Robust health beyond the pandemic

David Katz: [00:00:00] You know, health really isn’t the prize, having the life you want to have is the prize and you know, who doesn’t want to be vital enough to do the stuff they like to do? Who doesn’t want to be vital enough to travel the world when the pandemic is gone and we’re able to do that again. We want to be able to do those things.

Peter Bowes: [00:00:16] Hello and welcome to the Live Long and Master Aging podcast. I’m Peter Bowes. This is where we explore the science and stories behind human longevity. This episode is brought to you in association with Amazentis, a Swiss life science company that’s pioneering, cutting edge, clinically validated cellular nutrition under its Timeline brand. Now, I’m delighted to welcome to the podcast, Dr. David Katz. David is a prolific writer of books and peer reviewed publications focusing on food and the importance of what we eat for our overall health and crucially, our healthspan the number of years that we enjoy optimum health and well-being. David’s latest book with co-author Mark Bittman is How to Eat. It addresses many of those seemingly perennial questions about diet, calories, gluten, red wine. It’s a long list. David is an expert on the relationship between cellular health and longevity. And recently, like all of us, has been preoccupied by the coronavirus, not only trying to respond to it, but learning from it as we move forward with our lives. David joins me from his home in the US state of Connecticut. David, welcome to the Live Long and Master aging podcast.

David Katz: [00:01:27] Great to be with you, Peter. Thank you.

Peter Bowes: [00:01:29] Yeah, it’s a real honor to talk to you. And before we dive into all of those issues, maybe we could just turn the clock back a few decades for you and tell us what motivated you to become a doctor, to become a health care provider?

David Katz: [00:01:45] Well, the initial motivation was a fairly predictable one, my father’s a cardiologist, so I you know, I had the role model right in my own home, someone who was a lifelong learner, which kind of called out to me. I love the challenge of a demanding field of information, trying to keep pace with it and then applying that to do good in the world and in particular in medicine. The mission is to add years to human lives, add life to human years. That’s a pretty good calling. So I had that role model to me and I probably thought about all the other vocations I thought about. I love animals. I thought about being a veterinarian. I like a good argument. I thought about law, but I was inspired by my dad’s example. I also I was a rambunctious kid. Orthopedists put me back together any number of times. So I had an appreciation for what what modern medicine could do. And it was something of a path of least resistance is as a very able student. And it was really only after I completed university medical school and my training in internal medicine that I figured out what I really wanted to be when I grew up. So it was, you know, during your your training in internal medicine, which is so, you know, the general field of caring for adults and anything they get, you’re spending over 100 hundred hours a week in the hospital taking care of very sick people. And, of course, you know, that’s pretty all engrossing, learning how to prevent people from dying on your watch. And I certainly appreciated the privilege of that professional obligation. But I also have a native predisposition, Peter, to see the big picture. So if you step back and look at what’s going on in any given hospital, at any given time, easily eight out of 10 beds are filled with people who have horrible stuff they never needed to get. Heart disease doesn’t really need to happen very often. Many cancers don’t need to happen. Pulmonary disease is certainly emphysema and chronic obstructive pulmonary disease related to smoking does need to happen. A lot of infectious diseases. And back then there was a lot of HIV doesn’t need to happen because we can control the behaviors that transmitted on and on. It went so. So heart disease, stroke, diabetes, dementia, cancer, infectious disease, filling hospital beds. And and I kind of thought of my training is learning how to be one of the king’s horses and one of the king’s men in the Humpty Dumpty nursery rhyme. Right. We were trying to patch health back together again, but it was never going to be fully intact. So I thought, we’ve got to do better than this. What I really want is the opportunity to interact with these people 10 years or 20 years before they ever wound up in this hospital bed to change their trajectory so they never get this sick in the first place. How can I do that? And I found my way to preventive medicine training. I did a second residency in preventive medicine, the art and science of addressing vulnerability before bad stuff happens, and the rest, as they say, is history. So my my career ever since teaching patient care research, writing, you know, every every means at my disposal now as an entrepreneur has been focused on preventing chronic disease, promoting health. And I’ve been a practicing clinician for 30 years. I’m now retired from that. So treating disease after develops is is in my wheelhouse, too, but so much better if you can preserve vitality before there cracks in that shell because famously you cannot unscramble an egg.

Peter Bowes: [00:05:34] So your view of what it means to be a doctor has has really changed quite significantly, hasn’t it, since those days when you were in medical school?

David Katz: [00:05:42] Well, you know, the privilege of caring for people in those hours of most urgent need should not be understated. It really it’s very rarified. You know, those times when I had patients in the ICU, those times when a family, you know, in desperate distress turned to me a tremendous burden and an incredible privilege. And I really wouldn’t trade the immediacy and the urgency of those interactions for anything. So so that part of the vision remained intact. But what I didn’t know as a young person admiring my father and the many hours he put into treating heart disease and saving lives was how much of the disease burden he was dealing with. And pretty much everyone in the so-called health care system was dealing with didn’t need to develop. And I say so-called health care system because by and large, it’s a disease care system. It isn’t really about preserving health. It isn’t really about establishing and fortifying health. It’s about waiting for bad stuff to happen and then trying to fix what’s broken. So that’s that’s mostly a disease care system. And we can and in my view, should evolve a genuine health care system where we’re much more focused on the establishment and preservation of health. And then, of course, we need the resources to deal with what breaks, because things will always break. There will always be the slings and arrows of outrageous fortune. Bad stuff will will happen. We will remain vulnerable, but we can do much more to prevent that bad stuff. And interestingly, Peter, sort of a historical anecdote. I completed my training in internal medicine in 1991, and then I went to Yale to do my training in preventive medicine, public health, which I completed in 1993. And that year, within just a few months of my graduation, a paper came out in the Journal of the American Medical Association, which I consider one of the most seminal papers of the modern age, and it was entitled Actual Causes of Death in the United States. It could just as readily have been actual causes of death in the modern world because there’s nothing unique to the epidemiology of the U.S. The modern countries around the world experience much the same. What the two authors, Bill Fagih and Mike MacGinnis, pointed out was that the things listed on death certificates as causes of death are, yes, OK, the proximal causes of death, atherosclerosis of the coronary arteries, obstructive disease of the lungs, and on and on it goes. But these in turn are effects of something else. These aren’t really causes at all. You know, to say that someone who died of heart disease died because they had atherosclerosis of the coronary arteries is pretty much tautological. Right. And we’ve learned nothing. What we really want to know is, wait a minute, what caused the coronary arteries to get sick in the first place? And those answers are lifestyle practices. Those answers are overwhelmingly what we do with our fingers, whether or not we bring tobacco products to our lives, what we do with our forks, the food we bring to our mouths, what we do with our feed, the physical activity we get every day, how we manage stress, how much sleep we get, social interactions, it’s lifestyle, overwhelmingly lifestyle. And that that paper actually concluded that a list of ten modifiable factors, some of them behaviors, some of them social policies, our exposure to environmental toxins, for example, rules on highways and byways. Collectively, they explained away almost all of the premature deaths in the US and by extension, the modern world. But just three of those behaviors accounted for 80 percent of the premature deaths in the U.S. every year. And those three, I referred to them ever since his feet forks and fingers. But again, physical activity, dietary pattern and fingers. Don’t bring cigarettes to your lips. Back in 1993, it’s almost thirty years ago now, tobacco was the number one cause of premature death and the combination of bad use of feet. And for so lack of physical activity, poor dietary patterns. We’re No. Two and three. If you flash forward to to now diet is the number one cause of premature death in the modern world. That’s just incredible. It’s something we completely control, something we manufacture, something we peddle to one another. And it’s the leading cause of premature death. And by the way, you noted this during the intro. You know, we’re having this conversation during the pandemic, even during the pandemic. Poor diet quality is responsible for more deaths than the virus in the United States, for example, where we’ve had two hundred and seventy thousand deaths to. covid, well, every year in this country, 500000 people die prematurely from poor diet quality Frankenfood basically. And unlike the virus, we have total control over the supply of Frankenfood. So it’s unconscionable. So that’s what essentially happened to my perspective on medicine with so much of the disease burden completely under our control, subject to what I consider the master levers of medical destiny, what we do with our feet, forks and fingers and really not responsive to advances in technology or pharmacotherapy. That’s not the answer. I thought, well, you know, I really do need to evolve my focus on the medical discipline to encompass not just disease care, but genuine health care, the promotion of health. And again, rest is history. That’s what I’ve been doing in every capacity at my disposal ever since.

Peter Bowes: [00:11:34] Yeah, it’s fascinating and you mentioned bad things happening and referred to covid-19, and it really is difficult, isn’t it, to look at life these days without seeing it through this prism of coronavirus. And you have certainly been one of the most prominent voices, media appearances through your writing YouTube videos as well, a loud voice really attempting to sort the fact from fiction, which I think a lot of us have struggled with during this pandemic. I’m just curious at this stage and just to say we’re recording this on the 1st of December and this episode will be published in a week’s time because things are actually moving faster at the moment. We’re on the cusp of getting at least two vaccines being made available to people certainly here in the United States and likely around the world as well. How do you assess where we are right now?

David Katz: [00:12:20] Well, the as you say, Peter, extremely difficult to sort through the flow of information, and I think in many ways the info Dimmick is what has made this pandemic unique. We’ve had other pandemics. In the 1950s, there was a strain of the flu that was pandemic and really quite severe. And what’s unique about this is the confluence of the global propagation of a virus and the viral transmission of information and in particular opinion about information and opinion, about opinion, about information via the Internet. This is the first pandemic in the Internet age, and that’s changed everything. And I think it’s gone a long way toward pushing people into opposing corners. One of the notorious liabilities of the Internet is echo chambers. You go shopping for the opinion you already own. You find someone else who owns it, too. That validates it back to you. And your own opinion is fortified and becomes more extreme. There’s actually a book on this concept called Going to Extremes by Cass Sunstein, who’s a Harvard professor and was an adviser to the Obama administration. And so what happened early in the pandemic was, you know, there was a camp that was somewhat prone to panic and that evolved into the shelter in place, lock everything down view of the pandemic. And then there was another camp that was prone to think, you know, we’ve had pandemics before. We never locked everything down. This is exaggerated. It’s over hyped. This is drama over data. We really you know, the world should continue on and, you know, there’ll be some casualties, but it won’t be that big a deal. Well, the truth, of course, is in the middle, this virus is serious and the pandemic is serious. And sars-covid-2 warrants respect. And we needed to protect people in new ways. But on the other hand, it was never a one size fits all threat. And that’s what I’ve emphasized from the very beginning. And what made me the prominent voice on this that I inadvertently became was two things. One, my tendency to see the big picture and my willingness to shop for valid arguments anywhere they reside. So I actively resist the temptation. I always have to be pushed into an extreme point of view. And so hunker in a bunker. No, not entirely right. Liberate my state. No, not entirely right. There’s merit and demerit in both sides. So I saw that. I saw with the data coming out of China and South Korea that that some people were vulnerable to severe bouts of this infection, but many were not. You know, for many of us, the risk of a severe bout of sars-covid-2 is vanishingly remote. We’re much more likely to be hurt crossing the street than from this virus. So we needed to differentiate from my point of view and essentially match the protection to the level of risk. And then the second thing was my opinion. I have some contacts at The New York Times. I had written some columns that already had very significant uptake. I think one of my columns on Medium was viewed 500000 times. So I reached out to my my friends at The New York Times and said, you know, I seem to have struck a nerve here. Perhaps The New York Times would be a platform for me as well. And, you know, I ran the gauntlet of the editors at the opinion pages and they published a piece of mine. And then that piece, which was written very early in the pandemic, caught the attention of three time Pulitzer Prize winner Tom Friedman, long time correspondent and columnist at The New York Times. And then Tom started to channel our conversations in his columns. And the next thing I know, I was, as you say, I was a prominent voice in the pandemic, which, by the way, you know, in full disclosure, some of my my former colleagues at Yale and others opposed because I’m not a virologist and my career has not been preferentially focused on infectious disease epidemiology. On the other hand, I’m formally trained in epidemiology of written textbooks on it and a board certified in preventive medicine, public health. And and what I was bringing to the public discourse was not rarefied knowledge of virology, but a willingness to look both at the implications of the infection and the implications of what we were doing to social determinants of health, what we were doing to supply chains, food security, income, mental health. And by virtue of all of that, Peter, the view that I evolved and have defended ever since is that we should have practiced. And to the extent we have time to to sort anything out rather than just waiting for vaccines now should still practice total harm minimisation, in other words. To identify who’s likely to be harmed by the virus and how do we best protect them, who’s more likely to be harmed by, you know, economic collapse and food insecurity, desperation, addiction, suicidal thoughts, domestic violence, child abuse and all of that. And we’ve seen spikes, by the way, in all of that during the pandemic. And how do we best defend against that? So the goal is total harmminisation. And the means to that end that I advocated at the start was what I called vertical interdiction. In other words, rather than one size fits all protection. If we’re locking things down, let’s lock them down for everybody. Rather, let’s stratify vertically based on level of risk and let us meticulously protect nursing homes. Let us diligently protect older people and people with chronic disease. Let’s relax the protections for people in middle risk tier. So, you know, younger, generally healthy adults. And let’s relax them almost completely for kids who are vanishingly low risk of severe covid outcomes.And then the only thing we need to make that actionable is policy is grown ups running our countries who then offer guidance on what exactly do we do when those risk takers intermingle. And, you know, again, there’s there are a lot of details here we don’t have time to get into. But I’ve been working on this throughout the pandemic. But, you know, the answer would essentially be any time risk takers intermingle, everyone needs to adopt the behaviors that conform to the needs of the highest risk person in the mix. It’s not rocket science and it would minimize the disruption to society, maximize protection from the virus. I still think that’s the right approach in terms of where we are now. Just to to complete my answer to your question. I think the level of exposure certainly here in the U.S. and, you know, I think it’s fairly similar in the UK is extremely high. There was just a report out from our Centers for Disease Control and Prevention that the number of documented cases in the US is off by a multiple of eight. I had actually done this math myself two months ago and wrote a column suggesting much the same that it was off by an order of magnitude. So in other words, we’re reporting that that something nearing 10 million people in the U.S.have been exposed. No, actually, it’s 100 million people who have already had the infection. We also know that a lot of people have some native resistance, maybe half the population. Well, if 100 million have been infected and as many are natively resistant to one hundred and fifty million or two hundred million, that’s you know, that’s half or more than half of the US population. Sadly, the rest of our population has exposed themselves now. So right now we have a bad surge. Again, we do keep hearing, you know, it’s going to be surge upon surge. I don’t think so, because, you know, after a meaningful exposure, people are immune. So I think we this has become heresy, Peter, to use this term, which doesn’t make sense to me. I’m going to I’m going to be brave and use it anyway. I think we are well on our way to herd immunity. And, you know, the vaccines are coming fairly soon, it looks like. But by the time they get here, you know, it may be that the portion of the population that is still needing them is relatively small, but they’re good news just the same, because if we combine, you know, those who’ve been through the infection, those who have native resistance, plus the availability of one or more vaccines for those who need it, I do see a light at the end of the tunnel.

Peter Bowes: [00:20:57] But when you say, well, on the way to herd immunity, you can see why people will be skeptical of that when they look at the soaring numbers of new cases. And I’m in Los Angeles right now, Los Angeles County, which has just gone into quite a significant lockdown, at least stay at home order situation. People, I think would perhaps be nervous of that observation that this herd immunity is developing right now.

David Katz: [00:21:22] So, you know, I speak from firsthand experience, I live in the Northeast, as you said, I’m in Connecticut, not far from New York City. During the peak in New York City last March, I volunteered, came out of clinical retirement and worked a number of shifts in an emergency department in the Bronx. And really the what at the time was the global epicenter of the pandemic. And our hospitals filled up were overwhelmed. It peaked. It crested and it waned. And, you know, within a span of weeks, the overwhelm dissipated. And what we’re seeing now is that the hard hit areas of the country from back last March, last April are not experiencing a surge now. So, you know, yes, hospital census is high throughout parts of New York state that were not hard hit before, but New York City. Not so. Connecticut, not so. So that’s what I mean, if if you did not formally have a significant wave of covid, it would have been much, much better to avoid the wave altogether and not be bowled over in the rough surf of infection, you know, to stay carefully away from the virus through social distancing mask and personal hygiene and a the vaccines which are now coming soon. Sadly, we didn’t do that. So, you know, I think we locked down late and indiscriminately, certainly here in the Northeast. I think other parts of the country did lock down in time, but then they came out with pandemic fatigue haphazardly, indiscriminately. And it what’s particularly important, Peter, it would have been fine to open up society on purpose. It would have been fine to do it in a way where there was disciplined oversight. OK, so we’re going to go out, you know, the waves that we keep talking about, waves of infection. Well, let’s talk about waves we control. How about phasing back to normalcy in waves? The lowest risk people? First, let’s put our toes in the water, see what happens, make sure there are no rip tides or sharks, and then have everybody, you know, that goes out first as well. Then a higher risk group can go out and higher risk. These are the kinds of things that I was advocating from the start. It was never a good idea to send everybody out there. You know, don’t worry, Grandma, the water’s fine. Well, no, it’s not, you know, viruses in circulation. So you’re right. What’s happening in L.A. County now, you know, is tragic. It was avoidable. The lessons of northern Italy and New York City could have been learned. Should have been learned. They were not learned. And yet it’s still valid to talk about herd immunity because what’s happening in your part of the country now already happened in my part of the country. And we’re not having a significant surge in New York City or in Connecticut right now because we already did. And in the aftermath of that, where you land is herd immunity. Now, the thing about herd immunity, again, it’s become heresy because it sounds like, you know, let’s let’s let the virus get people. Absolutely not. You know, herd immunity simply means enough people are immune, that we stop transmitting it to one another. And whether we get there because enough people have been infected or because of a vaccine, the goal is the same. So the goal of a vaccine is also herd immunity.

Peter Bowes: [00:24:31] That’s actually a good point. I think the term itself, herd immunity, is often just basically misunderstood.

David Katz: [00:24:36] Yes, it’s become very fraught and it’s as I said, I’ve written textbooks, multiple textbooks on epidemiology. You can’t write an epidemiology textbook and not use that term. It’s a term of art. You know, it refers to the goal in the termination of any major contagion. That’s how contagions end. And it doesn’t matter whether it’s, you know, contrivance of our own, like a vaccine or its native infection. Either way, that’s the goal. You know, essentially enough of us are dead ends that we stop transmitting the virus to others and we protect both ourselves. But if we’re immune and the people that we can’t transmit the virus to, so that’s herd immunity. The term should not be fraught. It’s not political. It’s not ideological. And it has nothing to do with let’s let this disease get vulnerable people and hurt them. No, rather, you know, if we had been if we had been comprehensive in our approach to the pandemic and had grown ups running the country from the start, you know, we would have said, well, you know, again, data out of South Korea suggests that this is a mild infection in 98 and 99 percent of people. And we can identify those people. You know, it’s basically anybody under 50 in good health. Can this disease hurt people in that group? Sure. If the dose of exposure is overwhelming, if they have certain genetic vulnerabilities. And so, you know, there’s no absolute guarantee, but the risk is vanishingly small. And for example, we talk about kids. The risk of kids being hurt by sars-covid-2 is not zero, but it’s less than the risk of them being hurt because of the commute to and from school and much more likely to be hurt by their school bus than by this virus. So, you know, again, what that means is some segments of the population can safely encounter this virus with a vanishingly low risk of suffering any harm. And that’s the group that can develop immunity and massively reduce viral circulation and reduce the risk of transmission others. But while that’s happening, those who are vulnerable to severe infection need to shelter away from it and wait for that immunity to develop again. We can accelerate that process with the vaccines. So, yeah, I’m very, very disheartened by what’s happening in L.A. County and other parts of the country. It didn’t need to happen. But like everything else about the pandemic, we’re letting it manage us. We never managed it. We were too divisive. We lacked the federal leadership. Too many decisions were delegated to governors. So we had different policies based on the politics of a state rather than a multidisciplinary group of scientific experts convened at the federal level to issue policy guidelines for everyone. And and, you know, tragically, almost all of us now know people who’ve paid for those mistakes with their lives. And my heart goes out to anyone and everyone who’s been touched by that as my own family has been.

Peter Bowes: [00:27:39] Just a quick counter argument, and it’s the one you often hear to the example you gave of the child going to school and having more chance of being hit on the road in an accident than being infected by the coronavirus. The argument you hear then was, well, even if the child is hit by a car as he’s walking or she’s walking to school, they’re not going to go home. And in fact, grandma, as they would if they were infected with the virus at school, that’s a situation that strikes fear into people that, yes, my child might be relatively very safe going to school, but there is that chance that the virus could be then brought back into the home.

David Katz: [00:28:13] No question about it. And so, again, what I would argue, Peter, is that that doesn’t mean kids shouldn’t go to school. It means we needed to develop policies to say what happens when that child comes home, if grandma lives in that house because that’s manageable. It’s absolutely manageable. We need it. And, you know, the way I thought of that, we needed a Camp David like summit on coronavirus response policy. So, again, if I had run the zoo and obviously I did not. So all I all I could do was opine. But here’s what I imagined, folks. We need several weeks to take stock of the threat, not based on data from South Korea, but based on home data. How is this going to affect Americans? Right. Because our health is different to begin with from South Koreans. Lots of obesity here, lots of diabetes here. So we are going to lock everything down for a minimum of three weeks. We’ll extend it if we have to, but we don’t anticipate the need while we’re locked down for three weeks, we the grown ups running the country are going to convene a Camp David summit. Every relevant expert immunology, virology, infectious disease, social determinants, economics, unemployment, poverty, you know, all the things that are that are going to be impacted by the decisions we make. Pediatrics, geriatrics, internal medicine, you know, every every we’re going to cover the population every which way. We’re going to listen to every opinion. Every idea will have to run the gauntlet of those opposing points of view. And we will convene a national conversation at the close of that summit and share with you our thoughts on how we transition back to degrees of normalcy. And we will, based on the recommendations of this multidisciplinary panel, convene a group of however many worker bees we need, you know, people with master’s degrees in public health. Maybe we need 500 of them. And each of them is assigned three pages of detailed policy guidance based on some given permutation. What about, you know, a 52 year old parent with type two diabetes? Can their kids come home from college? Yes or no? And, you know, you can imagine all the different permutations, right? Travel, no travel. Multigenerational household, yes or no. Chronic disease, yes or no octogenarians. Yes or no. On and on it goes right. Well, OK, lots of detail there, but OK, each of 500 people writes up three pages. You have a 1500 page detailed policy manual. You then translate that into an interactive website where people do not need to read 1500 pages. They just use a few clicks to, you know, use dropdown boxes, find their situation. And there’s three pages of detailed guidance. Here’s how your family can manage risk that could have been done. That should have been done, I hope, for the next pandemic because there will be another one sometime. We do a heck of a lot better than this. But before ever, Peter, we got ahead of the virus. The viral spread of divisive opinion got ahead of us. And as I say, I think what it did, it just pushed people into extremes of lock it all down or you’re trotting on my civil liberties, liberate it all. And we became so engaged in lobbing insults at one another, nobody bothered to listen to anybody else. And the promise of the middle path was obscured and neglected.

Peter Bowes: [00:31:42] Well David let’s move on now and talk about food and and nutrition in particular, and I know you work with Amazentis, my partner for this podcast, and we’ve talked at length on previous episodes about mitochondrial health and the science behind Urolithin A and their product, Mitopure. And I’d like with you just to take a little step back and talk about the importance of the microbiome and cellular nutrition. Why should we think about this?

David Katz: [00:32:13] Well, just quickly, Peter, to to construct a bridge for us, I gave opening remarks recently at the virtual annual meeting of the American College of Lifestyle Medicine, and I entitled those remarks the acute case for chronic health. And the bridge then is we’ve been talking about covid, inevitably, and I agree with you, let’s move on and talk about other things. But they’re far more related than most people realize. So we were discussing, you know, how there’s a massive risk differential for covid related outcomes. Well, that that risk differential is predicated on one thing we don’t control, and that’s age. And a whole lot of things we do control related to our health. And ultimately, that comes all the way down to cellular health and the health of the ecosystem within the microbiome. But generally, people in robust good health are massively less vulnerable to bad outcomes during the pandemic and oh, by the way, more vital in general. So, you know, the very same things that add years to life and life to years. And, you know, I do think it’s reasonable to transition to these other matters because, again, even during the pandemic, it’s the usual neglected scourges that are taking more years from life, more life from years. In the United States heart disease kills eight hundred people a day. Eighteen hundred people a day. 655,000 people a year. And this is every year. And most of those deaths are premature. So the importance of cardiometabolic health cannot be overstated. And ultimately, that does come down to, you know, the building blocks within us. And some of the connections that are part of the bedrock of vitality are only first now being understood. So obviously, the microbiome has been much under the lens of scientific scrutiny over recent years and has spilled over to become something of a pop culture preoccupation. Well, well, rightly so, in the sense that the cells in our body are outnumbered by the bacterial residents of our body by an order of magnitude, if not more so, you know, trillions of bacteria outnumbering our cells 10 to one. You know, in a sense, we’re a rounding error within our own skin. And that says something about the unbelievable importance of these bacterial colonies to our physiology, our healthy metabolism. It just stands to reason then that shifts in those bacterial colonies would have massive implications for shifts in health, how we process cellular turnover, how we process spent hormones and enzymes, how the chemical messengers that cells use to communicate with one another are metabolized and even basic products of digestion. Since much of the microbiome by no means all of it. But much of it resides in the gastrointestinal tract. It’s a major component of our digestive system. So, you know, imagine swapping out entire populations of bacteria that digest and metabolize this way versus that way and not having it affect human health. It’s almost unimaginable. So what we’ve discovered fairly recently is that there is this extremely important, potentially quite fraught or potentially quite promising interaction between how our behaviors affect our microbiome and how the behaviors of our microbiome, in turn, affect our health. One of the really good examples of this is a compound called TMAO. People have probably heard about it. It’s a metabolite of carnitine concentrated in meat. If you have a particular kind of microbiome, in fact, the kind of microbiome associated with eating lots of meat to begin with, you tend to produce a lot of TMAO when you eat a wide variety of things, but in particular when you eat meat. So, you know, it’s not just your eating meat, but you’re eating meat and you have a microbiome that is adapted to a high intake of meat and animal products. And TMAO has been recognized as a significant cardiac risk factor. If you eat less meat, for example, as a matter of routine, you start to and you eat a variety of plant foods, for example, and a higher intake of fiber. Fiber is a crucial nutrient for many bacterial species. And so you shift your microbiome to a more plant, diet friendly microbiome, even if you do occasionally eat meat because you’ve changed the composition of your microbiome, you produce less TMO, so it’s not just what you eat, it’s the overall pattern of your diet, reshaping the overall pattern of your microbiome, which then in turn changes what you do, what your body does with the food you put into it. I mean, it’s just it’s a fascinating collection of interactions. So this all brings us back to our friends at Amazon is where I’m very proud to serve on the Science Advisory Board. Their focus, uniquely, is on mitochondria. Mitochondria are fascinating there, as you I’m sure know, Peter. I mean, they’re off the chart fascinating because what they represent, if you go back far enough and we’re talking, you know, many, many hundreds of millions of years, they represent a parasite that invaded cells and somehow found the interior of cells such a hospitable place to take up residence that they became permanent residents. So, you know, they were naturalized. They got their green card, then they became citizens. And, you know, now they’re full fledged members of the cells they invaded. But that’s how it started out. We actually have a whole separate set of of genes in terms of their origin. So, you know, our our mitochondrial DNA is separate from the chromosomes we talk about. It’s really quite fascinating. But in any event, these these invaders of our cells developed a symbiotic relationship where where they live and thrive and replicate within ourselves and have in turn become the engines of those cells, basically the source of energy generation in the form of ATP. And I imagine some people are wincing, you know, remembering biology class very long time ago. But that’s that’s where ATP is generated. Well, as you might imagine, the capacity to generate energy within a cell varies with the the number and the vitality, essentially the health status of the mitochondria and mitochondria age and become frail. And if you’re running your cells on senescent frail mitochondria, you’re less good at energy generation. You could imagine that, you know, everything about your body would suffer the consequences of that. Well, here’s how all the dots connect. Then a healthy microbiome can metabolize certain compounds that are found in a variety of fruits, concentrated as fate would have it in pomegranate, but be present in other foods too, into a compound called Urolithin A and Urolithin A enters our cells and accelerates the process of mitochondrial replacement, a process called mitophagy, essentially cleaning out the old and replacing spent mitochondria with newly produced mitochondria. And and therefore, you know, at the most fundamental level, you really are down. You know, we’re within our cells. This is this is the bedrock of human physiology. You’re enhancing energy generation. If that sounds like it would be something good for your vitality. Oh, yeah. If it sounds like it would be something good for your longevity. Oh, yeah. If it sounds like it would be something good for for your functional ability and stamina. Oh yeah. And you know, Amazentis, is engaged in an extensive volume of ongoing research to validate this first in animal studies and subsequently in people. And those trials are ongoing now and the results are very exciting. But essentially what they’ve done is they’ve concentrated this byproduct of a healthy microbiome that’s interacting with compounds found in and in fruits in particular. Pomegranate said, well, you know, not everybody has the right microbiome and certainly not everybody has the right microbiome encountering optimal amounts of these precursors. And the product Urolithin A can be concentrated and directly stimulate mitophagy, we can directly we’ve kind of cut out all the middlemen, if you will, and directly enhance the rate at which cells replace spent mitochondria with young vital mitochondria. And that’s their product Mitopure. And it’s not, of course, a substitute for taking good care of yourself. But there’s an interaction there, too. You know, if you are older, if you don’t have a lifetime of fitness behind you, getting engaged in physical activity may be challenging because you don’t have the stamina. The idea that we can rely on brilliant innovations like Mitopure to give us a jumpstart is very exciting to me because. I think it creates an opportunity for ever more people to engage in the value proposition of lifestyle medicine, so I see these things as synergistic that Mitopure can enhance vitality at the cellular level. And then I would say once you have that enhanced vitality, folks put it to good use and invest more in establishing a healthy lifestyle, because that’s the gift that keeps on giving. Healthy people have more fun. And by the way, that’s something we tend to neglect. I as a physician, I’ve seen too many examples where health seemed to take on moral overtones. You know, you could imagine there’s an admonishing finger wagging at you. You know, you should be healthy because that’s what good people do. No nonsense. You know, health really isn’t the prize. Having the life you want to have is the prize. And you know who doesn’t want to be vital enough to do the stuff they like to do? Who doesn’t want to be vital enough to travel the world when the pandemic is gone and we’re able to do that again. I mean, we want to be able to do those things.

Peter Bowes: [00:43:14] Well, that encompasses my entire philosophy about human longevity and why we want to age an age well, that we want to continue enjoying all of those things that you’ve just listed. Just on that one point, which I’ve got to say I totally agree with you talk about nutritional supplements not being a substitute for looking after ourselves to some extent throughout my progression of understanding these issues struggled with where do you start and where do you stop with supplementation if your to the best of your knowledge, eating the best diet that you can, that you’re taking as much exercise and looking after yourself, where do you start and stop in terms of complementary additions to your diet? And I think that’s essentially what we’re talking about, that it’s not a substitute, but it can ultimately add to the quality of your life.

David Katz: [00:44:01] It’s an excellent question and it invites commentary in several directions for a number of years, I wrote a column for U.S. News and World Report and a couple of those were written online.A couple Of them went into their print publications as well One of those I entitled supplemeninstitution because you know we talk about supplements but I think a lot of people are viewing these shortcuts as substitutes. So, you know, instead of supplementing a healthy diet lifestyle. Well, now I can substitute for that. Well, no, that’s a mistake. There is nothing that can rival the benefits to longevity and vitality of living. Well, physical activity, optimizing diet, avoiding toxins like tobacco, excess alcohol, getting enough sleep, managing your stress, having strong and healthy social interactions, feed forks, fingers, sleep, stress and love that. I’m a former president of the American College of Lifestyle Medicine, and throughout my tenure, I spoke of that as the six cylinder engine of lifestyle as medicine feet, physical activity, fork’s dietary pattern fingers, no tobacco sleep, get enough stress, don’t get too much and love strong social connections. We are social animals. We need one another. There is no substitute except no substitute. But you ask an excellent question. You know, the very word supplement implies supplemental to something. If we’re talking about garden variety nutrient supplements, they are in fact supplemental to the nutrients we get from food. And I’m actually very pleased to say that my company, Diet ID, which has reinvented dietary assessment, is in the vanguard of personalizing nutrient supplementation. Even an optimal diet may leave some gaps. Vitamin D, zinc, vitamin B 12, omega three if you don’t eat fatty fish routinely. So there are a number of examples where you can look specifically at diet and say, what are we supplementing here? Mitopure as a case apart. So this is not a nutrient supplement. You could really think of this, you know, as an active metabolite. And its dependency is both on the pattern of your diet, the composition of your microbiome. So, you know, you’ve already got more than one variable, right? It’s not just what are you eating, but what are you eating? What is your microbiome? How are the two interacting? And even then, the levels of might appear that are optimal for enhancing vitality through accelerated mitochondrial turnover would be very, very hard to achieve, even with a really great diet and a healthy microbiome. And this isn’t the only example of that omega 3 is another good example. Sure, you could eat lots of wild salmon, but frankly, there aren’t that many wild salmon left in the world. Would that really be a great idea? It might be good for you. It wouldn’t be so great for the fish. And as a result of thinking both about the health of people and the health of our planet, I’ve started to advocate for routine omega three supplementation. You know, it’s it’s the most sustainable best way to get this critically important nutrient you’re not likely to get enough of even from a really optimal diet. And by the way, you can get the equivalent of fish oil from algae. So, you know, no fish need be harmed in the production of your long chain. Omega three supplement. I take one and I recommend one. And it’s an example of, you know, I don’t need to do a dietary assessment of myself to know that that’s a good idea because it’s a good idea in general. Advances like Mitopure create whole new opportunities to kind of hack our metabolism. Right. Because, you know, this really does go beyond just nutrient supplementation. It’s really looking at essentially, you know, functional medicine, these these pathways in our metabolism, how they work. How does how does particular input in terms of dietary intake relate to digestion mediated in part by, you know, stuff that’s native to our bodies and in part based on variations in the microbiome, what metabolites are produced? How do those reverberate through the the you know, the many pathways of cellular health? And how can we tweak that? That’s something beyond I mean, that’s 21st century, that’s something beyond nutrient supplementation. We started, Peter, to identify the the essential vitamins and minerals not that long ago. You know, it’s really the early decades of the 20th century when that work first began. You know, it’s interesting because you hear words like rickets beriberi. You know, it sounds medieval. But, you know, just just 100 years ago, we had pandemic rickets, you know, vitamin D deficiency. And it’s because we didn’t know anything about vitamin D. Scurvy was not that uncommon. Beriberi B, vitamin deficiency was not that uncommon. So we had to identify the active ingredients and make sure people were getting enough of those. Only very recently did we realize the critically important role of folate in preventing a kind of congenital anomaly called neural tube defect and fortified the food supply with that. So there are all these different ways. Understanding metabolic pathways allows us to go beyond just nutrient supplementation to fill a gap and instead start to think about, OK, we really want to optimize here what’s the optimal level of, say, folate to prevent this neural tube defect from developing? What is the optimal level of omega three intake to balance immune system response and all the other effects that may have? What’s the optimal exposure of urolithin A so that, you know, throughout the lifespan you have efficient mitochondrial turnover? That’s a brand new insight. And so there is I think and I added in the work that I’ve been doing in that space, I think is is a whole new way to do basic nutrient supplementation so that it’s artful, it’s rightsized, it’s personalized. And I really you know, I feel that that’s a really significant advance, but Mitopure’s a different kind of advance.

Peter Bowes: [00:52:30] Yeah, exactly, you referred to the ongoing clinical trials with your Urolithin A and Mitopure, I’m just curious to know what you think its potential is. And as I say, these are ongoing trials. But the results, as I’ve seen them, look very promising in terms of our physical endurance, muscle strength, running endurance. These are experiments that have been done in animals and now in humans as well.

David Katz: [00:50:53] Exactly right. So the the value proposition of optimising exposure to Urolithin A is enhanced mitochondrial turnover, rejuvenation of cells, and so preservation of vitality for longer periods of time, you know, essentially the effects of aging are partly mitigated. Well, you follow that logic where it leads and it sounds like you’re talking about an anti aging effect. Right. And so if there’s an anti aging effect, does it either, A, you know, allow people to be vital, active, functional, strong until, you know, one night they go to sleep and just don’t wake up the next day? So that that’s long been referred to in gerontology Literature as rectangular-ising the age curve, you know? So in other words, if you think about the normal human experience, we deteriorate as we age, right? We get weaker, frail or sicker. You know, that’s the standard experience. But the experts in this space have long said that’s not necessary. You know, if everything in the body is supported with optimal lifestyle, a healthy environment, you actually can stay quite robust until, you know, your cells can just no longer replicate anymore. You know, you kind of you hit the the end of the road and you just drop off a cliff. And, you know, to be clear, that’s a blessing. So, you know, you live long, you prosper with vitality. And then one night at 100 or 102, you go to sleep, you don’t wake up the next day, die in your sleep. And we know that’s possible. We know that’s possible. When lifestyle is the medicine, it can be from the blue zones. So the work of my my friend in National Geographic, fellow Dan Buettner, characterizing these five populations around the world, Ikaria, Greece; Sardinia, Italy; Okinawa, Japan; Loma Linda, California, and then Nicoya Peninsula Costa Rica, where people routinely live to be 100, don’t get chronic disease and mostly die peacefully in their sleep at 100 years old, they have the highest concentrations of centenarians of any populations in the world.

Peter Bowes: [00:53:06] And they are quite striking communities. I went to Loma Linda, spent some time there, made a documentary for the BBC about the people living there under you’ve got to go and see it to experience it. It is remarkable to me that this is just a little town outside of Los Angeles. You drive down the freeway, everything looks the same. There are fast food restaurants on the intersection as you drive off the freeway and drive into the town and everything looks like normal California. But then you get to meet the people there and you realize very quickly that their lifestyles are so different and they are lifestyles. And you’ve touched on it in this conversation. Those lifestyles that ultimately affect our well-being, that are focused on on diet. And it’s a largely vegetarian, some vegan diets there and a lot of exercise. And this isn’t exercise going to the gym. This is just having a very physical day. This is doing the yard work yourself. This is putting out the trash. This is just constant moving. But when you add up all of these factors, you can see why those people in Loma Linda are, as you put it, quite accurately living to 90, 100 years and then dying quite quickly, dying peacefully, but living a long life and extending that healthspan that we often talk about.

David Katz: [00:54:15] Exactly, so. Well, thank you for the vivid perspective of having been up close and personal. Totally agree. Friends with many of the Seventh Day Adventists who live in and around Loma Linda and very familiar. You’re exactly right, Peter. So it’s a comprehensive lifestyle formula. But but the reason I make that case is to say we know it’s possible. We know it’s possible for people to live to be 100, to not get chronic disease along the way and to die peacefully in our sleep. And again, those three things live long, prosper with vitality, more years in life, more life and years, and then a peaceful exit. Wow. that is a consumation devoutly to be wished – that is part of the ultimate value proposition of Mitopure. And so, you know, again, what we’re able to demonstrate in the short term with studies is enhanced muscle strength defense against what we call sarcopenia, which is the loss of muscle mass and function as we age. You know, early indications that stamina improves, you know, things that that are all closely related to the anti aging effect of optimizing lifestyle as medicine. That’s that’s all pretty exciting stuff. How far can this take us in? Can the rejuvenation of mitochondria mimic some significant portion of blue zone lifestyle. Can it can it make us live longer? So, you know, again, people should understand, of course, that all you can do in the near term, if you’re looking at effects on longevity, is examine pathways and these pathways. There’s an mTOR pathway of gene expression.

Peter Bowes: [00:55:57] Yeah.

David Katz: [00:55:58] There’s a certain one pathway of gene expression in many others. And the the the cell biologists at Amazentis know much more about this than I do. You know, again, my perspective tends to be public health. So, you know, I’m looking at populations. There are experts who spend all their time looking at the inner workings of cells. But, you know, I’ve looked at the data. So these these fundamental pathways related to cellular rejuvenation and longevity are directly impacted by your Urolithin A. So the again, the early evidence is, yes, this does extend life expectancy in a number of animal species where it’s been studied in order to show that it extends life expectancy in humans. You know, we need 100 year long study that’s going to take a while. So I wouldn’t hold your breath for that one. But what accrues between now and then is all of the suggestive evidence. Does it enhance stamina? Yes. Does it defend against Sarcopenia? That looks good. Does it enhance strength in people who haven’t been exercising routinely? Yes. Improves muscle function, improves functional ability. Does it have an impact on these critically important gene complexes related relating to aging, senescence and longevity? Yes, in every case. So right now it’s a combination of short term clinical outcomes in people combined with these fascinating insights from looking at these mechanistic pathways. But they all point to the ultimate value proposition, which is, you know, this may be support for a healthy, longer, total lifespan. And again, you know, the evidence will be accruing for some time to come. But part of the reason I got involved was looking at that body of evidence and saying, wow.

Peter Bowes: [00:57:53] Yeah, I agree, it’s exciting stuff, we are running out of time, David, I could talk about this all day with you. A couple of points I’d just like to touch on. And we’ve talked about the lifestyle factors that go into our overall well-being. And I often see those factors as a pyramid and a clearly diet and exercise are in there. But I always put sleep at the top of the pyramid in terms of its importance that if sleep isn’t good, nothing else seems to fall into place during the day, and that can include your attention to your diet and your exercise. I’m just curious in terms of the attention that we give to sleep, what do you put it?

David Katz: [00:58:27] It’s a really subtle question in many ways, Peter, because these factors all interrelate and I have long been an advocate, one to say you mentioned at the start my most recent book with Mark Bittman, How to Eat. And and, you know, that reflects my devotion to the topic of nutrition. And again, to be clear, diet has been recognized as the single leading predictor variable for all cause mortality in the United States today and throughout the modern world. So you could argue diet is number one. But in one of my prior books, Disease Proof, I devoted the entire final chapter to the concept of holistic profiling. And I was talking about my experience with patients over the years and saying, you know, sometimes I would talk until I was blue in the face about the importance of diet. And clearly I was talking to a patient who understood all that, and yet they weren’t fixing the problem. And the question was why? And the answer sometimes was a toxic marriage. They hated their job problems with their kids, chronic pain, chronic sleep deprivation. And so, you know, it occurred to me years ago, by working with patients, these things interrelate. So you may not be sleeping well because of your stress. So then which is more important to sleep or the stress? Well, you have to fix the stress to fix the sleep. You may not be eating well because you’re chronically exhausted and cranky. So you have to fix sleep to fix diet. You may not be exercising because you don’t have the energy, because you have chronic insomnia. So you have to fix the sleep to fix the exercise that right. So they all interrelate. And you know that that may sound sort of daunting, but I think it’s actually the other way around because any one of these that that you can troubleshoot empowers you to troubleshoot the next you know, if you have chronic pain and you get that under control, you can be more physically active, which enhances your vitality, which improves your mood, which helps mitigate stress, which helps you sleep better, which improves your energy, which reduces your perception of pain. And you go on and on it goes. If you have the energy because you’re sleeping better to be more physically active, you feel better about yourself, you now have more motivation to start to overhaul your diet. If you improve your diet, you feel even better about yourself. And by the way, high quality eating helps you sleep better, helps you handle stress better round and round it goes. So, you know, in many ways, I mean, we could talk about this as a pyramid where each of these rests on the others and you know, what’s at the base and what’s at the at the peak. I would say, you know, again, whether it’s a good metaphor or not, I’ve talked about this is a six cylinder engine. Right. And so what you want is you want lifestyle medicine to be working optimally for you. And if any part of the engine is blocked, the whole thing may fail. You know, you could fail to exercise, manage stress, eat well or interact well with other people simply because you’re not sleeping. You’re just cranky, miserable, frustrated. And, you know, the least I can do is eat potato chips to make myself feel better. I mean, everything could fall apart because of that one variable. But I think you could say much the same about, you know, overwhelming stress, which would prevent you from sleeping. So it’s critically important, no question about it. But I think what’s most neglected is, is the tendency for people to to recognize these interrelationships. And, you know, how important it is really to take care of of all of these core components that make us vital.

Peter Bowes: [01:01:54] And just in closing, taking care of all of those core components, do you have a routine that’s designed to nurture your own health?

David Katz: [01:02:03] I do, and it won’t surprise anybody I eat optimally and I have for a very long time, ever since this became my focus. And and just just to quickly put this out there, I’m not special, but my knowledge is special and my skill set is special. You could think about a pilot, a pilot, you know, isn’t a better person than you or me, but a pilot can fly a plane because they have a skill set. Right. So I’m a preventive medicine lifestyle medicine expert. If I didn’t know how to take really good care of myself, who the heck would? So it’s not better. You know, it’s not it’s not character. It’s not better willpower. It’s not more self-discipline. It’s skill, power. And I think everyone should recognize that because skills can be acquired. So I have those skills. So I eat optimally. I’m physically active every day. I’ve had patients over the years tell me they don’t have time to exercise. And I’ve said funny, I don’t have time not to because I’m so much more productive. You know, when I run on a body that that, you know, is sort of optimized that way, I respect sleep. I make sure I get eight hours a night. I’m not always good at it, but I you know, I give it the respect it deserves. I love my wife and kids. And, you know, I’ve got good friends and I get out in nature as much as I can. I work hard and, you know, so I have a sense of purpose. So it’s, you know, again, there’s no magic to it. But it is I think health deserves to be a priority. And often it’s not. It gets pushed aside. It really should be front and center for everybody, not because I as a physician say so, but again, because healthy people have more fun. It really is the single most important contribution you can make to your quality of life.

Peter Bowes: [01:02:42] And just to give me a little snapshot, you say optimum exercise, what does that entail every day?

David Katz: [01:03:46] Well, I’ve got a gym at home, and, of course, you know, that was particularly handy with the pandemic, but I was looking to be maximally efficient to begin with. And so I’ve got an elliptical rowing machine, weights actually refurbished a part of our basement for my kids many years. It was a bit of a dance studio. So extra space for working out so I can get a really good workout in indoors any day, any time of year. I also have two dogs and any opportunity I get to take them out for a walk in the woods. And I’m fortunate. I live 20 minutes from the Yale campus, but I live on three acres adjacent to hundreds and hundreds of acres of woods. I mean, this is a really nice setup. I can go for a lengthy hike from my door, and I do that as often as possible. And I’m an equestrian. I have a horse. So whenever I can, I’m out there on horseback, too. That’s a bit more of a commitment and not something most people are going to do. But I’m outside with my dogs hiking or on my horse riding whenever I can be. And, you know, many days I can’t be. But I get so my minimal workout would be, you know, the elliptical or the rowing machine for an aerobics workout. Various calisthenics, I would say, over the course of a typical day. You know, I’m probably working in about an hour and a half of formal exercise. And then in addition to that and you mentioned this about Loma Linda, Peter. And I think it’s a great observation. A lot of the best exercise is an exercise is just motion. So I relish the opportunity to move. You know, there’s a cartoon I saw years ago and it was very apt. It was a group of people waiting for an elevator right next to a staircase and a sign next to the staircase said fitness center, one flight up and they were waiting for the elevator to get there. I mean, that’s fairly that’s fairly typical, I think, of how most people view exercise. You know, you do it when you have to do it, but you avoid it when you can. No, I like the blue zone approach. All motion is good motion. So I’m just constantly in motion up and down stairs walking around, you know, anything I can do to increase my total motion in the course of a day? I do.

Peter Bowes: [01:05:52] David, this has been an inspiring, a fascinating conversation. Thank you very much indeed.

David Katz: [01:05:56] Pleasure to be with you, Peter. Thank you, stay well.

Peter Bowes: [01:05:59] And if you’d like to dig a little deeper into David’s work, his latest book, his 18th book is co-authored with the food writer Mark Bittman. It’s titled How to Eat. It’s a great read. I would thoroughly recommend it. I’ll put the details into the show notes for this episode. You’ll find them at the Live Long and Master aging website LLAMApodcast.com. That’s LLAMApodcast.com.

Peter Bowes: [01:06:21] This episode of the LLAMA podcast was brought to you in association with Amazentis, a Swiss lifescience company which is pioneering, cutting edge, clinically validated cellular nutrition under its Timeline brand.

Peter Bowes: [01:06:33] The LLAMA Podcast is a Healthspan Media Production. If you enjoy what we do, you can rate and review us at Apple Podcasts, you can follow us in social media @LLAMApodcast and direct message me @PeterBowes. Many thanks for listening.