Can I live to 120? Do I want to?

The Fountain of Youth is a mythical spring that restores the youth of anyone who drinks from it or bathes in its waters. Tales of such a spring have been recounted for thousands of years, appearing in the writings of Herodotus in the 5th century BC. The legend became particularly prominent in the 16th century, when it became associated with the Spanish explorer Juan Ponce de León, the first Governor of Puerto Rico. Ponce de León was supposedly searching for the Fountain of Youth when he traveled to Florida in 1513.

Modern seekers after the Fountain of Youth include tech billionaires who plan to be cryo-preserved until science finds the secret of eternal youth. Peter Thiel and Jeff Bezos have both heavily funded start-ups studying how to slow the aging process. Researchers have studied “blue zones,” where people live the longest, and are healthiest: Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Ikaria, Greece, and Loma Linda, California. Not only do these places have large numbers of residents in their 90’s and older, but they remain largely free of most of the diseases associated with aging. They share common attributes of lifestyle and diet noted below.

How long can we hope to live? The best evidence is that the limit to the human lifespan is about 120 years. It is very unlikely that any intervention will dramatically change this number.

Probably more realistic, and in my mind more important, is to delay the myriad ills that we accumulate as we get older: frailty, dementia, disabling arthritis, heart and lung disease. In other words, we should hope to extend our healthy years rather than simply living longer.

How can we accomplish this? Some of this is not new: do not smoke, drink little or no alcohol, maintain a healthy weight, eat a plant-focused diet and exercise regularly. If you do all five of these, you can add 12-14 good years to your life. Being socially engaged and having a sense of purpose is also helpful.

Further study is needed, but marked calorie restriction has been shown to extend the lifespan in many species, including mice, and is now being tested in human volunteers.

The diabetes drug metformin has been touted as having anti-aging properties and is being tested in two on-going trials. It is clearly beneficial in patients with type 2 diabetes; whether that will translate to the rest of us remains to be seen.

Some 20 years ago, reports began to emerge that taking blood from young mice and giving it to old mice seemed to dial back the clock on aging for the elderly rodents. Soon after, entrepreneurs began doing this with humans without any proof that it was effective, but researchers are now testing the idea. Still in the laboratory is injecting one of several new anti-inflammatory drugs. There are some indirect markers that suggest these may work, but as yet no meaningful results have been demonstrated.

So, at this point, practice as many of the lifestyle habits listed above as you can and wait to see what science has in store. Eat well, exercise and get involved in your community.

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We are what we eat

We must eat to live. Dining is also a pleasurable activity, particularly when the food is tasty and we are eating in a companionable setting. WHAT we eat can also have a huge impact on our health and longevity. What diets are best and do dietary “supplements” have an added benefit? Millions of people believe in dietary supplements and this is a multi-billion-dollar industry.

Like skirt lengths, diets go in and out of fashion. Among the headline-grabbers over the years have been the Atkins, Scarsdale, ketogenic and Neanderthal diets, none of which have been shown to have any health benefits beyond (usually transient) modest weight loss.

Diets that HAVE been shown to reduce cardiovascular disease and cancer include the DASH diet, the Mediterranean diet and a plant-based diet. The common factor in all three is an emphasis on fruits, vegetables and grains. The Mediterranean and DASH diets add fish, some poultry and olive oil. All three dramatically reduce red meat, processed foods and sugar.

Some 80,000 different “supplements” are sold in the United States!

The more they are carefully studied, the less supplements are found to be of value. Fish oil supplements are used by millions of Americans to reduce heart disease despite multiple studies showing no benefit. Vitamin D taken by middle-aged and older healthy adults was found to have no benefit in reducing fractures. Avocados, touted after an observational trial suggested benefit, were found to have no benefit when studied in a controlled trial. One study did find mild memory benefits from a multivitamin-mineral supplement given to older adults.

Are supplements harmful? Most are not, except to your pocketbook, but some can be dangerous. Products sold for weight loss have been linked to many deaths. There is also the caveat that supplements are excluded from scrutiny by the FDA and may or may not contain what the label says.

Bottom line? Try to eat a diet rich in fruits, vegetables and whole grains. Supplement it with nuts and fish. Drink alcohol sparingly if at all. Avoid processed foods and use meat more as a condiment than as the main source of calories in a meal.

Don’t waste your money on lots of supplements. If you wish, take a single multivitamin from a reputable manufacturer.

Oh, and while I am being a kill-joy – get out and move your body! Exercise beats most pills.

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It is not "Mental Health," it's the f...ing guns!

In 2020, firearm fatalities displaced motor vehicles accidents as the leading cause of death of U.S. youth (ages 1-19). We long ago dramatically reduced infectious deaths (though vaccine hesitancy threatens to upend this victory), and the “big five” have been auto accidents, firearms, cancer, suffocation and drug overdose – accidental in the youngest and intentional or accidental in teens.

Between 2000 and 2015, firearm deaths remained steady at about 10% of all youth deaths, but this has grown dramatically since, and guns caused 19% of young peoples’ deaths in 2021.

Children, of course, are not the only ones to suffer. Between 1990 and 2021, 1,110,421 Americans died as the result of gunshots: homicidal, suicidal or accidental. The death rate has roughly doubled between 2014 and 2021. Deaths disproportionally affect males: 86% of the 1.1 million deaths were men. When looking at deaths among young people, black boys are much more likely to be killed than non-Hispanic white youth. When we look at suicides, older white males are the victims more than any other group.

Comparison with similar countries emphasizes how much of an outlier we are in the U.S. An American is 30 times more likely to die by firearm than a French citizen. Not surprisingly, in France there are 15-20 privately-owned firearms per 100 population, while in the U.S. there are 120 per 100 people. Multiple studies have shown a tight correlation of numbers of guns in circulation and gun deaths. Within the U.S., states with tougher gun laws have significantly lower firearm mortality.

Certainly, social factors – mental health issues, including depression, poverty, lack of social supports – play a role, but these are not unique to Americans. Every country has its share of sociopaths, depressed people and people angry at the world, but only in America is it so easy for these people to obtain a gun.

If someone tries to kill themselves with an overdose, there is a high likelihood they will be saved and then given help. Very few of such people die of suicide. When the method chosen is a gunshot, the “success” rate is nearly 100%.

A fanatic can kill innocents with a knife (or their bare hands), but mass killings are almost always done with firearms.

Public opinion surveys consistently show that the majority of Americans support tougher gun laws, but our federal legislators seem under the control of the gun lobby. We must convince our legislature that the will of the people is for sensible gun control unless we prefer to remain World Champions in deaths by firearm.

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What happened to Damar Hamlin?

The media have been focused on the tragic collapse of Damar Hamlin, a professional football player, during a televised game last Monday. Hopefully it will bring more attention to this huge problem: some 350,000 sudden deaths occur annually in the United States, though it is rare for it to happen in a fit athlete.

Some terminology:

This was not a “heart attack,” the lay term for what health professionals call an acute myocardial infarction. An acute MI typically happens to an older person who has (sometimes unknown!) narrowing of the coronary arteries and is generally felt as chest tightness rather than sudden collapse, though this can occur. It would be very rare for a fit young athlete to have coronary disease. While possible, this is unlikely to have happened to Damar.

Nor was it “heart failure,” a condition in which the heart, because of weakened muscle, cannot adequately pump blood and which usually comes on very gradually and whose cardinal symptoms are tiredness and shortness of breath due to fluid backing up in the lungs.

This was a sudden cardiac arrest, in which the coordinated electrical activity that regulates the heart becomes totally uncoordinated. The ventricles, the main pumping chambers of the heart, no longer contract rhythmically. Instead, they quiver in a totally uncoordinated manner, and there is NO effective pumping of blood. This is called VF: ventricular fibrillation. The first organ to feel the lack of blood is the brain, and hence the sudden collapse.

While the commonest cause of this in the general population is coronary disease, in young people there are commoner causes. Bostonians with a long memory will recall the tragic death of Reggie Lewis, star player with the Boston Celtics, who collapsed and died during a practice in 1993.

One possible cause of VF in a healthy person is a blow to the chest which happens to occur at just the wrong time in the heart’s electrical cycle. This is called Commotio Cordis. It tends to be more common in younger males, possibly because their chests are less muscular and a blow is more easily transmitted to the heart. It has been seen in lacrosse or hockey players getting a stick in the chest and baseball players struck in the chest by a ball. This could have caused Damar's collapse.

Another cause is a cardiomyopathy, an abnormality, often congenital, of the heart muscle. If this is very localized, the athlete may be able to perform at a high level but still be prone to VF.

A specific form of cardiomyopathy, that may have been the cause of Reggie Lewis’ sudden death, is hypertrophic cardiomyopathy: the heart is too thick and during exertion there may be severe obstruction of blood flow out of the left ventricle.

The good news is that Damar appears to have been successfully resuscitated and with luck will come out of this tragedy with minimal damage. If so, he will owe his life to the prompt recognition of what had happened, prompt administration of CPR and prompt use of an AED: automatic external defibrillator. This last is a device that allows the general public to give a life-saving electric shock to stop VF without having to wait for medical personnel to arrive on the scene.

Time is critical: the brain suffers irreversible damage if resuscitation is delayed, even if heart function can be restored.

Learn CPR. If you have any influence, see that any place where groups gather has an AED and personnel trained in its use.

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Curing Alzheimer's? Lies, damn lies and statistics

If you flip a coin three times and all three times it shows heads, you would not be shocked. If you flipped it 50 times and it came up heads every time you would ask for a new coin! Statisticians have ways of describing the odds that something happens by chance, and this type of calculation is broadly used in medical trials.

When treatment A gives a different outcome than treatment B, this is generally accompanied by a “P value,” which expresses the likelihood that the difference was purely by chance. The commonly accepted metric that there is a real difference between two arms of a trial is a P value less than 0.05. If P<0.05, this says there is less than a 1 in 20 chance the results were not really different. The lower the P value, the greater the chance the results were not coincidental.

While many researchers worship at the altar of P<0.05, I urge caution. If you include very large numbers of patients, even small differences in outcome can be “statistically significant,” when the difference is meaningless to patient outcomes.

Let’s say you treat 10 patients with an aggressive cancer with A and 10 with B. After 3 years, all the patients given A are dead and 9 of those given B are alive. You don’t need a statistician to choose your treatment.

Instead, let us say you treat 1000 patients with A or B, and the average lifespan for those given A is 2 years and two months, while those given B live an average of 2 years and a month. Because of the large number of patients in the trial, it is reported that A is statistically better than B. Yes, but… Those given A were twice as likely to have to stop treatment for a time due to serious side effects, and spent several weeks more in hospital. Choice depends on individual values.

There is often a serious difference between statistical significance and clinical significance.

This brings me to lecanemab, the newest “wonder drug” for Alzheimer’s disease. Like several others released or in testing, this monoclonal antibody targets amyloid-beta, a protein that accumulates in the brain of patients with Alzheimer’s. I must note that experts are still not agreed on whether amyloid causes Alzheimer’s or is simply a marker of the disease.

The trial of lecanemab involved 1795 patients, half getting an infusion of the drug every two weeks and half getting a placebo. The results, touted loudly by the drug’s manufacturer showed a highly statistically significant difference (P<0.001) in favor of the drug.

When you dig deeper, the results are less impressive. Patients in both arms showed steady deterioration in mental acuity, though the decline was less for those on the drug. The absolute difference after 18 months was 0.45 on an 18-point scale, a difference, but a modest one.

A quarter of those given the drug had serious reactions to the infusion, and one in eight had brain swelling. There were two deaths in the active treatment group that remain unexplained. Potentially useful? Maybe. A game-changer? No.

Existing drugs like the cholinesterase-inhibitors (Aricept et al) also slow the decline but do not cure the disease. There is also recent evidence that this class of drugs prolongs life.

In the meantime, do things proven to help that are low cost and safe: do not drink to excess; every drink over 1/day progressively shrinks your gray matter. Eat less processed and more unprocessed food. Be sure your Vitamin D levels are in the normal range; if you do not live in the tropics, taking a daily supplement is advised. Be sure your blood pressure is below 140/80.

My bias is that chasing amyloid is chasing down a blind alley. Time will tell, but be cautious about “statistically proven” treatments of marginal clinical benefit.

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Doctor: would you mind saying that again, but in English?

It will come as no surprise to most of you that what doctors think they say and what patients hear are frequently not the same.

Every field has its own jargon, understood by the practitioners but not “outsiders.” Be honest: if you bring your car in for service and the service advisor says you have a bad solenoid, would you understand what this means? [engineers excepted]

A recent study published in JAMA Network Open described what researchers found when they asked a group of adults attending the Minnesota State Fair last year their understanding of common medical expressions used by doctors talking to patients.

Despite the fact that this was an educated group (90% had at least an associate degree and 65% a bachelor’s degree or higher), less than 10% correctly understood the question “Have you been febrile?” and 2% understood the statement “I am concerned the patient has an occult infection.” 11% knew what it meant when they were told “You will need to be NPO at 8 AM.”

A common cause of confusion is the frequent difference between common usage and medical meaning. In most circumstances, “positive” has a good connotation, but in “your lymph nodes were positive,” the opposite is true. Being told “your performance on the test was impressive” would make a student happy, but if your doctor says “your Xray findings were very impressive,” you had better worry.

Even doctors may miscommunicate if an abbreviation is used out of context. If one doctor says to another “the patient has MS,” does this mean they have multiple sclerosis or mitral stenosis? If it is one neurologist talking to another, the meaning will usually be clear, but if the neurologist is talking to a cardiologist, all bets are off.

How should this affect your behavior?

A good medical interaction should end with the doctor asking the patient to tell the doctor what they understood of the conversation, but this rarely happens in today’s frantic environment. You should take the initiative and tell the doctor what you believe they just told you. Do not be surprised if they say “no, that is not what I intended to tell you.” You can then hopefully get a clarification.

Remember: the only dumb question is the one you should have asked but did not. Do not leave a medical visit without being sure you know what you were told and understand all its implications.

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Out from the valley of the shadow of death

It has been a while since I last wrote, but there was good reason. On Sept 23, I went in to one of the country's "top ten" hospitals for a “minor procedure” that was supposed to let me out in 3-4 days. My surgeon was very well-respected. On the second post-op day I told the staff there was a problem but was reassured my recovery was normal. Late on the third day my blood pressure disappeared, a fever developed and I was rushed back to the operating room, where 2 quarts of blood were found in the abdomen, indicating a post-operative hemorrhage, and then I was admitted to the ICU in “guarded condition.” [Translation: may not make it.]

After 10 days in the ICU, I went to the surgical floor for a week and then a rehab hospital where I could not get out of bed without help. Two weeks of rehab, followed by home PT for a month and I am well on the way to recovery.

What lessons should you take from this experience?

First, let me remind you of my definition of “minor surgery:” surgery done on someone else. Something can always go wrong, so be very sure there are not non-surgical alternatives before agreeing to an operation.

Second, be your own advocate or have someone close assume that role. I was probably not insistent enough that studies were needed the day before everything went sour.

Third, be sure you have a written health care proxy and have reviewed it with your surrogate. Do you want to be on a ventilator? In what circumstances? This should be made explicit.

Fortunately, my tale has a happy ending, but that was far from guaranteed.

On another note, the newest Alzheimer’s drug has been reported to great fanfare, but I urge caution. As is all-too-often true with new drugs, the benefit was "statistically significant" but I was not impressed with the clinical benefit, and the two deaths in the trial remain to be explained. More when I have a chance to read the full paper.

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