How to figure out if I’m healthy

And I mean healthy enough to feel vital in your 70s.

I’d settle for this.

This is part 2 of a 3 part series of health. Part 1 was about how to get into A+ health. This week is about how to figure out if you’re healthy. And I mean really healthy. 

The motivation behind this post is that every primary care physician I’ve had has looked at my vitals and given me the thumbs up. Compared to a lot of folks, I’m doing fine. But I can be doing fine at 36 years old and be absolutely not fine 20 years later with the same exercise and diet. By the time physicians start noting issues, it can be quite difficult to get back into solid health.

So where do you need to be now in order to still be in excellent health 10, 20, or 30 years from now? This post goes into the major tests of figuring that out. And while some of this testing might seem overkill for younger folks, personally I find great value in knowing what my baseline “healthy” data looks like so I can reference it later on when I may not be as healthy. I did the vast majority of these tests last year, and wish I had done them even earlier.

And it’s hard to predict what you’ll find. Despite following what I thought was a healthy diet and exercise regime, my blood tests found I had high Lp(a) and ApoB and my heart rate recovery was nowhere near where I wanted it to be - things that could eventually contribute to heart disease. I also found my bone mineral density was relatively low, which means I’m at greater risk of breaking bones. All of these risks can take a while to mitigate and require lifestyle changes to do so, and it’s generally easier to do that earlier rather than later in life. 

Note: the medical test notes referenced in this post come from Peter Attia’s book Outlive. The exercise test notes come from Andy Galpin, PhD. Similar to my last health-focused newsletter, these are the most anal retentive experts I can find when it comes to medical and exercise health tests. Absolute top-tier Protocol Daddies. You’re in good hands.

I highly recommend using a spreadsheet to track test outcomes Here’s a spreadsheet template that I use personally to track outcomes from the tests described below. 

Do a blood test 

Attia recommends doing a full blood test panel in addition to these non-standard markers to get baseline data. And then following up with additional blood tests the monitor the areas you’re seeking to improve every 3 - 6 months.

Heart health: Measure your Lp(a) (pronounced El-pee-little-a) and apoB. I think these cost about $50 together, albeit are non-standard measures for most blood labs.

ApoB

• What it is. ApoB is the primary indicator of potential heart disease. Traditionally, most doctors look at a different indicator - LDL-C, which measured “bad cholesterol” levels. It turns out there are a few other items associated with cholesterol that are also useful to look at, and LDL-C and these other items are all encompassed in the ApoB reading (LDL and other heart indicators are all encased in apolipoprotein B, which is measured as “ApoB”).

• Target range. Most doctors only get worried if your ApoB level is above 100 mg / dl. However, any increase in ApoB beyond the levels necessary for living (which ~ 20 / mg / dl) is increased risk of heart issues. Given ApoB levels tend to rise over time, if you want to have healthy ApoB levels when you’re 70, Attia recommends getting ApoB levels as low as possible, with 20 to 30 mg / dl when you’re in your 30s and 40s as the gold standard. This is extremely low compared to what most doctors request, and likely requires assistance with drugs called statins (which I personally haven’t explored yet) but the point is to get this number as low as possible with diet and cardio exercise. Without statins, Peter recommends trying to get to 60 mg / dl. For reference, the 20th percentile of ApoB is 78 mg / dl. 62 mg / dl is 5th percentile, so getting to 60 is darn aggressive relative to modern standards.  

• How to lower ApoB levels: Consuming less dietary fat, eating more fiber, taking statins, quitting smoking

Lp(a) 

• What it is. Having elevated Lp(a) levels puts you at greater risk of heart attacks. It can form plaque and get stuck. It’s a highly genetic thing that you only have to get measured once since it doesn’t move around a lot with behavioral changes. About 20 - 30% of Americans have elevated Lp(a) levels that put them at risk of heart issues. 

• Target range. Ideal Lp(a) levels are 14 mg / dl. The highest risk category is 50 mg / dl and above. If you do have a high Lp(a), the best way to lower risk is to more aggressively manage your ApoB levels. 

• How to lower Lp(a) levels: This is largely genetically determined so it’s difficult to lower through behavioral change. For most folks, you can manage heart health risks implied by elevated Lp(a) levels by keeping ApoB levels to a minimum. That said, Lp(a) seems to be lowered ~30% by PSCK9 inhibitors (Repatha, Praluent) but you'd have to pay out-of-pocket (about $600 per month) since it isn't approved for that indication.

Cognitive / heart health: Get an Omega Fatty Acid panel. A standard part of these panels is DHA % and EPA % (aka Omega-3 Index).

• What it is. DHA and EPA are two Omega 3 Fatty Acids that have been shown to have a lot of cognitive and cardiovascular benefits, including longevity. This includes protection against neurodegeneration (e.g. Alzheimer's) and improving cardiovascular function (thereby preventing heart failures and related issues). DHA can be turned into EPA much more easily than EPA can be turned into DHA, so most supplements that provide both have more EPA than DHA. 

• Target Range: 8 - 12% combined for DHA % and EPA %. Average for Americans is between 4 - 5%. It takes 4 months of supplementing with fish oil or eating fish before it shows up in blood labs since that’s the lifespan of red blood cell which apparently is what’s being measured here.
  
  Note: some folks also track Omega 6 / Omega 3 ratios. In this podcast, Attia and his guest Bil Harris recommend targeting 8 - 12% combined DHA + EPA% as opposed to Omega 6 / Omega 3 ratios, as the ratio is irrelevant if Omega 3s are up.

• How to improve numbers. Eat fatty fish and supplement with fish oil. 

Check your blood pressure

Attia says blood pressure is one of the most underutilized tools given many people walk around with high blood pressure and don’t know it. He recommends people knowing their blood pressure and managing it aggressively if they’re not in range. Having elevated blood pressure for long periods of time can lead to kidney damage and damage to arteries of the heart and brain. High blood pressure also seems to play a role in all chronic diseases, except for cancer. 

• What it is: Standard test involving a stethoscope / armband or automated cuff. 

• Target range: Systolic reading of 120 mm Hg or lower and a diastolic reading of 80 mm Hg or lower (also referred to as having a blood pressure of “120 over 80”). Elevated is when systolic is between 120 - 129 and diastolic is 80 or below. Having blood pressure of 130+ over 80+ is considered having hypertension. Having blood pressure of 120 over 81+ is also considered hypertension. These numbers are discussed here.
  
  Additional notes from Attia’s podcast with Huberman: Attia says most doctor readings are inaccurate. You need to sit in a chair for 5 minutes doing nothing before testing to get an accurate reading. He recommends his patients take blood pressure readings 2x/day for two weeks to get an accurate reading. Additionally, he says automatic cuff readings often given higher readings than manual readings, which are considered more accurate. That said, he recommends people start with automatic cuff readings because it’s easier. As of today, there is no watch or wearable device that provides accurate readings. 

• How to improve numbers: Get adequate sleep and do cardio exercise. If still not in range, there is medication available that Attia briefly mentions here.

Get a continuous glucose monitor

• What it is: A sensor that sticks via tiny needle in the back of your arm or stomach and measures blood glucose levels every few minutes. Elevated blood glucose levels over long periods of time increase the risk of all 4 major types of disease/death: atherosclerotic disease, cancer, neurodegenerative disease, and type 2 diabetes. 

• Cost: In my experience, bare bones CGMs such as Abbot’s Libre 3 cost $40 for 14 days with a physician prescription and coupon, or $85 without the coupon. CGM services like Levels, which provide an app with more metrics and recommendations (but with the same underlying sensor, can cost a few hundred dollars a month). 

• Target range: 

  • Average glucose level of 100 mg / dl or below. 

  • A standard deviation of 15 mg / dl or less

  • Avoiding spikes of over 160 mg / dl 

  • In general, the lower the average glucose, the better, and and lower variability is better.

• How to improve numbers: Eat foods with a lower glycemic load. This generally means avoiding sugar and refined carbs / processed foods. Eating fiber and exercise will also blunt glucose spikes, so eating more fiber with meals will lower your average glucose levels.

Get a DEXA scan

• What it is: Measures body fat %, visceral fat, and bone mineral density. Radiation exposure is super low in these scans, so you don’t have to worry about that. Body fat % is the least important of these markers. Visceral fat, or fat that accumulates around the abdomen, is considered particularly unhealthy since it creates inflammation around vital organs, and is associated with metabolic disease. Bone mineral density measures bone strength - especially important for when we age and are at risk for breaking bones due to falling. According to Attia in this podcast, women are especially at risk for lower bone mineral density.

• Cost: About $200 in urban centers

• Target Ranges: 

  • According to Attia in this podcast, we should have standards around visceral fat as a percent of total body weight, but to date we don’t. Here is a reference table of visceral fat values by gender, age, and percentiles. I imagine Attia would target the most aggressive percentile here (15%) or lower. 

  • Bone density: have a positive t score. A t-score of 0 would mean your bone mineral density is the same as a healthy 30 year old. Positive (such as 1.0) means I’m 1 standard deviation ahead of someone who’s 30 years old and my gender. Negative t scores indicate long term at risk of fractures

• How to improve numbers

  • Visceral fat: Exercise and diet. 

  • Bone mineral density: In short, strength training. Bone mineral density is very hard to improve after bone maturation occurs in one’s early 20s. So it’s very important for young folks to do strength training (lifting weights). This is very different than what I was told growing up, which was that lifting weights as a young man blunted one’s growth! For older folks, the goal is to slow the rate of decline, which is also achieved through strength training. This can be supported through Vitamin D supplementation and eating sufficient protein.

Get a CT angiogram by age 40

• What it is: A scan to see plaque around the heart. Previously doctors recommended calcium scans for plaque issues, but these scans only measure calcified plaque, not soft plaque that later turns into calcified plaque. Around 15% of people with a calcium score of 0 have plaque issues, which is high enough in Attia’s opinion to upgrade to a CT angiogram. It’s advised to get this scan once between ages 35 to 40. These are expensive however (I haven’t gotten one as a result), and a calcium scan is recommended over no test at all.

• Cost: CT Angiogram scans run $1000-1500 or so. I'm not sure if insurance might cover this if you did a cheaper CAC test first and saw issues. You could plan ahead and elect $1000 of FSA dollars to do it pre-tax to save around $250+ (depending on how much you pay in taxes) if you have to pay out of pocket. Calcium scans, on the other hand, also cost only ~$130, and are absolutely better than no test at all.

• Target: Zero soft and/or hard plaque.

• How to lower plaque: Everything under “How to lower ApoB levels”

Cancer scans

It’s worth noting that cancer is the hardest of the 4 major disease types to prevent. The major modifiable risks are smoking, insulin resistance, and obesity. Pollution in air and water may also be a factor but data here is less clear.

Out of the dozens of types of cancer, we have agreed upon and reliable screening methods for 5: 

1. Lung cancer: MRI or CT Scans

2. Breast cancer: mammograms

3. Prostate cancer: prostate exam

4. Colon / colorectal cancer: colonoscopy

5. Cervical cancer: Pap smear

Attia did not have specific advice that strayed from normal recommendations for screenings aside from colorectal cancer.

For men

• Colorectal cancer screening: Get a colonoscopy by the age of 40. A doctor puts a flexible tube in your butt with a camera at the end and looks for colorectal cancer, which is the third deadliest cancer (behind lung and breast/prostate) but easy to treat if found early. Attia recommends following up every 2 to 3 years with another colonoscopy.

• Prostate cancer screening: Get a blood test for PSA (prostate-specific antigen). Normal is at or below 1 for this test. This test has had a lot of false positives and negatives, which is an issue since the next step if you think you have it is a biopsy of the colon. To be able to early detect and get higher resolution on whether prostate cancer is present, look at additional factors such as PSA velocity (change of PSA over time), PSA density (PSA value normalized to the volume of the prostate gland) and free PSA (comparing amount of PSA that is bound vs. unbound to carrier proteins). American Cancer Society recommends getting one by age 45 for men with average risk.

For women 

• Breast cancer screenings: Attia recommends stacking mammograms, ultrasounds, and MRIs to get the best picture of breast cancer risk and avoid unnecessary procedures. He does not go into detail about what age women should start screening - the American Cancer Society recommends starting screenings no earlier than age 40, and then start annual screenings by age 45.

• Cervical cancer screening: Attia does not have non-standard advice here. Standard advice according to Mayo Clinic is to get an annual pap smear starting at age 21. A Pap smear involves collecting cells from the cervix — the lower, narrow end of the uterus that's at the top of the vagina.

For current and former smokers: 

• Low dose CT scan or MRI for lung cancer: Attia does not go into how early smokers should screen. Mayo Clinic recommends screening for smokers and former smokers starting at age 50, or anyone with a “20 pack year” history - which is someone who smoked a pack a day for 20 years. Smoking two packs a day for 10 years would also be a 20 pack year history. 

Exercise tests

Dr. Andy Galpin, who is a fitness coach for athletes and Founder/Director of the Biochemistry and Molecular Exercise Physiology Laboratory at Cal State Fullerton, recommends doing a battery of tests 1x / year to see how well you’re doing across strength and cardiovascular indicators. He is known for being incredibly methodical and holistic in how he thinks about fitness. His particular battery of tests, described below, covers what he lays out as the important areas to test for to assess long term fitness: power, force/strength, muscular endurance, anaerobic capacity, and maximal aerobic capacity. The full podcast that goes through his exercise test protocols is here.

Whether you do well or not on these tests or not, the prescription is still to follow an exercise regime similar to the one described in How to get into A+ health, but with a bit more focus on the weaker areas. Attia has his own version of this for his clients and tends to be more aggressive in his targets, although I have not found a source where he details exactly what to do and what targets to pursue. 

Galpin’s targets are the ones I include in the fitness test tracker spreadsheet. 

Power

Galpin defines power as speed x strength.

Broad jump: 

• How: Do a standing jump (no running). Measure from tip of toes on jump to back of heel upon landing

• Target: 

  • Men: Your height.  

  • Women: 85% of your height

Vertical jump:

• How: Do a standing jump (no running). Two feet on ground. Use both hands. Measure from standing height of fingertips on both hands to lower of both sets of fingertips upon jumping. 

• Target: 

  • Women: 20 inches (no age specs given)

  • Men under 50: 24 inches

  • Men over 50: 20 inches

Strength

Galpin defines this as well can you move something one time (not repetitively).

Leg extension:

• How: This is a specialized piece of gym equipment that looks like this

• Target: 

  • Through age 40: Body weight

  • Every decade thereafter: body weight minus an additional 10%

Deadhang: 

• How: Literally hang from a bar, fully extended, for as long as possible

• Target: Hold for 60 seconds

Goblet squat:

• How: Should look like this. 

• Target: Hold ½ your body weight for 45 seconds.

Muscular Endurance

Galpin defines this as how many repetitions you can do of a particular movement.

Front plank

• How: Should look like this

• Target: Hold for 60 seconds or more

Side plank: 

• How: Should look like this

• Target: Hold for 45 seconds or more

Pushups:

• How: Chest should touch the floor when contracted and arms should be fully extended when extended. 

• Target: 

  • Women: 15 (5 or less is a red flag)

  • Men: 25 (10 or less is a red flag). 

Anaerobic Capacity

Galpin defines this as the maximum amount of work you can do in 30 - 120 seconds of all out work.

Heart rate recovery:

• How: Wear some kind of heart rate monitor. Get your heart rate up as much as possible - and try to hit your max heart rate. A rule of thumb for what your target max heart rate is is 220 minus your age. So mine would be 220 - 36 = 184, although testing it at a fitness lab is the gold standard. I got mine tested and it’s actually 181, but close enough. Once you hit your max heart rate, stop working out and rest for 1 minute. After 1 minute, measure your heart rate. So if my max heart rate is 181, and one minute after stopping working out it’s 165, then my heart rate recovery is 16 beats / minute.

• Target: You want your heart rate recovery to be 30 beats / minute.

Aerobic Capacity

Galpin defines this as how much work can you do in the 8 to 15 minute range.

VO2 max: 

• How: Go to a lab and get it tested with an aerobic test. 

• Target: Ideal is 55+ ml /kg / min for men and 50+ ml / kg / min for women. Minimum target is 35+ for men and 30+ for women.