A research-based protocol for longevity

According to the CDC, the main causes of death for a 35 year old (my age) are unintentional injuries (poisoning through narcotics and psychodysleptics or motor vehicle accidents), followed by cancer, coronary heart disease, suicide or homicide [1]https://wisqars-viz.cdc.gov:8006/lcd/home.

If you fast forward to 65 years+, the main causes of death change to coronary heart disease, cancer, lung disease, stroke, and Alzheimer’s for both men & women [2]https://wisqars-viz.cdc.gov:8006/lcd/home.

So, what should I do in order to minimize risk of death at 35, while optimizing for longevity – aka do things now that will have a positive impact on my health for when I’m 65 years old?

Before I start, two disclaimers:

  • This post summarizes my opinion on the topic, backed by research papers with large effects on (mostly) large sample sizes. That said, I am not a medical professional, and this post is not intended to diagnose, treat, cure, or prevent any disease. The content below is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
  • I’m the CEO & co-founder of Ezra, a healthcare startup that’s created a new way to screen for cancer everywhere in the body using a full body MRI powered by Artificial Intelligence. I’m including an annual full-body MRI in my recommendations below. While recent research supports an annual full-body MRI, I’m also slightly biased, hence the disclaimer.

Every day:

  • Sleep well (7-8+ hours / night)
    • Lack of sleep has been shown to significantly increase risk of all-cause mortality, diabetes, hypertension, cardiovascular disease, and obesity [3]https://pubmed.ncbi.nlm.nih.gov/27743803/. I try to sleep 8 hours a night. To sleep well, I set the temperature around 65 Fahrenheit and make my room as dark as possible.
  • Exercise
    • Exercise decreases blood pressure, inflammation, and reduces risk for cancer [4]https://pubmed.ncbi.nlm.nih.gov/28718417/ [5]https://pubmed.ncbi.nlm.nih.gov/28324125/. The ideal exercise protocol should include a combination of cardio and resistance training. Resistance training has been shown to improve muscle mass, bone density, and reduce blood pressure (more so than cardio alone) [6]https://pubmed.ncbi.nlm.nih.gov/32422599/. I’m personally partial to compound weightlifting exercises (squats, deadlifts), as they’re a very efficient way to train. I also recommend low-impact cardio such as swimming, cycling, or rowing. I’m a big fan of running, too, but my empirical evidence from a dataset of one shows that running is not that great for my knees.
    • I’ve also found that exercising in the morning is best for compliance.
  • Practice meditation and yoga
    • Meditation and yoga have been shown to reduce blood pressure, which lowers the risk for stroke and coronary heart disease. Meditation also reduces stress, which is a cause for high blood pressure and high cholesterol [7]https://pubmed.ncbi.nlm.nih.gov/28384004/ [8]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923750/. Thus, meditation and yoga have a double whammy effect on lowering blood pressure and risk for heart disease.
  • Eat healthy food, not too much, mostly veggies
    • Focus on eating mostly a mediterranean diet – veggies, nuts, fruit, fish. It’s been shown to decrease the risk of cancer and cardiovascular disease, and increase overall life expectancy [9]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352455/.
    • For the most part, avoid carbs, sugar, fructose, and alcohol. These all lead to insulin resistance, Type 2 diabetes, and increase fat deposition [10]https://link.springer.com/article/10.1007/s00394-016-1340-8. Also, unbeknownst to me until I started doing this research, fructose has the worst impact on health, and it’s found in pretty much everything you crave – sugary soft drinks, burger buns, ketchup, etc.. I don’t want to completely eliminate these from my diet (I don’t want to live like a monk), but I treat them as rare treats and consume sparingly.
  • Skip breakfast (you can still have black coffee, I’m not crazy) or dinner
    • If you can, start doing intermittent fasting (which basically means skipping breakfast or dinner). It helps reduce caloric intake, which helps you lose weight. There’s also some evidence that a caloric deficit increases longevity by reducing blood pressure, and by decreasing risk for cancer and other diseases [11]https://pubmed.ncbi.nlm.nih.gov/28202779/. And it allows your gut to take a break.
  • Be careful when crossing the street, and don’t text and drive or walk
    • Motor vehicle accidents are a leading cause for death in young people. Look three times before crossing any street (yes, three times). Don’t jaywalk (if you do, look three times before doing it). If you drive, put your phone on sleep mode while you’re driving, so you’re not tempted to text or even speak on the phone.
  • Take precautions to stay physically safe
    • Homicide is a leading cause for death in young people. Luckily – I live in New York, the safest large city in America, but even so I try to be vigilant about what’s going on around me.
  • Get a cold shower in the morning
    • Exposure to cold is known to activate the sympathetic nervous system and increase the blood level of beta-endorphin and adrenaline. Additionally, due to the high density of cold receptors in the skin, a cold shower is expected to send an overwhelming amount of electrical impulses to the brain, which could result in an antidepressant effect. A large study (3,000+ people) has shown a 29% decrease in self-reported sickness after a 30-day cold shower regimen [12]https://pubmed.ncbi.nlm.nih.gov/27631616/.
  • Spend time with people you love
    • An active social life and time spent with friends & family leads to less stress, which is good for health. Recent research has shown a direct correlation between social factors and healthy aging [13]https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1809-98232017000600878.

Once / week:

  • Eat meat sparingly
    • If you like meat (I do), try to limit meat intake to once or twice per week, and eliminate consumption of processed meat completely. Processed meat has been shown to increase risk for cancer, heart disease, and type 2 diabetes [14]https://www.sciencedirect.com/science/article/abs/pii/S0278691516301144?via%3Dihub. Unprocessed meat seems to be neutral but further evaluation is needed, so I’d err on the safe side and try to minimize consumption.
  • Don’t drink too much alcohol
    • I like red wine, but try to limit consumption at once per week. Drinking too much alcohol decreases sleep quality, negatively impacts cardiac function, increases risk of liver disease, and may lead to dementia and depression [15]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821259/ [16]https://pubmed.ncbi.nlm.nih.gov/25880513/ [17]https://pubmed.ncbi.nlm.nih.gov/29041989/ [18]https://pubmed.ncbi.nlm.nih.gov/28950395/ [19]https://pubmed.ncbi.nlm.nih.gov/21382111/.
  • Measure your weight
    • I don’t believe in measuring your weight every day as weight fluctuates quite a bit, but weighing yourself every week is very useful to observe trends. I use a scale that connects to my wifi and uploads weight data into my Apple Health.
  • Do a 24-hour water fast
    • Fasting has been shown to reduce body weight, cholesterol, and blood pressure [20]https://pubmed.ncbi.nlm.nih.gov/26374764/. My 24-hour fasting protocol is basically have dinner, then don’t eat anything until the next dinner. It’s pretty easy, especially on a busy day. It’s gotten even easier since I started doing intermittent fasting a few years ago. I basically skip breakfast and lunch on the days I’m doing a 24-hour fast.

Once / month:

  • Measure blood pressure.
    • While the probability is low that a healthy 35 year old male (that’s me) would have high blood pressure (currently 117/70), I want to see how trends evolve over time. I have an Omron wireless blood pressure monitor that automatically uploads the data to my Apple Health, and I have a monthly reminder to take my blood pressure on the last Sunday morning of the month, before having coffee.

Once / quarter:

  • Get blood tests
    • At the bare minimum, a good panel will include cholesterol, fasting insulin, testosterone (for guys), inflammation markers, iron, and vitamins. A good primary care physician should be able to design a good panel. I may publish mine at one point (you can email me for a sample, in the meantime).
    • Some people might prefer doing blood tests every 6 months. I think quarterly is better, as it gives you more immediate feedback on changes you’re making (or that you need to make).
  • Do a multi-day fast. It’s excellent for weight-loss (you can easily lose 10-12 lbs in a 3-5 day fast), and some doctors have used multi-day fasts as a way to reverse Type 2 diabetes. I found this book very useful to plan for multi-day fasts.

Every 6-12 months:

*Note: a lot of the recommendations below err towards aggressive cancer screening. More data is needed to support these, but I’m in the “more is more” camp on this one, due to how aggressive cancers in young adults are.

  • Get a full-body MRI
    • A full-body MRI is a safe and effective way to check for cancer, or other life-threatening diseases (e.g. aneurysms) [21]https://pubmed.ncbi.nlm.nih.gov/29627288/ [22]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248944/ [23]https://pubmed.ncbi.nlm.nih.gov/28091804/ [24]https://pubmed.ncbi.nlm.nih.gov/25810696/. You can sign up for a full-body MRI scan through Ezra, a startup that offers full body MRI scans powered by AI across New York, San Francisco, and Los Angeles (Disclaimer: I’m the co-founder & CEO of Ezra). Some folks believe you shouldn’t be worried about cancer before the age of 40, but the reality is that in 2020, there will be approximately 89,500 new cancer cases and 9,270 cancer deaths in adolescents and young adults (AYAs) ages 15 to 39 years in the United States. You don’t want to be a statistic [25]https://www.cancer.org/cancer/cancer-in-young-adults/key-statistics.html. There is some legitimate concern around over-diagnosis caused by incidental findings in full-body MRI. At Ezra, we use multi-parametric MRI (functional and anatomic imaging) to minimize over-diagnosis, and have a medical team on staff trained to guide you through any abnormal findings.
  • Get a DEXA scan
    • This will give you bone density and muscle mass data, which is especially important as you get older. You want to increase muscle mass and maintain or increase bone density as you age. An MRI and a DEXA scan will influence what type of exercise you should do (e.g. low bone density -> weightlifting).
  • Get a pap smear every 12 months
    • If you’re a woman, do a pap smear and an HPV co-test every year, as it’s been shown to reduce death rates from cervical cancer. This is especially valid if you’re under 40 years old [26]https://pubmed.ncbi.nlm.nih.gov/27598026/.
  • Get a mammogram and / or a Breast MRI
    • If you’re a woman over 40, do a mammogram every year. I personally think women should also get a baseline mammogram when they’re 35; this will also show if a woman has dense breast tissue. If you have dense breast tissue, a Breast MRI has been shown to increase early-stage clinically significant breast cancer detection [27]https://pubmed.ncbi.nlm.nih.gov/31774954/. If you decide not to get a baseline scan in your 30s, definitely start doing a mammogram and / or breast MRI every year starting the age of 40.
  • See a dermatologist
    • If you have moles and / or live in an area with a lot of UV exposure, do a dermatology skin check every 6-12 months. It’s quick and it will help detect melanoma or other types of skin cancer early. Further evaluation is needed to determine whether this practice will decrease skin-cancer mortality [28]https://pubmed.ncbi.nlm.nih.gov/27583318/, but the probability of over-diagnosis is low, and I’d rather err on the cautious side.
  • See your dentist
    • Seriously. Teeth and gums are important, and you’ll only realize how important they are once you start having issues. Floss. See a dentist every 6 months, and get an X-ray every 2 years. It will help you discover issues before they become serious. If you’re in New York, I strongly recommend you go here.
  • Donate blood
    • If you’re male, donate blood every 6-12 months to reduce iron stores, which has been shown in some studies to decrease risk of heart attacks [29]https://pubmed.ncbi.nlm.nih.gov/9326996/ [30]https://pubmed.ncbi.nlm.nih.gov/9737556/.

Every 5 years:

  • Get a low-dose chest CT with calcium scoring
    • A LDCT with calcium scoring is the best way to detect heart disease and lung cancer (especially if you’re at risk of lung cancer due to smoking) [31]https://pubmed.ncbi.nlm.nih.gov/31995683/ [32]https://pubmed.ncbi.nlm.nih.gov/31754800/. Those at very high risk of lung cancer should consider doing a lung scan every year / every two years. We offer LDCT scans at Ezra.
  • Get a colonoscopy
    • The American Cancer Society recommends colon cancer screening using a stool test or colonoscopy starting the age of 45, for those at average risk [33]https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html. However, there’s increasing evidence of colon cancer in young adults [34]https://pubmed.ncbi.nlm.nih.gov/30659375/, so I personally think colon cancer screening should start at 40 for those at average risk, and 35 for people with high risk (due to family history).

Other considerations:

  • Avoid hospitals, especially the Emergency Room
    • Almost 50% of poisonings are caused by drugs mis-administered during surgery, or inadequate prescription drugs [35]https://wisqars-viz.cdc.gov:8006/lcd/drill-down?causeLabel=Unintentional%20Injury&agegrp=35-44. Furthermore, avoidable medical errors are a leading cause of death in the United States [36]https://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx. In the ER, as much as 40% of emergency room nurses have witnessed or caused medical errors [37]https://pubmed.ncbi.nlm.nih.gov/29076206/. Try to stay out of the ER. While there is no guarantee, adhering to the list above will decrease your risk of landing in the ER.
  • Get a genetic test to check for genetic predisposition to heart disease or cancer. I really like Color Genomics.
  • Regardless of whether you’re male or female, get an HPV vaccine. It’s been shown to substantially reduce risk for cervical cancer [38]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992181/.
  • You’ll notice I have not included any nootropics in my recommendations (i.e. resveratrol, metformin, NMN, rapamycin). I haven’t yet tried any, but I intend to. David Sinclair takes them, and a recent small trial has shown that they can potentially reverse aging in humans [39]https://www.nature.com/articles/d41586-019-02638-w [40]https://www.amazon.com/dp/0008380325/ref=cm_sw_r_tw_dp_LLEdGb4D2PFX0.
  • Don’t stress about that Apple Watch data
    • Wearable sensor data is useful, but not super actionable. Sure, walk more steps.
    • Resting heart rate trends are interesting (lower is better), and heart rate variability is useful to avoid overtraining. But IMHO the most useful wearable sensor data is knowing how much you sleep every night, and optimizing that. The Oura ring and the Whoop are both great at tracking sleep. The Apple Watch tracks sleep as well but I find it too bulky to sleep with.
  • If you can afford it, I recommend investing in some technology to help you sleep better. This tweetstorm from Nat Eliason is pretty good.

This article covers a lot, and it does take a certain amount of discipline to do all the things I recommend above consistently. What’s important is to just get started, and if I were to choose the things to start with, I’d say: exercise, get weight under control (if you’re overweight), and get screened for cancer.

A final thought: don’t smoke. If you smoke, the only takeaway from this article should be to stop smoking. Lung cancer kills more people than all other high incidence cancers combined [41]https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2020.html. Quitting smoking will decrease your risk of cancer, heart disease, Type 2 diabetes, and stroke more than everything else in this list combined. Don’t smoke.

Thanks to Michael Chen MD, Esther Dyson, Balaji Srinivasan, Sabina Gal, and Kim Scott for reading drafts of this.

References

References
1, 2 https://wisqars-viz.cdc.gov:8006/lcd/home
3 https://pubmed.ncbi.nlm.nih.gov/27743803/
4 https://pubmed.ncbi.nlm.nih.gov/28718417/
5 https://pubmed.ncbi.nlm.nih.gov/28324125/
6 https://pubmed.ncbi.nlm.nih.gov/32422599/
7 https://pubmed.ncbi.nlm.nih.gov/28384004/
8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923750/
9 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352455/
10 https://link.springer.com/article/10.1007/s00394-016-1340-8
11 https://pubmed.ncbi.nlm.nih.gov/28202779/
12 https://pubmed.ncbi.nlm.nih.gov/27631616/
13 https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1809-98232017000600878
14 https://www.sciencedirect.com/science/article/abs/pii/S0278691516301144?via%3Dihub
15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821259/
16 https://pubmed.ncbi.nlm.nih.gov/25880513/
17 https://pubmed.ncbi.nlm.nih.gov/29041989/
18 https://pubmed.ncbi.nlm.nih.gov/28950395/
19 https://pubmed.ncbi.nlm.nih.gov/21382111/
20 https://pubmed.ncbi.nlm.nih.gov/26374764/
21 https://pubmed.ncbi.nlm.nih.gov/29627288/
22 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248944/
23 https://pubmed.ncbi.nlm.nih.gov/28091804/
24 https://pubmed.ncbi.nlm.nih.gov/25810696/
25 https://www.cancer.org/cancer/cancer-in-young-adults/key-statistics.html
26 https://pubmed.ncbi.nlm.nih.gov/27598026/
27 https://pubmed.ncbi.nlm.nih.gov/31774954/
28 https://pubmed.ncbi.nlm.nih.gov/27583318/
29 https://pubmed.ncbi.nlm.nih.gov/9326996/
30 https://pubmed.ncbi.nlm.nih.gov/9737556/
31 https://pubmed.ncbi.nlm.nih.gov/31995683/
32 https://pubmed.ncbi.nlm.nih.gov/31754800/
33 https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html
34 https://pubmed.ncbi.nlm.nih.gov/30659375/
35 https://wisqars-viz.cdc.gov:8006/lcd/drill-down?causeLabel=Unintentional%20Injury&agegrp=35-44
36 https://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx
37 https://pubmed.ncbi.nlm.nih.gov/29076206/
38 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992181/
39 https://www.nature.com/articles/d41586-019-02638-w
40 https://www.amazon.com/dp/0008380325/ref=cm_sw_r_tw_dp_LLEdGb4D2PFX0
41 https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2020.html