So this is going to be a different approach to what we look at for biologics. So this is not going to be another talk on PRP or BMAC or how do you, you know, so this is going to be a little bit different thought process and look at how you look at biologics. So these are some of my disclosures, none of which are relevant. And so let's talk about healthy aging, right? The aging athlete, we want to talk about how do we do this healthily? How do we do this functionally? How do we do this well, right? So the World Health Organization has called the process of developing and maintaining a functional ability, so remember functionality, that enables well-being in older age. And this is the goal, right? We want to be functional and we want to be happy and healthy as we age. So when you look at life expectancy in the U.S., and I know Dr. Wright talked about this a little bit, but since the 1900s, life expectancy has been increasing from usually in the 50s and, you know, when you, back in the early turn of the century, you used to die because infection, accidents, all the bad things, right? But then as medicine evolved, what happened is our age expectancy increased, right? So now we're up in the mid-70s, almost pushing 80s. And of course, with life expectancy increases, expectations also increase, right? So with the fitness boom of the 1970s, normal exercise, periodic exercise is part of a way of life. And so our baby boomers, 40% of our baby boomers consider regular exercise as an essential part of remaining connected to their peers, right? So this is a social part of it, right? So not just a physical part, but also the social part. And then 82% consider it important to mental health, right? So it makes you happy, keeps you connected, and this is all part of aging well. So a little bit about biology and hormones. We talked a little bit about that, but so I'm just, I'm not going to go more into it, but the idea is that hormones change, right? You think about aging, hormones are going to decrease, right? This is both men and women. So testosterone decreases around your 50s, and this is andropause, or male menopause, right? Where symptoms are fairly similar, right? Low energy, there's depression, decreased motivation, difficulty concentrating, fatigue, insomnia, all this stuff we don't want to have happen in our lives, right? Same with women. So women in their 40s start having this perimenopausal effect. And then when you hit your 50s, then this is probably more towards the, what we know of typically as menopause, right? The rage, the anxiety, the mind games, bone loss, heat flashes, all that stuff. Everything we don't want to deal with. So there's a whole other field of looking at hormones, and this is not what I'm going to be talking about today. So sarcopenia. If you guys don't know what the concept of sarcopenia is, because this is probably more in the cancer realm, but this is something that really we should be thinking about as orthopedic surgeons. We're in the musculoskeletal space. So sarcopenia is the idea that where you have loss of muscle tissue, and this is thought to be a normal part of the aging process. So contributors include physical inactivity, right? The less you exercise, the less muscle mass you have. Unhealthy diets, chronic diseases, right? So sometimes you just can't exercise because you just don't have the metabolic processes that allow you to exercise. And what goes with that was insulin resistance and inadequate protein intake. So there's a lot of factors that are involved with sarcopenia, but the bottom line is sarcopenia is related to frailty, falls, and fractures. So all the bad parts of aging, right, where you lead to death and dysfunction. So I guess dysfunction and then death, I guess. It doesn't go the other way around. Okay. So the idea is that, so if you think about how we look at disease processes in life, so what happens when we age, right? You start having cancers, cardiovascular disease, diabetes, and Alzheimer's, right? So let's look at how we've attacked cancer, right? The war on cancer was declared in 1970s. What have we done in those years? We treat, you know, we figure out how to look at cancers, stage two, stage three, stage four. So we're not, we're looking at what the end points sequelae is, and we haven't really made a huge dent in the death rate with cancers, right? We'll look at cardiovascular disease. We've been trying to, we've improved mortality rate a little bit, but only by two thirds in the last 60 years. So as much as medicine's doing great, we're also targeting the end product, the end point. When you look at type two diabetes, this is definitely a growing epidemic, almost like a growing public health crisis, right? Metabolic syndrome, where you start having insulin resistance, increased blood sugars. This is kind of that weird gray area, but this is a major problem, because all this is all tied in together, right? So this metabolic syndrome, metabolic derangement leads to type two diabetes, heart diseases, cancers, and Alzheimer's. So perhaps we should be flipping the script a little bit and maybe thinking about this from an earlier standpoint. Stop treating the end point, end disease, start seeing what we can do earlier, and how do we prevent this, right? So we're at AOSSM, right? And we're all about evidence-based. So let me talk, I'm going to talk to you about what the evidence shows. What is a prescription for longevity, how do we stay functional, and how do we age well? And the idea is that the fountain of youth is actually exercise. The literature is overwhelmingly related to exercise. So exercise is important. So the question is, how do you exercise? Any type of movement is great. So we know that exercise prolongs lifespan, preserves your cognitive function and physical function. So it can be anything from aerobic to endurance, right, so the cardiovascular side of it. Then there's also strength training. So how you want to do that, plyometrics, high intensity training, just heavy weight training, that's part of exercise. And then of course, how do you feel your body, right? How much do you eat? What do you eat? And is there anything you can add in terms of supplements, right? But the reality is if you don't fuel this well and you don't build your metabolic function well, you can't out-supplement bad diet and bad juju to begin with. So going way back into med school, if you guys remember what VO2max is, I don't know how many of you actually use this in your practice today, but VO2max is kind of the variable in terms of how you look at endurance and performance. And this is really a measure of aerobic capacity, how fit you are, how much oxygen do you need to be able to go sit around, not very high, right? But then to be able to run up the mountain or go run and go chase something, right? So this is closely linked to medical comorbidities like cardiovascular disease as well as type 2 diabetes. The interesting thing is VO2max is actually the strongest predictor of morbidity and mortality. So the risk of death is higher than, this variable is more important than smoking, obesity, hypertension, or dyslipidemia. So this study in JAMA showed that if your VO2max is pretty piss poor, basically, you do have an increased relative risk of death almost four and a half times. So this is eye-opening. The reality is you need to have some functionality, some ability to have aerobic capacity. So the interesting part of this study showed that the cardiorespiratory fitness that you do is inversely associated with long-term mortality and there's no upper limit of benefit. So the key is there's no upper limit of benefit. That means it's endless, right? So the more aerobic capacity to have, the healthier you are, the better off you are. So cardiorespiratory fitness is key. And then now let's look at muscle training. So metabolic fitness. So, you know, we're musculoskeletal doctors. So the muscle is kind of the key to everything. So this is where we can have, if you have good muscle, then that is the key to whole metabolic fitness. And the reason being is that, you know, the more blood vessels that go into the muscles that helps transport your metabolic substrates, you decrease your risk for everything, type 2 diabetes, peripheral artery disease, and lifelong exercise can preserve this regardless of sex and intensity. The other part is mitochondrial function, which is how you, this is the aerobic enzyme activity that's related to mitochondrial content. And this is how you want aerobic enzyme capacity. So this is all how metabolic function occurs in your body. So muscle training leads to metabolic fitness. So you want to keep the muscles going. So what we know what happens is as we age after 70, lean body mass decreases. So how do we increase that? So strength training is key. Endurance training will augment muscle mass also. The question is how do we know, we don't really know how that happens later on in life. When I say later on life, we're talking about 60s and 70s. So the other part that's a really interesting concept is looking at intermuscular adipose tissue, which is the tissue, the fat that's between fascia of skeletal muscle and in between muscle groups. Normal aging, if you look at the quads in males is once you hit your 70s is 116% compared to where you were at your youth. And then for women, it's much higher at 162%. But this intermuscular adipose tissue is decreased by aerobic exercise. And the whole point is that if you increase intensity, you basically enhance lipid oxidation. And this also helps with decreasing that insulin resistance and cardiovascular risk. So the prescription, what's based on the evidence is what prescription for exercise should look like is that you should always have stability, like foundational balance, flexibility, and mobility, right? But the other part is strength training is key. You need to have some kind of, you want to build that muscle mass, you want to maintain that muscle mass. Aerobic efficiency was also important. So you do want to do zone two training, which basically means you can move enough, but still have a little bit of conversation. So you don't want to be completely out of breath. But then you need to have a little sprinkling of zone five intensity in there, which means can you do that sprint? Can you do that run? You know, like how many times have you been at the airport? And I can tell you this recently, because that was like my little wake up call was that you get your flight canceled or delayed, or you're barely going to miss your connector and you have to sprint across the entirety of like two terminals and not barf along up. So that is why zone five is so important to have in your training. So let's talk about diet. So longevity is tied into diet. So this is a really interesting study looking at 16 years observational study, prospective cohort. So prospectively looking at these patients, right? So 237,000 men, 179,000 women looking at 78,000 deaths. Protein intake, they're looking at protein based diet, I mean, sorry, plant based diet versus regular diet. So plant protein intake decreases a lower overall mortality and cardiovascular risk. So the interesting part is if you swap just 3% of your energy from animal protein into plant protein, this roughly translates to increasing one year of your life. So as much as we love steaks, and I mean, for those of you who do eat meat, you know, that's kind of a big deal, right? And interestingly enough, if you take even just swapping out egg protein, that changes your risk tremendously by about almost a fifth in men and women. Red meat itself, it's a little bit lower change, but about 10% difference. So going plant based is, again, the evidence is very clear, right? And looking at phytonutrients, these are what helps preserve body tissues from oxidative stresses. And interestingly enough, these studies have shown that increasing more plant based and increasing more colorful diet, you know, that also helps in your ability to mitigate effects of cortisol and decrease your ability for cognitive decline. So the next study I looked at was looking at actually something called the MIND diet. So these are ones that are high in berries, high in green leafies, and natural plant foods. So these are patients that if you take this MIND diet, you have a slower decline in your global cognition, right? So you want to still stay sharp in your age as you get older. And so the idea is that even just if you strictly adhere to the MIND diet, you have a 53% reduction in risk of Alzheimer's disease, and that's pretty remarkable, right? Even just even partial adherence to this diet has a 35% risk reduction. So eat your blueberries, eat your green leafies, and, you know, maybe that combats part of that meat, but if you want to still have meat in your diet. So let's talk about gerontoxins. I don't know how to say this quite right, but gerontoxins are basically, they're dietary advanced glycolation end products. So it's all the yummy bits of barbecued food. So unfortunately, it's not that healthy for you. So this is linked to Alzheimer's pathogenesis, right? All that plaque that builds up in your brain. So foods that are low in AGEs include anything that's boiled, anything that's raw, anything that's stewed. A lot of your beans, your fruits, your veggies are also low in AGEs. Anything that's high in AGEs, look at that list. That's everything that we kind of, I don't know, personally, I say that that's the yummy stuff, right? So it's the broiling, grilling, frying, roasting meat and meat-derived products. So if it kind of gives you an idea of what this breaks down to. So if you boil chicken, that gives you a thousand units of AGEs as opposed to broiled chicken, which is 9,000. So nine times higher. So if you decrease some of that input, that might help at least preserve some of your cognition and decrease that risk of Alzheimer's disease. So let's talk about supplements, right? So now that you figured out your diet, whether that be plant-based or whatnot, let's figure out what supplements we can add because, you know, supplements got to be better. Like what can we not get in our diet? So we've all heard about resveratrol, right? This all started from the French paradox back in 1992 and realized that this was only done in one lab that was never reproduced by anyone else. So it's all hype. It doesn't work. And the amount of resveratrol that you would have in red wine, because wouldn't it be great if you drank a glass of wine every day and that was what's going to make you lost forever, right? The reality is if for you to drink that much wine, that's not responsible by any means and probably not humanly possible. It's a lot. So, but the interesting thing is I came across this other concept. This is called rapamycin. So if you ever heard of rapamycin, it's, you know, the New York Times calls it an antibiotic, but we know it's an antifungal, right? So this is a medication that's used for suppressing the immune system in transplant patients and it's treatment for certain cancers. So the really cool things that this study showed that it extended life. So they gave this rapamycin to geriatric mice. So super old mice, 600 day old mice, right? So if anyone who works with mice, that's like a super old mouse, right? And then what they did is they gave it, they gave this rapamycin and this extended the life by 28% in males and 38% in females. So the equivalent in the human lives would be like, if you were a 65 year old and you took this pill, you'd have lived to 95. So it's really intriguing. It's a lot. It's still kind of early on. I don't know much about it, but it seems really interesting, really interesting. And the idea is that how rapamycin works is through mTOR. So mTOR is this mammalian target for rapamycin. And what this is, it's a gene that's actually highly conserved in all animal species from worms to chickens to cows to us, right? And it regulates proliferation, autophagy, and apoptosis. This gene is related to cancers, arthritis, insulin resistance, and osteoporosis. So all the good and bad things in life, right? So then I kind of, I know I'm a little bit out of turn here, but I want to talk about how much should we eat? So the idea is that caloric restriction without malnutrition, there is great evidence that is very good. Because the reason why it actually works probably is because mTOR, it activates mTOR and it takes you down that autophagy pathway. So what is autophagy? So yes, there's Marie Kondo here. So what autophagy is, is when your cell decides to flip off and go into the cell cleaning phase and it gets rid of all the junk in your life and what gives you happiness, right? So it's the, it's the Marie Kondo of your cells. So that again, it goes through the mTOR pathway. So let's talk about other supplements, creatine. Yes, it's making a comeback. So creatine, interestingly enough, is actually really indicated in older patients and the aging athlete, I think. So it has effects on muscle for sarcopenia on bone and also senescence. So it helps actually have effects on frailty and cachexia. So some of the data that shows out there, you can either pre-dose it, low dose it, kind of chronic dose it, or just dose it when you exercise. Some of the best data out there shows that if you, the best effects are with exercise and then creatine is when you supplement. So five grams per day when you're doing a resistance training. So on the days you're doing resistance training, take your creatine supplement. And that helps maintain and build lean tissue mass and strength. And then omega-3 fatty acids are great anti-inflammatory effects and it regulates intestinal absorption of calcium. So in conclusion, how are we looking at the biologic, a way of looking at the aging athlete is let's start looking at how we can improve that longevity functionality and look at exercise. So exercise is fountain of youth. So resistance training three days a week, zone two aerobic training. So where you're getting your heart rate up, but you can still have a conversation and then every once in a while, throw a couple sprints in there. When it comes to diet, plant-based is best. And really the data is almost, you can't argue with it. And then you want to potentially do some prolonged fasting. So whether it be intermittent fasting or fasting for a day, that actually does set off that mTOR and allows for that autophagy to occur. And the supplements, what does seem to help is creatine on strength training days and omega fatty acids. So thank you. Thank you.

healthy aging

exercise

diet

supplements

longevity