#107 - Medicine 3.0 with Dr. Avinish Reddy

Dr. Reddy explains that while most people know their LDL cholesterol, ApoB is a superior marker for cardiovascular risk. He uses an airport analogy: LDL-C measures passengers (cholesterol content), while ApoB measures planes (particle count). More planes (ApoB) mean more risk, regardless of passenger count. This is particularly crucial for individuals with metabolic disease or diabetes, where LDL-C can be misleadingly low despite high ApoB (LDL discordance). Additionally, Lp(a) is a genetically determined lipoprotein that behaves like LDL but is more dangerous due to its stickiness and inflammatory nature, leading to more plaque. It's often overlooked because there's currently no direct treatment for high Lp(a), but knowing its level helps categorize a patient's overall risk (low, medium, high) and informs the aggressiveness of other interventions. Since it's genetic, a single test is sufficient.

Dr. Reddy emphasizes that while biomarkers are important, direct imaging provides invaluable insights into cardiovascular risk. A Coronary CT Angiogram (CCTA) uses dye to visualize coronary vessels, detecting both calcified and non-calcified plaque. A Coronary Artery Calcium (CAC) score is a cheaper, quicker alternative that only detects calcified plaque, but can have false negatives. He recommends that everyone should have one of these tests by age 45, with the timing influenced by family history and lab results. For younger patients (mid-to-late 30s), he advocates for the Carotid Intima-Media Thickness (CIMT) test. This less common ultrasound checks for early thickening of the carotid artery walls, indicating plaque processes long before they might appear on a CCTA or CAC scan. CIMT acts as an 'early water damage' detector, providing a crucial window for prevention when interventions are most effective, even if the coronary CT is still clean.

Dr. Reddy recommends heart rate recovery as a simple yet effective metric for cardiovascular health. After intense exercise, the speed at which your heart rate returns towards baseline indicates the efficiency and flexibility of your cardiovascular system. He suggests aiming for a drop of 25-30 beats per minute within one minute post-peak exertion. This metric is easily measurable by patients themselves (e.g., on a spin bike) and provides immediate, objective feedback. The ability to see quick improvements motivates patients to continue their cardiovascular training, acting as a 'carrot' rather than a 'stick.' It's a good proxy for overall cardiovascular fitness and a predictor of longevity.

VO2 max is presented as a powerful objective measure of cardiovascular fitness and a strong predictor of longevity. Dr. Reddy highlights the striking statistic that moving from a below-average to an above-average VO2 max can reduce mortality risk by 50%, a benefit comparable to quitting smoking or managing diabetes. He stresses that the goal isn't necessarily to achieve elite athlete levels, but to focus on consistent improvement, as even small gains (e.g., from 20th to 30th percentile) yield significant mortality benefits. While professional lab tests offer the most accurate measurement, wearable devices like Apple Watch or Oura Ring can provide useful directional trends, even if their absolute accuracy is limited. The key is to track improvement over time rather than fixating on a single, potentially inaccurate, absolute number.

Dr. Reddy explains that traditional primary care relies heavily on A1C and fasting glucose, which are good for population trends but lack sensitivity for early individual detection of metabolic issues. He advocates for checking fasting insulin, which can reveal rising insulin resistance years before glucose or A1C levels become abnormal. For a more in-depth assessment, he uses the OGTT (similar to the pregnancy test), where glucose and insulin are measured at baseline, then at 30 minutes, 1 hour, and 2 hours after a sugary drink. This dynamic test reveals how quickly blood sugar rises and falls, how high it spikes, and critically, if the body is overproducing insulin to manage the glucose load. Excessive insulin production is an early sign of insulin resistance, allowing for intervention when conditions like pre-diabetes are still fully reversible, long before they manifest on routine fasting labs.

Dr. Reddy strongly recommends annual DEXA scans for all his patients, not just those over 65, which is the traditional medical guideline for osteoporosis screening. While DEXA is critical for assessing bone mineral density (T-score) to detect osteopenia or osteoporosis, he highlights its additional value in measuring muscle mass through the Appendicular Lean Muscle Mass Index (ALMI). This ALMI score allows patients to objectively compare their muscle mass to peers of the same age and gender, providing a tangible metric to track progress with resistance training. This comprehensive assessment helps in the proactive prevention of both osteoporosis (porous bones) and sarcopenia (age-related muscle loss), both of which significantly increase the risk of falls and subsequent fractures, particularly hip fractures, which carry a 20-30% mortality risk within 12 months for those over 70.

Dr. Reddy stresses that resistance training is not just for building strength in youth but is a lifelong necessity to combat sarcopenia and osteoporosis. He explains that muscle strength directly impacts mobility in older age, preventing struggles with daily activities like getting out of bed or climbing stairs. For bones, while peak density is achieved by the late 20s, resistance training helps prevent deterioration thereafter. The key, he emphasizes, is consistency over long periods (months, years, decades), rather than just weekly adherence. He advises patients to track the weeks they *don't* work out to identify breaks in consistency, as travel or busy periods often lead to missed weeks that are easily forgotten. This long-term, consistent effort is essential to 'slow that age related deterioration down' and reduce the risk of debilitating falls and fractures in later life.

Dr. Reddy underscores the critical link between sleep and neurodegeneration, citing that sleep disruption increases dementia risk by 33% in older adults. He recommends using a sleep tracker, not for long-term monitoring, but for a short period (e.g., a few weeks) to help patients understand their actual sleep duration versus their time in bed. Many patients mistakenly believe they get 8 hours of sleep when they are in bed for 8 hours. The goal is to make patients aware of their sleep deficits and motivate behavioral change. His practical advice is simple: 'just try and go to sleep 1 hour earlier than you think you need to.' This aligns with the host's common recommendation for an additional 45-60 minutes of sleep. He also notes the negative impact of late-night eating on sustained high blood glucose and reduced sleep quality.

Dr. Reddy champions social connection as the 'encapsulating penumbra of all health,' arguing that even perfect physical and cognitive health is diminished without mental wellness and social resilience. He cites the Harvard Study of Adult Development (Harvard Study of Happiness), the longest-running study on health and happiness, which identifies strong relationships as the number one predictor of long-term well-being, surpassing lab values or macros. He emphasizes that it's the *quality*, not quantity, of relationships that matters, and it's never too late to start building them. Practical strategies include joining social leagues (e.g., walking, pickleball) to integrate exercise with social interaction, and consistently wearing hearing aids or glasses to maintain engagement and prevent social disconnection, which is a modifiable risk factor for dementia. He also supports volunteering as a 'Trojan horse' for social connection, providing purpose and community engagement.

Dr. Reddy argues that physical and mental health are inextricably linked, and social connection plays a far greater role than commonly understood, even by physicians. He cites objective data indicating that social isolation increases the risk of early death by 50%, a figure comparable to the risks associated with smoking or obesity. This perspective pushes back against the prevalent focus on quantifiable metrics like macros and lab values, advocating for a greater emphasis on 'immeasurables' such as the strength of friendships and family bonds. He hopes that within 5-10 years, social connection will be discussed with the same gravitas as sleep, becoming a fundamental part of healthcare. The challenge lies in developing formal medical measures and protocols for improving social bonding, but he believes that a doctor's recommendation, backed by evidence, can be a powerful catalyst for change.

Dr. Reddy argues that the current standard of care, which often uses a 10-year risk assessment, is too reactive. He believes that true prevention of cardiovascular disease must begin decades earlier, looking at a 20, 30, or even 40-year risk horizon. This proactive approach aims to intervene before plaque even begins to form in the arteries. He provides an example of a 39-year-old patient with no family history but a small amount of plaque detected via CT angiogram, placing him at the 84th percentile for his age. Dr. Reddy's goal is not just to keep him low risk for the next 10 years, but to actively manage his health so that by age 50, his plaque burden remains the same, effectively moving him to a much lower percentile risk (e.g., 14th percentile) relative to his peers. This demonstrates a precision health approach focused on long-term trajectory modification.

While many people are more dedicated to structured workouts than ever before, Dr. Reddy points out that overall 'general movement' has drastically decreased due to technological advancements and changes in work culture, such as working from home. He illustrates this with a patient who lost 5 pounds during a four-week trip to Italy, despite eating unhealthily and not exercising. The key difference was her daily activity, getting 15,000-20,000 steps sightseeing, compared to her usual 6,000-8,000 steps at home. This anecdote underscores that even if someone exercises six times a week, a lack of general movement throughout the rest of the day can undermine metabolic health. He suggests simple actions like walking after dinner or tracking daily steps (aiming for more than the common 3,000-4,000) can make a significant difference, often more painlessly than intense gym sessions.

Dr. Reddy highlights a common paradox in his practice: highly successful, health-conscious individuals who meticulously track every biomarker, exercise rigorously, and adhere to strict diets, yet often report feeling unfulfilled or 'not thriving.' He questions whether the relentless pursuit of optimal data points can sometimes lead to an over-optimization that detracts from the richness of life, particularly social connection. He gives examples of patients who prioritize individual workouts over family dinners or avoid social gatherings due to dietary restrictions. His approach is to integrate social connection into health recommendations, such as prescribing one hour of exercise per week with others (e.g., walking, playing pickleball). This strategy aims for long-term consistency and enjoyment, recognizing that the motivation to return to exercise in older age often stems from the desire to engage with friends, rather than solely from health metrics.