need to retire that.

 [43:58:46.650] - Dr. Gordon
We need to retire that. Something I learned from an oral surgeon. Talking about sleep apnea is equally as many sleep apnea patients are athletes because we are not very good in our athletic endeavors at keeping our blessed mouth closed. So we have rushing air going through a delicate pathway, and we can make it floppy and misbehaving. And those people, if you have that Kind of sleep apnea. You probably don't snore. Snoring is when you stop breathing and wake yourself up again, kind of. Or wake your partner up again. Hypopnea. And that can be pretty low oxygen. And you just tolerate it for 40 minutes and you move your jaw a little bit and you start breathing again. And nobody knows you were suffocating for a minute and a half. Except an oxygen tracker.

 [43:59:48.150] - Dr. Lemanne
Well, you know, these devices now check, track your oxygen levels too.

 [43:59:52.350] - Dr. Gordon
Not as sensitively as a little. You know, we all had pulse oximeters during the COVID pandemic because we wanted to know. Even if I know is if you had Covid and your oxygenation went down as low as 91% you were supposed to go to the emergency room and not before that or something like that. I don't remember what the number was. But you know, if you get these little pulse oximeters that you wear on your finger and strap it to a bracelet you wear on your wrist, you can do a perfectly good home sleep study either through the local hospital or through the respiratory care people or we have rentable devices at our office. You can test for sleep apnea without going and sleeping in a sleep lab.

 [44:00:34.570] - Dr. Lemanne
Absolutely. Recently, whoops band was tested against in lab polysomnography, which is the gold standard and was equal.

 [44:00:45.690] - Dr. Gordon
Oh, big information 

[44:00:48.480] - Dr. Lemanne
Yeah. So these devices are becoming very sophisticated and I'm a big. I expect hospital at home to be a thing in the next few years. A lot of patients will be able to stay at home with these devices monitoring their vital signs better than a nurse, more frequently than a nurse coming in every eight hours to measure them with a little blow up balloon sphygmomanometer and those kinds of things. And we'll be able to do most of the things that we do in a non ICU setting.

 [44:01:23.300] - Dr. Gordon
And then they're going to have a little robot at the bedside that can respond accordingly.

 [44:01:30.090] - Dr. Lemanne
Yes, I think so. I do. I think we'll be able to do operations robotically on astronauts that are up in space and all sorts of things. Yes, I think it's really, it's an exciting new frontier. That's the medicine 4.0.

 [44:01:44.580] - Dr. Gordon
Yeah. Yeah. I'm still quite engaged in enjoying medicine 3.0, which in my mind is so much more, you know, I somehow I have no idea why. I think just because there's a doctor shortage, I've received a number of texted, would you be interested in this position as a doctor and we'll give you $100 million or something.

 [44:02:07.810] - Dr. Lemanne
I Mean, it's just unbelievable. And it's, you know, it's like these are jobs you would never take.

 [44:02:12.760] - Dr. Gordon
I would never take. I'd rather wait tables where I can talk to somebody. As long as, you know, I'm willing to agree. I agree. You'd live in the car. You've done that, haven't you?

 [44:02:23.560] - Dr. Lemanne
I have actually. It was an rv. It had a bathroom and a kitchen. It was a nice big long one.

 [44:02:29.000] - Dr. Gordon
But I've lived in a teepee. Did you know that?

 [44:02:32.040] - Dr. Lemanne
Did you really?

 [44:02:33.160] - Dr. Gordon
Yeah.

 [44:02:33.550] - Dr. Lemanne
That's pretty cool. You're pretty crunchy, aren't you?

 [44:02:34.590] - Dr. Gordon
 I was lying in that teepee thinking, maybe I'll go to medical school. I think it's good to take a circuitous path towards life. And one of the things that's enabled us to stay in medicine and healthcare because we started maybe a little later than had we gone left foot, right foot all the way through and weathered it through. You know, we Both practiced medicine 2.0 quite a bit before the sun began rising on this new field of medicine, this 3.0, or healthspan medicine or precision medicine. A lot of different things to call it.

 [44:03:15.930] - Dr. Lemanne
Well, yeah, but I'm going to push back a little bit on that. I always had an interest, always since childhood in how diet, exercise, lifestyle affected serious chronic illness. I mean I didn't have those, the vocabulary for it, but that was my, those were my interests.

 [44:03:34.160] - Dr. Gordon
Uh huh. No, I was interested too.

 [44:03:36.400] - Dr. Lemanne
I bet you were. You know, and in fact, when I announced to my med school friends that I was going into oncology, the response was uproarious laughter because that does sound.

[44:03:47.710] - Dr. Gordon
Like a very medicine 2.0 specialty.

[44:03:50.830] - Dr. Lemanne
You're not going to do well in that. Lemanne was the, you better pick something.

 [44:03:54.500] - Dr. Gordon
Else, put yourself in it. I think. You know, when I was in, must have still been in high school, I came across the writings of Adele Davis.

 [44:04:04.320] - Dr. Lemanne
Yes, yes.

[44:04:06.090] - Dr. Gordon
And I remember, you know, charging into the kitchen and saying, one pound of raw beef liver. Right up my alley. But charging into the kitchen and saying, we have to start buying whole wheat bread. You know, this white bread is worthless.

 [44:04:22.490] - Dr. Lemanne
I can see you doing that. Yeah, you drove your parents crazy rally.

 [44:04:25.510] - Dr. Gordon
Probably just a little bit. But yeah, so I remember Adele Davis.

[44:04:27.490] - Dr. Lemanne
You know, she died of aml, I believe.

 [44:04:33.150] - Dr. Gordon
Oh yeah. And I always Acute myelogenous leukemia, which. 

[44:04:37.070] - Dr. Lemanne
I think is related to infection in many cases. And I wondered if it was the raw animal products, you know, not that they're bad for you in general, but that you could pick up Something possibly, I suppose, or maybe it was completely unrelated, but I remember that. And she wasn't that old. And that was instructive to me. It was instructive in the sense that no matter how good something sounds, we have to look at it carefully and.

 [44:05:06.480] - Dr. Gordon
Really evaluate it and know if you're taking a risk, that you're doing it as carefully as possible. Which brings to mind so recently Scientific American put out a. An electronic version only, at least at the point I've seen it, seen it. Publication and compilation of different experts talking about healthspan, that's the name of the special production that you can presentation that you can access online. We'll put a link to it. And they do mention that, really. So there's a great search on for a single intervention, a drug that could extend health span without compromising it in any way. And they discuss the two methods that are on the table that have some legitimacy and some track record in that regard, one of them being metformin, which is very effective if you have any tendency towards type 2 diabetes. It will extend your life and I believe, reduce your risk of cancer and other things. Right.

 [44:06:16.120] - Dr. Lemanne
Apparently, metformin in patients who are diabetic is associated with a decreased risk of cancer and a decreased risk of cancer mortality in type 2 diabetics who have a diagnosis of cancer compared to type two diabetics who don't. Now, there are some problems with that because type 2 diabetics who have cancer or who don't in the past, anyway, I think this is going away. But in the past, when these studies were done, were often treated with insulin, and insulin is a driver of growth, cancer growth. So that may have been some confounding, although I'm sure that the researchers took some, you know, made some great efforts to reduce that confounding. But those studies are there. They make metformin very, very interesting. And I do think that that's something we ought to look at. I, I tend to tell patients, you know, what metformin does is it prevents blood sugar from going higher. It doesn't lower blood sugar, but it prevents it from going up. And you can do that with diet. You can do that with diet and also with food timing. So why not try that first? Because that's the goal, actually. Not taking the drug.

 [44:07:30.260] - Dr. Gordon
Yes.

 [44:07:30.700] - Dr. Lemanne
Yeah, it's interesting.

 [44:07:31.430] - Dr. Gordon
And that's when circling back to your question with the discussion with the patient about what are your goals? Are you willing to make some sacrifices towards your goals? I'm not really willing to give up my granola well, then you may need metformin. But I think that's a wild thought, isn't it?

 [44:07:49.080] - Dr. Lemanne
I'm going to eat this food, but I'm going to have to take drugs to do it. That's kind of a wild thought when you.

 [44:07:57.320] - Dr. Gordon
I think the bigger disadvantage of metformin is partly because you take it every day, which is a contrast with the other drug I'm going to talk about. But you take it every day and it blocks your. Keeps your blood sugar from going too much higher and it also prevents you a little bit from making new muscle tissue. So isn't sarcopenia a side effect of metformin?

 [44:08:24.220] - Dr. Lemanne
Absolutely. And, you know, I think the second drug you're going to talk about has the same effect.

 [44:08:29.230] - Dr. Gordon
Well, it has the same effect. So the second drug. Da da da da da da is rapamycin. And rapamycin has terrible side effects if you take it all the time because it's an immune suppressant. It was a diabezogenic and a diabeciogenic. Interesting. But that's if you. So if you take it all the time, it blocks your immune system. You get sick more often, you don't respond to vaccines, you get sarcopenia and evidently you get fat. I didn't know that. Using it intermittently. It's described as taking the role serving as well as a limited fast. And we've discussed you're an excellent faster. I'm a not very good faster, but I've never tried to take the slightly more extended fast that you have, which you say it always gets better after the first day. But rapamycin is probably the most promising in that we have data in even mammals, though they be lowly rodents for it actually extending lifespan and health span for those creatures studied.

 [44:09:48.790] - Dr. Lemanne

There's a lot of data now in dogs, thanks to Matt Kaeberline. Right.

 [44:09:52.190] - Dr. Gordon
Well, it's coming. Nothing they've published and there's a little bit of observational work through Matt Kaeberling and actually his. It must be his wife, Tammy Kaeberling. So Matt's own. We've, I think talked about this before, but you know what? I think it was in an episode we actually didn't bring to light. But Matt Kaeberling's story of. He had done a lot of work with this. So he was a University of Washington professor. He is not a physician and he was doing a lot of work with rapamycin and had his suspicions that it would help him speed up the repair process for his frozen shoulder. He had a frozen shoulder and the doctor said, it's just going to take a while for your body to reabsorb all that scar tissue and put everything back together in a working way. And he says, huh, remove all the scar tissue, kind of remove the dying senescent cells, and maybe get my shoulder to heal faster. So he took it so he could toss footballs with his teenage son. And he had a remarkable recovery far in advance of what the doctors predicted for him. So that inspired me to take rapamycin and to kind of follow it a little bit, including during the pandemic.

 [44:11:13.670] - Dr. Gordon
And so I do offer rapamycin to my patients, but with all the disclosures that we don't really know. And we're going to monitor it carefully. And when I monitor it carefully with people, they take blood tests before they do the rapamycin and three to six months into it to make sure I haven't wiped out their immune system. And I also make sure that they don't have any rapamycin in their system between doses and things like that. But there was a clinic where a large number of the patients in the clinic were there and were taking rapamycin. And when they got Covid, just spontaneously, half of them stayed on the rapamycin and half of them went off the rapamycin when they got sick, which would have previously been my recommendation. But the ones who stayed on the rapamycin did better in terms of severity, length of disease, and percentage of long Covid affecting those who had it. So just totally observational. Could have been confounded in a number of ways, but makes me. Oh, and there are studies showing that rapamycin can increase response to vaccines in older people, because we older people don't respond to vaccines with as great an immune vigor and memory as you younger folks.

 [44:12:35.600] - Dr. Lemanne
You're including me in the younger?

 [44:12:37.840] - Dr. Gordon
Yeah. You're so young, Don. I remember being that young. 

[44:12:41.250] - Dr. Lemanne
That's generous. Yeah. Well, all those things are really interesting about rapamycin, which is used in oncology to treat certain cancers, like specifically kidney cancer. Not so much anymore, but it wasn't.

 [44:12:52.920] - Dr. Gordon
How is it used? What kind of dose? What kind of.

 [44:12:55.300] - Dr. Lemanne
I don't know. I'd have to look it up. We don't use it anymore.

 [44:12:58.400] - Dr. Gordon
It was used.

 [44:12:59.170] - Dr. Lemanne
It was used. We have better treatments now. But yeah, it's really interesting. And it's really interesting about the COVID You know, fisetin, which is an antiseinescent supplement, will also possibly decrease the inflammation from COVID by calming down the immune system. You know, a lot of the Damage from COVID is over activation of the immune system. Kind of a cytokine stimulus. So it's really interesting. Perhaps that's how rapamycin is working, cutting down some of the damage.

 [44:13:34.740] - Dr. Gordon
We'll have to remember this about thinking about fisetin now. So the kind of the longevity intervention for fisetin is episodic, is that right?

 [44:13:43.970] - Dr. Lemanne
Yeah, it's given once monthly, sometimes once weekly, something like that. There are various protocols at a pretty high dose, very high dose, like 1,500 milligrams two days in a row, once a week or once a month, something like that. And you know, check with your doctor's people before you do this. But that's something that you could. It's probably safe for most people. But do check before you jump into that. Don't take my word for it. And yeah, so I think those things are very, very interesting. I don't think that, you know, one drug will ever be the solution. I could be wrong, but I don't think one drug will be the solution to longevity.

 [44:14:29.100] - Dr. Gordon
Nothing bypasses those curses.

 [44:14:30.990] - Dr. Lemanne
Unless it's an anti entropy drug which is the driver of the timeline of the universe. Without entropy you don't have time. Without time, I guess we'd all live forever or just live for a moment. I don't know. But ask Einstein. But I think looking at these drugs right now is very, very, very interesting. But please do it with your doctors.

 [44:14:51.600] - Dr. Gordon
Yeah, and I started it because I have arthritis in my knees and don't have knee replacement because you lose range.

 [44:15:00.070] - Dr. Lemanne
Of motion, you also lose brain cells. But that's a different.

 [44:15:04.050] - Dr. Gordon
When you lose, when you have your knees replaced, you lose brain cells from.

 [44:15:07.830] - Dr. Lemanne
The anesthesia and the surgery. And just the surgery itself is carcinogenic. So you know, the more operations someone has, the higher the risk.

 [44:15:15.460] - Dr. Gordon
Okay, we're going to talk about that next time. But I will say that, you know, so that's my chronic debility of advancing age is musculoskeletal and I do think that the rapamycin. But you know, and if it. So I totally happy to grant that it's placebo because I want it to work. But I think when I take the rapamycin my knees feel a little bit better until it then it's time for another dose and taking it weekly. So if on top of the good exercise and it better enables me to exercise, it's a partner but the connection.

[44:15:56.220] - Dr. Lemanne
That's a good point. So anything that can keep somebody moving is probably, you know, that drug gets a lot of Points for that.

 [44:16:05.100] - Dr. Gordon
It gets a lot of points. And if it enables me. Well, you know, that was the great thing about dental braces is it definitely reduced any tendency I had towards snacking.

 [44:16:19.640] - Dr. Lemanne
You didn't go for the liquid snacks? That's what I would have done.

 [44:16:22.520] - Dr. Gordon
Oh, no, I did not go for the liquid snacks. Oh. But yeah, so breaking the habit of snacking. You know, it would be interesting to have a podcast talking about overeating and the life practices drugs and modern drugs that are used for that. All of them with their pros and cons.

 [44:16:47.150] - Dr. Lemanne
Oh, I'd love that. And my favorite, you know what my favorite is?

 [44:16:50.090] - Dr. Gordon
What's your favorite?

 [44:16:50.850] - Dr. Lemanne
CGM gives you a picture of what your food is doing to you or for you.

 [44:16:56.890] - Dr. Gordon
What is a CGM, Dr. Lemanne?

 [44:16:58.720] - Dr. Lemanne
Oh, sorry. Continuous glucose monitor. It's a patch, a sensor that you stick on the back of your arm. It sends a Bluetooth signal to your iPhone app and it gives you a tracing of your glucose every minute or every five minutes, whatever your particular sensor is set for. And so you can see immediately how a particular snack or meal or lack of sleep, et cetera, affects your blood sugar curves.

 [44:17:24.320] - Dr. Gordon

So do you encourage patients or do you yourself, if you've done this, keep a little log that includes all those details, everything you eat and when you're sleeping and things like that.

 [44:17:34.220] - Dr. Lemanne
I do encourage that. I have, I use a whoop band for sleep and I, rather than make patients log it, that's just automatic. It gets logged by the whoop band and we can certainly match that up with the cgm, the continuous glucose monitor curves and you can see, you know, when someone misses, you know, three hours of sleep, two or three hours of sleep, especially a couple days in a row, their blood sugar goes immediately into the diabetic range. It doesn't matter what their diet is. They could have the most beautiful diet. If you're not sleeping, you're going to be sick. And pretty quickly, it's not subtle and.

 [44:18:15.330] - Dr. Gordon
It'S not mild and it changes. So I knew it changed. So they've done observational studies where they had resident subjects. And some of the resident subjects were their sleep was restricted to something like six hours versus the others who were allowed to sleep eight hours. And what they logged was nothing so sophisticated as their blood sugar, but their choices at the free feeding buffets that were included for the resident sleep study.

 [44:18:46.700] - Dr. Lemanne
Oh, yeah.

 [44:18:47.360] - Dr. Gordon
And those who slept a restricted number of hours made poorer choices.

 [44:18:52.860] - Dr. Lemanne
Well, it increases your appetite, increases cortisol level, decreases willpower. Willpower is a molecule, a neurotransmitt, and you can run out of it.

 [44:19:01.590] - Dr. Gordon
Is that what it's called? Will power?

 [44:19:03.120] - Dr. Lemanne
Amine? You know, let's call it that.

 [44:19:07.780] - Dr. Gordon
Okay. And with that, do we have anything else we want to say? I mean, we could go on forever about healthspan because there's so many interesting details and I love this intersection of attention for your brain, your cancer risk or treatment, and your enthusiasm and relationship with your life. I mean, what a web this all is. Anything else we want to say about healthspan?

[44:19:34.560] - Dr. Lemanne
I'm good.

 [44:19:35.460] - Dr. Gordon
I'm good. And I can't wait to talk about some of the little issues we touched on today. So see you next time.

 [44:19:42.460] - Dr. Lemanne
See you next time. Deborah.

 [44:19:45.920] - Dr. Gordon
You have been listening to the LemanneGordon Podcast where Docs Talk Shop for.

 [44:19:52.080] - Dr. Lemanne
Podcast transcripts, episode notes and links, and more. Please visit the podcast website@docstalkshop.com Happy eavesdropping. Everything presented in this podcast is for educational and informational purposes only and should not be construed as medical advice. No doctor patient relationship is established or implied. If you have a health or a medical concern, see a qualified professional promptly.

 [44:20:27.920] - Dr. Gordon
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 [44:20:39.930] - Dr. Lemanne
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[44:20:54.500] - Dr. Gordon
Again, if you have any medical concerns, see your own provider or another qualified health professional promptly.

 [44:21:01.350] - Dr. Lemanne
You must not take any action based on information in this podcast without first consulting your own qualified medical professional. Everything on this podcast, including music, dialog and ideas, is copyrighted by Docs Talk Shop.

 [44:21:20.000] - Dr. Gordon
Docstalk Shop is recorded at Freeman Sound Studio in Ashland, Oregon.