Super Agers by Eric Topol - a review

Super Agers is a new book by renowned research physician Eric Toppel. The book summarizes a tremendous amount of research on the aging process, identifying how people can live longer, more fruitful lives. With many of our members in that stage of life where healthy aging is a high priority, the discussion was energetic, and our personal experiences insightful.

Our original goal was to run through the book chapter by chapter, but our meeting took on its own direction, and we chronicled series of personal experiences and stories; these elicited new ideas and personal perspectives, bringing science to life for each of us personally. Interestingly, one of the book's central themes was on the new uniqueness of care, capturing and assessing individual characteristics of every one of us.

Joel had recommended the book so he led our discussion, providing us with a comprehensive chapter-based outline which we used as our basis for getting started. Broadly speaking, the first part opened with the notion of "Healthspan" versus "Lifespan", in short how well we can navigate the latter years. The book then chronicled lifestyle habits, which we can control, from our genome, which we can’t.  The middle chapters went deeper into chronic diseases such as cancer, atherosclerosis, and autoimmune diseases, and the final chapters brought it all together to answer, what do we do?

Joel’s initial question asked, who among us has had, or currently lives with, a chronic disease. The results were representative of a broader sample of our age class: within this group of nine guys, we're sporting arterial blocks, a scheduled open-heart surgery, prostate cancer, kidney issues, congenital heart defect, and a few other chronic maladies.  Which we live with. Unlike our ancestors.

This led to an appreciation for how Topol frames advanced aging into two categories: the “Wellderly” and the “Illderly”. The former refers to an ability to engage in activities that we enjoy and can continue to enjoy, and those that give us purpose, goals for anyone facing illness or mortality. The story begins with a tale of two patients; one who lives well with a few chronic maladies, the other, with few.  Both live well by most broadly accepted standards.

Topol identifies five important dimensions impacting health for people of a certain age: lifestyle+, cells, omics, AI, and drugs and vaccines. Lifestyle+ refers to the things that we control as individuals: Diet and exercise, social engagement, mental engagement, and limited tobacco and alcohol use. We all agreed that lifestyle+ is where we focus our personal energy; the lane where we can actively pursue goals or change habits.  Independently of lifestyle+, today we are witnessing an explosion of new discoveries: in the genome, in cellular structure, the effects of AI, and in newly composed drugs and vaccines.  These are all important on their own, but their confluence and impact together is game changing. Topol believes and argues compellingly that these dimensions are converging to offer unique health approaches for every individual’s personal health span extension: the uniqueness referred to earlier.

On this topic, Joel remarked that there exists today a nearly 20 year lag from clinical discoveries to practice applications.  “Standard of Care“ is the professional guide for typical practice standards. This is why many of the proactive - as opposed to reactive - steps that people can take or medical providers recommend, today often are not discussed.  Most doctors and other medical practitioners follow the lagging standards, so we must be our own best advocates for Important new tests and discovery of risks that are not yet part of current “Standards of Care”.   

On new drugs discoveries, the emergence of GLP1s cannot be understated.  Glucagon-like peptide-1 (GLP-1) agonists are a class of medications mimic a natural hormone called GLP-1 that help regulate blood sugar levels.  Originally developed as a drug for treating diabetes, GLP1’s attack obesity in particular, but with many other downstream positive effects. Cardiovascular disease, neurodegenerative diseases including Alzheimers and Parkinsons, substance abuse and other addictions, liver function and even sleep apnea are some examples.  Benefits accrue to more than just the overweight! When generics and pill-based treatment arrives for GLP1s, making them more accessible, many more people will be taking these, accruing unknown benefits. They're that good.

On the topic of drugs, Jeff added that we must also remember that drugs have many unintended consequences, many of which do not even present themselves clearly, but which can have deleterious effects on patients. Jeff recounted a meeting with a group of healthcare providers who were discussing a patient who had been on 26 different medications. Jeff had posed the question “Aren’t WE killing him?”   Given a choice between pharmaceuticals and lifestyles, how many primary physicians are talking about pharmaceuticals vs. those who are talking about lifestyles? Given today’s economic structure around medical care, particularly a reactive vs proactive approach, too many are still talking about pharmaceuticals.

When we took up the topic of omics, (which is another word for the genome, our organic chemical makeup), our discussion turned to one different but important ‘omics’, economics. Our federal government spends approximately $850 billion on Medicare and another $580 billion on Medicaid each year, and yet the number of chronically sick people continues to grow. Make no mistake: politics drives healthcare costs. Today’s government shutdown is actually a fight at the margins, where taxpayer subsidized health insurance becomes more, or less, attractive than employer sponsored health insurance.  This is the trillion-dollar question. Within the same political realm, whether you like RFK Jr, or not, his criticism of highly processed foods, unnecessary dies, and many other effects from our existing food supply system, are valid.  The potential effect of his advocacy for better food for more Americans could have truly beneficial societal effects.

Compounding issues such as lifestyle+, air pollution, and access to healthy food choices for our socioeconomically challenged citizens, today recipients of SNAP benefits (food stamps) consume a far higher volume of sugar-based drinks compared to similar income-based groups NOT receiving government benefits (both consume more sugar based drinks than higher income groups).  My own work at L Street Mission showcases a central problem for the poor: food choice and food decisions.  Our most vulnerable no longer have a food insecurity problem in America; they have obesity and nutritional problems.  While L-Street Mission gets lots of donations of bread, donuts and pastries, the superfood smoothies I bring are accepted and consumed by only a small fraction of our patrons. Colon cancer anyone?  Diabetes? It's brutal. I push the nutrition hard; but people have choices, and so many choose sugar.

One of the interesting characteristics of so many of the late-stage chronic illnesses, (diabetes, cardiovascular disease, and cancer), are that they often remain latent for 20 to 30 years before presenting themselves. As Ernest Hemingway had said, these things happen very slowly until they happen all of a sudden.  We kicked around the question of whether it is prudent to encourage our children – many in their 30s – to have polygenic risk scores (an inexpensive genome analysis that identifies a proclivity for many chronic, and rare, diseases), or other ways to identify high risk conditions to drive lifestyle choices. Some of us argued in favor of having such information, and others felt that these results can create more stress than new purpose. It’s a tough one, best to be discussed openly based on current risk-reward alternatives. Remember, we all need to be our own best health advocates. Take the oxygen mask first, then attend to others.

For our age group, there are a few highly recommended tests that focus on prevention. A P-Tau-217 is a simple test that detects biomarkers for Alzheimer's, including possible onset date!   The high sensitivity C – reactive protein (hs-CRP) tests for inflammation; inflammation may indicate cardiovascular disease, stroke, infection, and autoimmune diseases.  Another is the CT calcium test, which scans the heart for plaque buildup, and retails for about $75.   Finally, a polygenic risk profile mentioned above can be especially meaningful for younger people, to identify diseases we may be at greater risk for later, to redirect lifestyle+ choices.  Prevention is cheap relative to treatment, nevermind dealing with unforeseeable treatment surprises.  Two especially interesting drugs amongst all the snake oil out there are metformin and rapamycin. While metformin may inhibit muscle growth, it is a powerful anti-inflammatory and may be worth the required additional exercise. These are examples of taking control of your own healthcare, following the new trend of changing healthcare from reactive to predictive.

Also on the notion of lifestyle, we spent some time talking about nutrition. When reading the ingredients of any food product, if there are ingredients that you can’t pronounce or that have never existed in in your kitchen, best to pass on that product. A lazy man’s path to similar analysis - without reading al the ingredients - is the Yuca app when shopping in the aisles other than the produce, meat or dairy.   Recommended for making better food choices. The logo here is linked to Yuka US.

We talked a little about the pharmaceutical industry where “Every cured individual is a lost customer”. I personally am not ready to vilify drug companies as much as some do, but the profit motive can often conflict with the most socially efficacious solutions. Jeff’s criticism on the author was that while he was excellent at citing research, he fell short on the “buts”, meaning the unpublished deleterious effects both on individuals and society at large.  Coercive efforts to vaccinate young people during Covid was abhorrent given the low morbidity for the group, while incidence of myocarditis and other effects of certain mRNA treatments were actively suppressed. "Science" took a massive credibility hit during Covid.

Back on broader topics, we talked about how health has become a political issue because of its massive economic value. On a broader societal scale, when some were asking the question, how can we create a system that is more proactive than reactive, we discussed specific examples of how agency and free choice allows many people to make good or poor decisions, or not make any decisions, about their health.  We can't help everybody, but we can help ourselves and maybe influence others.

Bill closed with a story about a friend who was about 80, visiting his primary care physician. The doctor asked him when his father died. The guy said my father is 101 and doing great. The doctor, being surprised, asked, “Well what about your grandfather?” To which the patient replied, “Yeah, my grandfather is alive, too, 121; in fact he’s about to get married”. The astounded doctor then asked, “Why in the world would your 121-year-old grandfather ever choose to get married?”, to which he replied “He didn’t choose to, he HAS to!”   This was a good close to a great discussion about Super Agers.

In a nod to returning to our roots of great literature for our next book, we chose Mary Shelly’s Frankenstein, or the Modern Prometheus, an examination of emergent science without morality, masculinity and feminism, life and love, and a host of fertile ground for a robust discussion.