I had a patient arrive recently for a Precision Consultation and it became quite apparent that sleep was a big part of her clinical picture. Reviewing her history I saw quite the supplement stack.

Twelve items. Seven of them were for sleep.

Magnesium glycinate. Melatonin. L-theanine. Ashwagandha. Glycine. A “sleep restoration” blend with six more ingredients folded inside it. Something with valerian she couldn’t quite remember the name of.

I asked her which ones were working.

She wasn’t sure. Maybe the magnesium. Possibly the Ashwaganda, but she’d started that around the same time as two other things, so it was hard to say. Each one had been added after she heard it was good, somewhere: a podcast, a friend, a headline. Nobody had subtracted anything.

I asked if anyone had talked to her about sleep training, or cognitive behavioral therapy for insomnia.

No. Nobody had.

And I understand why seven bottles felt like the more appealing plan. CBT-I means looking honestly at what’s happening at 2 a.m., the checking the clock, the scrolling, the bed that has quietly become associated with lying awake instead of sleeping. It takes weeks. It takes some discomfort before it works.

A bottle is easier. Swallow this, sleep better. Wouldn’t it be nice if it worked that way.

What I learned about supplements in medical school could pretty much be summed up in two words: expensive urine. Take a multivitamin, absorb what you need, pee out the rest. Congratulations. You have very expensive urine.

Subscribe now

We learned pharmacology in excruciating detail. Receptors, pathways, mechanisms of action, drug interactions, half-lives. We learned how to treat disease, recognize dangerous side effects, and weigh whether a medication’s benefits outweighed its risks. Supplements mostly lived outside that world. Magnesium, creatine, fish oil, herbal medicine got a passing mention, if that.

Looking back, I think medicine got some of this wrong. We were too dismissive of nutrition and of substances that didn’t arrive through the traditional pharmaceutical pipeline. There are supplements with good evidence behind them, particularly for the right person, at the right dose, for a specific reason.

But something interesting has happened in the space medicine left behind. An enormous wellness industry moved in. And now I sometimes find myself sitting across from someone who tells me quite firmly that they don’t want to take medication, while I’m looking at a supplement list twelve items long.

I get how it happens. Every bottle sounds like a good idea. Magnesium supports muscle and sleep. Omega-3s support the heart and brain. Probiotics support the microbiome. Turmeric supports a healthy inflammatory response. Who wouldn’t want all of that?

This is where two ideas get constantly blurred together in the wellness world: a mechanism is not the same thing as an outcome. It is relatively easy to find a biochemical pathway through which a substance might affect inflammation, cortisol, mitochondrial function, or neurotransmitters. That does not mean taking it will meaningfully improve your sleep, prevent dementia, or help you live longer. The human body is spectacularly more complicated than a pathway drawn on a graphic.

The Marketing Is Very, Very Good

Walk through the supplement aisle now and you aren’t simply buying magnesium or vitamin C. You can buy Sleep. Calm. Mood. Focus. Cortisol Support. Hormone Balance. The label tells you the outcome before you’ve turned the bottle around.

And when you do turn it around, things can get murkier. A product may list a “proprietary blend” of several ingredients along with the blend’s total weight, without disclosing how much of each ingredient is actually in it. That matters. If a study found an effect at a specific dose, and your bottle contains that ingredient but not the amount, you don’t know whether you’re taking anything close to what was studied. My patient’s sleep blend was a good example: six ingredients, one combined number on the label, no way for either of us to know if the melatonin dose inside it matched anything in the literature.

Natural Is Still Pharmacology

We’ve created a cultural divide between “medications” and “supplements,” as though one is artificial and the other simply helps the body along. Your liver does not recognize this distinction. If something you swallow changes your physiology, it is biologically active. It may help. It may do nothing. It may interact with something else you’re taking. It may cause harm. “Natural” tells you where a substance came from. It doesn’t tell you whether it works or whether it’s safe.

Red yeast rice is one of my favorite examples. People take it because they’d rather not go on a statin. But red yeast rice can contain monacolin K, which is chemically identical to lovastatin. Sometimes we reject the medication and end up taking a less standardized version of the same pharmacology, because the bottle feels more natural. That doesn’t mean everyone should be on a statin. It means the same question applies to both: what’s the evidence this will help, and what are the risks?

When Testing Creates Treatment

There’s a related trend in functional and longevity medicine worth scrutinizing, including from those of us practicing in this space. We can test more than ever before. Sometimes that’s enormously useful; catching an iron deficiency or a significant cardiovascular marker can change someone’s trajectory. But more data isn’t automatically better medicine. Test enough biomarkers, particularly ones without well-established reference ranges, and you will almost always find something outside “optimal.” Once something looks abnormal, there’s a powerful urge to fix it. Often with a supplement. Test, treat, retest, watch the number move.

The harder question gets skipped: did improving that number actually improve the person’s health? Changing a biomarker isn’t the same as preventing disease. A plausible mechanism isn’t the same as demonstrated benefit. A protocol that began with an expensive lab panel isn’t automatically more scientific than one that didn’t.

So How Do You Know What You’re Buying?

Unlike prescription drugs, dietary supplements generally don’t undergo FDA approval for safety and effectiveness before they reach the shelf. That doesn’t mean they’re unregulated; manufacturers have legal requirements around manufacturing, labeling, and safety. But the framework is substantially looser than the one governing medications.

This is where third-party verification helps. Look for USP Verified or NSF certification when available. These programs can confirm the bottle contains what the label claims, and that it’s been checked for contaminants. But there’s a limit to what that buys you: third-party testing can tell you whether the label is honest. It can’t tell you whether you needed what’s on it in the first place.

Before You Buy Another Bottle

I don’t think the answer is throwing away the supplement drawer. I think the answer is getting intentional about what’s actually in it.

For each one, you should be able to answer: What am I taking this for? Is there reasonable evidence it improves that outcome in someone like me? What dose was studied, and am I taking that dose? Could I get this through food instead? Could it interact with something else I’m on? How will I know if it’s working? Is there a non-supplement approach, like CBT-I for sleep, with better evidence behind it? And when will I stop taking it?

Supplements have a funny way of accumulating. One gets added for sleep. Another gets added because a friend swore by it. Three years later nobody remembers why half of them are still there.

Medicine made a mistake when it treated nutrition and supplements as not worth discussing. The fix isn’t swapping unquestioning faith in pharmaceuticals for unquestioning faith in wellness. The goal in both worlds is the same: evidence, context, and judgment.

I didn’t tell my patient to throw out her seven bottles. I told her what CBT-I actually involves, and that it has better evidence behind it for insomnia than almost anything on her shelf. That may be a hard pill to swallow. A course of therapy sounded like more work than a glycine capsule.

It is more work. It also has a much better chance of actually fixing the thing she came in for.

Line your own bottles up on the counter sometime and ask, one at a time, why each one is there. If you can’t remember, that’s worth sitting with and evaluating each one objectively, it may even save you some money.

Share

Leave a comment

Every morning, I make coffee. If you’ve been following this substack you probably know this.

It’s not because I can’t function without it. And it’s not because I’ve calculated the optimal caffeine dose for cognitive performance, or waited precisely ninety minutes after waking because someone on the internet told me that would protect my cortisol.

I make coffee because I love coffee.

I love the smell of it filling the kitchen and taking a big whiff before my first sip. I love wrapping my hands around a warm mug, especially on a cold Central Oregon morning with a crackling fire. I love those first few minutes before the day has gathered momentum and kids wake. Coffee, for me, is as much ritual as stimulant.

So this is not going to be an article telling you caffeine is bad.

It started, actually, with a question from my newspaper editor: would I write something about energy drinks? He had heard there might be a connection between energy drinks and pancreatic cancer.

I’ll admit, energy drinks weren’t exactly a subject I’d been waiting to write about. But pancreatic cancer got my attention.

So I went looking for the science.

Subscribe now

Do Energy Drinks Cause Pancreatic Cancer?

The short answer is: we don’t have evidence that they do.

But there is a fascinating piece of research that may be behind some of the concern.

Researchers studying pancreatic ductal adenocarcinoma, the most common type of pancreatic cancer, compared tumor tissue with normal pancreatic tissue. They found substantially higher concentrations of taurine inside the cancerous tissue. Taurine will sound familiar if you’ve ever turned over a can of Red Bull or another energy drink. It’s a naturally occurring amino-sulfonic acid found throughout the human body, in foods, and commonly added to energy drinks.

In the study, taurine concentrations were about 2.5 times higher in pancreatic cancer tissue than in matched normal tissue. The researchers also identified changes in an enzyme involved in taurine production, suggesting that pancreatic cancer cells may alter their own metabolism in ways that increase taurine. When researchers interfered with this pathway experimentally, tumor growth was affected.

That’s interesting cancer biology.

It is not evidence that drinking taurine causes pancreatic cancer.

The researchers did not give people energy drinks and watch them develop cancer. They did not show that people who consume taurine develop pancreatic cancer more frequently. They weren’t studying energy-drink consumption at all, they were studying what was happening inside a tumor that already existed.

That’s an important distinction, and one we lose surprisingly often when early scientific findings make their way into headlines and social media. Finding that a cancer cell uses a particular substance does not mean consuming that substance caused the cancer. Cancer cells also use glucose. That doesn’t mean eating an apple causes cancer.

Could there eventually be more to learn about taurine and cancer? Absolutely, that’s what science does. We keep asking questions. But right now, I would not tell someone to stop drinking an energy drink because we have evidence it causes pancreatic cancer. We don’t.

That doesn’t mean I’m particularly enthusiastic about energy drinks.

Just for a different reason.

Because after spending some time thinking about them, I became much more interested in another question.

Why do we need so much help staying awake?

What Is “Energy,” Anyway?

Walk into almost any convenience store and there is an entire glowing wall promising energy. Energy for your workout. Energy for your meeting. Energy for the drive home. Energy without sugar. Energy with vitamins. Energy in increasingly enormous cans and increasingly cheerful colors. Redbull gives you wings after all.

But caffeine doesn’t really give you energy.

While you’re awake, a substance called adenosine is involved in the biological processes that create sleep pressure. The longer you’ve been awake, the stronger that pressure generally becomes. Caffeine works largely by blocking adenosine receptors in the brain. So the tired signal is still there; caffeine temporarily makes it harder for your brain to hear it.

And caffeine is remarkably good at this. It improves alertness. It can improve aspects of athletic performance. It can make a sleep-deprived person feel much more functional. There are times when that is enormously useful.

I’ve worked 100s of overnight shifts in emergency departments. I am not going to sit here and tell a nurse at three in the morning that what she really needs to do is honor her circadian rhythm.

Sometimes you need the coffee.

The problem comes when overriding fatigue stops being an occasional tool and becomes the way we live

.

The 2:30 Feeling

You probably know the feeling.

Lunch is over. The morning’s momentum has disappeared. You’re staring at your computer and reading the same sentence for the third time. Somewhere around two or three in the afternoon, your body seems to be suggesting something completely incompatible with the modern workday.

Rest.

We tend to blame lunch for this. And certainly a large meal can make it worse. But researchers have demonstrated a genuine mid-afternoon decline in alertness and performance that can occur even when people haven’t eaten lunch. It appears to be part of our underlying circadian biology.

In other words, the afternoon slump isn’t necessarily a malfunction.

You may just be human.

Cultures around the world figured this out long before we had sleep laboratories. The siesta wasn’t invented because generations of people lacked ambition. In many places, the day traditionally contained a natural pause. They would go to work, heat rose, food happened, things slowed down, some slept and then they returned to the day.

Modern sleep research gives some support to what those cultures observed intuitively. Midday naps can reduce sleepiness and may improve memory, learning, and aspects of executive function and emotional regulation (although the relationship between habitual napping and long-term health is complicated, particularly in older adults.)

I’m not suggesting America shut down every afternoon for a two-hour siesta.

Although I’m willing to discuss it.

I am suggesting something more modest: perhaps we should stop interpreting every fluctuation in energy as something that needs to be fixed.

The Energy-Drink Loop

Here’s where things get interesting.

Imagine you’re tired at three o’clock. You grab an energy drink containing 200 milligrams of caffeine. You feel better. You finish your work. Maybe you get your workout in and feel proud of your successful day.

Except caffeine’s half-life is commonly somewhere around three to seven hours, with substantial variation among individuals. That means a meaningful amount of your 3 p.m. caffeine may still be circulating when you’re trying to sleep that night. Caffeine can increase the time it takes to fall asleep, decrease total sleep time and sleep efficiency, and reduce sleep quality.

Perhaps you still fall asleep easily. That doesn’t necessarily mean caffeine isn’t affecting your sleep as sensitivity varies tremendously from person to person.

Then morning comes. You’re a little less rested. So you need more caffeine. By three o’clock, you’re exhausted again. so you reach for another energy drink.

We can end up treating the consequence of inadequate recovery with something that may contribute to inadequate recovery.

And suddenly the question isn’t whether taurine is secretly giving us pancreatic cancer.

The more useful question might be why we’re drinking the can every afternoon in the first place.

Not All Tired Is the Same

There is an important distinction here.

A dip in alertness at 2:30 in the afternoon is one thing. Feeling exhausted from the moment you wake up until you crawl back into bed is another.

Persistent fatigue deserves attention. Sometimes the answer really is insufficient sleep. But fatigue can also accompany sleep apnea, iron deficiency, thyroid disease, medication effects, depression, inadequate nutrition, and a long list of other medical conditions. If you consistently sleep seven or eight hours and still wake feeling as though you haven’t slept at all, or if you require escalating amounts of caffeine simply to function normally, I don’t think the answer is a bigger energy drink.

That’s information worth investigating.

But neither should we pathologize ordinary physiology.

Humans were not designed to maintain identical levels of alertness, hunger, body temperature, strength, and cognitive performance for sixteen straight hours and then instantly fall into eight perfect hours of sleep because the clock says bedtime.

We are rhythmic creatures. Our biology rises and falls.

Perhaps the problem isn’t the afternoon slump.

Perhaps it’s our insistence that there shouldn’t be one.

I’m Still Drinking My Coffee

Tomorrow morning, I will make my coffee.

I’ll probably drink it slowly while the day is still getting started. I won’t feel guilty about the caffeine, and I won’t pretend that every cup needs to be justified by a randomized controlled trial.

Some things can simply be lovely.

But there is a difference between enjoying a stimulant and needing one to continually override what your body is asking for.

We’ve become remarkably good at silencing the body’s signals without stopping to ask what they’re trying to tell us. Hunger gets suppressed. Stress gets pushed through. Sleepiness gets caffeinated away. We optimize ourselves for more productivity and then wonder why we feel depleted.

So the next time the afternoon slump arrives, before automatically reaching for something promising energy, try something else first.

Step outside. Let daylight hit your eyes. Walk for ten minutes or even some calf raises or squats by your desk. Drink some water. Eat something nourishing if you’re actually hungry. Close your eyes for twenty minutes if your life allows it.

Or maybe, occasionally, just acknowledge: I’m tired.

Not broken. Not lazy. Not inadequately optimized.

Tired.

And perhaps, every once in a while, the healthiest response to that signal isn’t to defeat it.

It’s to listen.

Leave a comment

Share

Subscribe now

References

Nam H, Lee W, Lee YJ, Kim JM, Jung KH, Hong SS, Kim SC, Park S. Taurine synthesis by 2-aminoethanethiol dioxygenase as a vulnerable metabolic alteration in pancreatic cancer. Biomol Ther (Seoul). 2025 Jan 1;33(1):143-154. PMID: 39637922.

Reichert CF, Deboer T, Landolt HP. Adenosine, caffeine, and sleep-wake regulation: state of the science and perspectives. J Sleep Res. 2022;31(4):e13597.

Monk TH. The post-lunch dip in performance. Clin Sports Med. 2005;24(2):e15–23. PMID: 15892914.

Leong RLF, Yu N, Ong JL, et al. Exploring the nap paradox: are mid-day sleep bouts a friend or foe? Sleep Med. 2017. PMID: 28899546.

Gardiner C, Weakley J, Burke LM, et al. The effect of caffeine on subsequent sleep: a systematic review and meta-analysis. Sleep Med Rev. 2023;69:101764. PMID: 36870101.

I had just finished giving a talk about muscle.

The talk was called Strong Enough to Catch Yourself, and the room was mostly filled with older adults. I had spent the better part of an hour talking about what happens to muscle as we age. How we begin losing it earlier than most people realize. How power, our ability to produce force quickly, declines even faster. How eventually this stops being a conversation about toned arms or how much you can deadlift and becomes a conversation about whether you can get yourself off the floor, carry your groceries, climb a flight of stairs, catch yourself when you stumble.

I believe this deeply. Muscle is not simply something hanging from our bones. It is metabolically active tissue, a reservoir of glucose and amino acids, an endocrine organ, and one of our greatest sources of physical reserve when illness or injury arrives. Strength and cardiorespiratory fitness are among the physical characteristics most consistently associated with how well we age. I talk to my patients about protein. I want them lifting things that feel heavy. I want them building strength before they desperately need it.

So when someone raised her hand during the Q&A and asked whether I had heard of the Blue Zones, I knew what she was asking.

Of course I had heard of them.

But the question resurfaced a tension I have been carrying for a while and when I can’t stop thinking about something it is time to write about it.

Because sitting in front of me at that talk was also an 85-year-old yoga teacher who is remarkably healthy, moves beautifully, and has never lifted a weight in her life.

There it was.

If muscle is medicine, if older adults need more protein, if progressive resistance training is one of our most powerful tools against frailty, then what do we make of people who have lived extraordinarily long, healthy lives without protein shakes, gym memberships, DEXA scans, creatine or carefully programmed sets of heavy squats?

I decided to go back and look.

Not because I wanted to prove the Blue Zones wrong. And not because I wanted to prove myself right. I wanted to look again, with a physician’s skepticism but also genuine curiosity, at people who appear to have done the thing the rest of us are spending an extraordinary amount of money trying to figure out.

Live a very long time while remaining remarkably well.

Subscribe now

First, what do we actually know about the Blue Zones?

The term Blue Zones grew out of demographic research identifying regions with unusually high concentrations of centenarians and people living into very old age. The best known include Sardinia in Italy, Okinawa in Japan, the Nicoya Peninsula in Costa Rica, Ikaria in Greece, and Loma Linda, California.

Over time, those observations became a much bigger cultural story. There were books and documentaries and lists of common behaviors: eat mostly plants, move naturally, have purpose, belong to a community, maintain close relationships, manage stress. In fact, learning about these places inspired me down this path to opening my own clinic about what it means to age well.

There is wisdom in much of that and it makes a good headline. But scientifically, we need to be careful about what the Blue Zones can actually tell us.

They are not randomized controlled trials. We did not assign one village in Sardinia to walk hills and eat beans and another village to drive SUVs and eat protein bars and then wait eighty years to see what happened. These are observational populations. There is also legitimate debate about the accuracy and completeness of some extreme-age records, and the demographic evidence is stronger for some Blue Zone regions than for others.

That does not make the observations meaningless. It simply changes the question.

The Blue Zones cannot tell us what caused someone to live to 100.

They can, however, make us curious about what long-lived populations have in common.

And that is where things become interesting.

They didn’t exercise. They moved.

One of the most repeated observations about traditional Blue Zone populations is that they generally were not “working out” in the way we understand exercise today.

There were no Pelotons in the Sardinian mountains. No Zone 2 prescriptions. No 5 x 5 strength programs.

There was simply life.

People walked. They climbed hills. They gardened. They cooked. They cleaned. They carried things. They worked with their hands. They got onto and off the ground. Their physical environment required movement throughout the day because movement was how things got done.

Modern exercise science increasingly tells us that this matters.

Large studies using accelerometers and step counts consistently find that greater daily movement is associated with lower mortality, and the benefit begins well below the well known 10,000 steps. A large 2025 meta-analysis found substantial health benefits around 7,000 steps per day compared with very low activity levels. Other wearable studies have found that even brief bursts of vigorous activity embedded into ordinary life, climbing stairs, walking quickly uphill, carrying something heavy, are associated with lower mortality among people who do not report structured exercise.

This raises an important possibility.

Perhaps people in the Blue Zones weren’t exercising less. Perhaps the distinction between exercise and life simply wasn’t as sharp.

Think about how different that is from the environment many of us inhabit now. We wake up and sit. We drive somewhere and sit. We work and sit. Food arrives at our doors. Elevators carry us upward. Machines wash our dishes, clothes and floors. We can move through an astonishing percentage of our lives without ever needing to lift anything heavier than a laptop.

Then we drive to a gym and spend an hour deliberately recreating the physical demands we systematically removed from the other twenty-three.

Maybe we built the gym because we removed life.

That isn’t an argument against the gym. It may be one of the strongest arguments for it.

But muscle still matters

If anything, going back through the evidence made me more convinced, not less.

Low muscular strength is consistently associated with higher mortality in older adults. Strength is also intimately tied to function: getting out of a chair, climbing stairs, recovering from a stumble, carrying something, maintaining independence. Muscle provides metabolic reserve during illness and injury, and skeletal muscle is a major site of glucose disposal. When we lose enough muscle and power, the consequences are not theoretical. They show up as falls, fractures, disability, loss of independence and an inability to recover from things that a younger or stronger body could absorb.

And we can change this trajectory.

Older adults respond to resistance training. They can become stronger. They can improve function. They can preserve physical capacity much later in life than we once assumed. In a randomized trial of adults around retirement age, a year of heavy resistance training produced strength benefits that were still evident years after the supervised training period ended.

But there is an important distinction buried inside that evidence.

The evidence that strength matters is stronger than the evidence that every human must lift a barbell.

A barbell is a tool.

A dumbbell is a tool.

A resistance band is a tool.

So is your own body moving against gravity.

The physiological question is not whether your muscles recognize a gym membership. It is whether you regularly ask them to generate enough force that they have a reason to remain.

And suddenly I was thinking again about the woman sitting in front of me. Eighty-five years old. Teaching yoga. She may never have lifted a weight.

But she has spent decades lifting herself.

And then there is protein

This is where the longevity conversation becomes even more complicated.

Modern longevity culture has become almost obsessed with protein. Depending on whom you follow, you might come away believing that the primary nutritional challenge of aging is figuring out how to squeeze another thirty grams of protein into breakfast (hint mix protein powder in your yogurt or oatmeal).

The Blue Zone story sounds almost like the opposite prescription.

Traditional diets in many of these regions were heavily plant based: beans, lentils, whole grains, vegetables, fruit, nuts, olive oil, with varying amounts of dairy, fish and meat. They were not necessarily vegan, but enormous servings of animal protein were not generally the center of every meal.

So which is it?

Again, biology refuses to give us the tidy answer we want.

There are legitimate reasons longevity researchers have been interested in protein restriction. Nutrient-sensing pathways involving mTOR, IGF-1 and other growth signals appear to influence aging in laboratory models. Constantly stimulating growth may not be biologically desirable across an entire lifespan. Some observational human research has even suggested that high protein intake in middle age, particularly animal protein, may be associated with worse outcomes.

But aging changes the equation.

Older muscle becomes less responsive to the same anabolic signal, a phenomenon often called anabolic resistance. A small amount of protein that might robustly stimulate muscle protein synthesis in a younger adult may produce a smaller response in an older one. That is one reason expert groups commonly recommend protein intake above the basic adult RDA for healthy older adults, often around 1.0–1.2 grams per kilogram per day, with greater needs during illness, recovery or substantial physical training. Many people aim closer to 1 gm per pound of body weight.

And intriguingly, some human studies suggest that the relationship between protein and longevity may change with age. In one widely discussed observational study, higher protein intake between ages 50 and 65 was associated with worse outcomes, while after age 65 the relationship shifted and higher protein intake was associated with lower mortality.

That study has limitations and should not become a prescription by itself. But the biological question it raises matters.

What is optimal at 45 may not be optimal at 85.

At some point, the threat we are trying to protect against changes. A younger body is usually worried about too much growth signaling, too much protein pushing pathways that may not need pushing. An older body starts worrying about too little — not having enough muscle in reserve to survive a hip fracture, a bad flu, two weeks in a hospital bed unable to get up and move. Frailty becomes dangerous. So does losing muscle during an illness and being unable to stand up off the floor.

So I am not ready to throw away the protein conversation. But here is the honest part: I don’t think I actually know the number.

I can tell you what the position papers recommend. I can tell you that older muscle needs a bigger stimulus to build the same amount it used to build easily. I can tell you that a diet built mostly around beans, fish and vegetables looks nothing like what most longevity accounts are currently pushing on people, and that the two of them appear to have arrived at long, healthy lives anyway.

What I can’t tell you is why. Whether Sardinians and Okinawans were quietly meeting their protein needs some other way, whole food, unprocessed, spread evenly across a day that never stopped demanding physical work. Whether decades of consistency does something a gram target can’t capture. Or whether the number itself is more forgiving than the current obsession with it suggests.

I don’t think anyone actually knows that yet. I’m still working it out.

The goal is not more protein. The goal is enough muscle and physical reserve to carry us through the later decades of our lives. I just can’t tell you the exact number that gets you there, and I’ve stopped pretending I can.

The things that don’t fit neatly into a lab report

There was another problem with reducing the Blue Zones to a debate about protein and barbells.

It misses perhaps their most important lesson.

People in these traditional long-lived communities did not simply move differently. They lived differently.

They ate meals with other people. Family members remained woven into daily life. Older adults often continued to have roles within their families and communities. People walked outside. They belonged somewhere. Many had religious or spiritual communities. Their days contained rhythms of work and rest and human contact.

Those things are much harder to prescribe than creatine.

They are also much harder to monetize.

But they matter.

Large studies consistently associate social isolation and loneliness with increased mortality. In a meta-analysis involving more than two million adults, social isolation was associated with roughly a 30 percent greater risk of premature death. Relationships are not merely pleasant additions to a healthy life. Human physiology appears to care whether we belong.

Purpose is harder to measure, but it matters too. So do sleep, stress, exposure to daylight, food quality and the environments we build around ourselves.

This is where I think modern longevity culture can lose the plot.

We are spectacularly good at isolating variables.

VO₂ max. Grip strength. ApoB. Lean mass. Protein.

I measure many of these things. I believe many of them are useful.

But humans do not live as isolated variables.

Imagine a 75-year-old who hits her protein target every day, lifts three times a week and has excellent grip strength but spends most of the remaining hours of her life sitting alone.

Now imagine another who walks to see friends, tends a garden, cooks mostly whole food, carries her groceries, gets onto the floor with her grandchildren, eats dinner with people she loves and has somewhere she feels needed.

Which one has the better longevity protocol?

Science cannot give us a clean answer.

Maybe that’s the point.

Strong enough for what?

I think this is why my own thinking about movement has expanded beyond “exercise.”

I still want people to strength train. Especially in modern life, where so little muscular work is demanded of us, deliberately lifting heavy things is one of the most efficient ways I know to preserve strength and physical reserve.

But I also want something bigger.

When I think about movement through what I call North360, my shorthand for training the body’s full range of natural capacities rather than just its gym numbers, I think about the capacities human bodies were built to use: walking, squatting, carrying, climbing, hanging, getting onto and off the ground, moving quickly when necessary, balancing, throwing, dancing, playing. Not because every one of those movements needs to appear on a workout spreadsheet, but because together they represent something more important than fitness.

They represent a body that can participate in life.

And that brings me back to the 85-year-old yoga teacher.

When she told me she had never lifted a weight, my first instinct was to see her as a contradiction.

Now I don’t think she is.

She has spent decades moving her body through space. She balances on one leg. She lowers herself toward the floor and gets back up. She bears her own weight through her arms and legs. She moves her joints through ranges many people lose decades earlier. And at 85, she is still teaching other people how to move.

Maybe she didn’t need exactly the intervention I prescribe to someone whose life has stopped asking those things of them.

That is different from saying muscle doesn’t matter.

In fact, it may tell us something much more important.

The people in the Blue Zones may not have needed to optimize longevity because their lives were already asking their bodies to do many of the things we are now trying to prescribe.

Walk.

Carry.

Climb.

Cook.

Grow things.

Eat food that still resembles food.

Know your neighbors.

Sit down with people you love.

Have somewhere to go in the morning and someone who notices when you don’t show up.

And yes, in a world that has engineered much of that movement away, lift something heavy. The gym cannot compensate for an unhealthy life any more than a bowl of beans can compensate for profound sarcopenia.

Perhaps the lesson is not to choose between the Blue Zones and modern exercise science.

Take the best of both.

Build muscle. Preserve power. Eat enough protein to support the body you are asking to perform, even if none of us can hand you an exact number for what that means. But then step outside the gym and build a life that asks something of that body.

Because the goal was never the deadlift.

The goal was always to be strong enough for the life you want.

Subscribe now

Leave a comment

References & Further Reading

Blue Zones and exceptional longevity

1. Pes GM, et al. Blue Zones, an analysis of existing evidence through a scoping review. Aging and Disease, 2025. PubMed

2. Poulain M, Herm A. Blue Zone, a demographic concept and beyond. American Journal of Lifestyle Medicine, 2025. PubMed

Movement, strength, and longevity

3. Ding D, et al. Daily steps and health outcomes in adults: a systematic review and dose-response meta-analysis. The Lancet Public Health, 2025. PubMed

4. Stamatakis E, et al. Association of wearable device-measured vigorous intermittent lifestyle physical activity with mortality. Nature Medicine, 2022. PubMed

5. Bloch-Ibenfeldt M, et al. Heavy resistance training at retirement age induces 4-year lasting beneficial effects in muscle strength. BMJ Open Sport & Exercise Medicine, 2024. PubMed

6. Ling CHY, et al. Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. CMAJ, 2010. PubMed

Protein, muscle, and aging

7. Bauer J, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. Journal of the American Medical Directors Association, 2013. PubMed

8. Kristiansen JB, et al. Age-related anabolic resistance and post-absorptive muscle protein synthesis: systematic review and meta-analysis. Frontiers in Physiology, 2026. PubMed

9. Levine ME, et al. Low protein intake is associated with a major reduction in IGF-1, cancer, and overall mortality in the 65 and younger but not older population. Cell Metabolism, 2014. PubMed

10. Farsijani S, et al. Animal protein intake is inversely associated with mortality in older adults: the InCHIANTI study. The Journals of Gerontology: Series A, 2022. PubMed

11. Song M, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Internal Medicine, 2016. PubMed

Connection, purpose, and the parts of longevity we can’t put on a DEXA scan

12. Wang F, et al. A systematic review and meta-analysis of 90 cohort studies of social isolation, loneliness and mortality. Nature Human Behaviour, 2023. PubMed

13. Sutin AR, et al. Purpose in life and mortality: a meta-analysis and individual-participant analysis. Psychological Medicine, 2026. PubMed

I had one of my favorite playlists on, the kind I know well enough that I don't really listen to every word anymore. The music was keeping pace with my feet, the trail moving beneath me, my mind wandering the way it does when I run.

And then I heard it.

“It's alright. You were dancing through the lightning strikes.”

I've heard the song many times before. I love it. But sometimes a line finds you at exactly the moment you're ready to hear it.

What struck me wasn't the lightning.

It was the dancing.

When we talk about making it through the hard parts of life, we tend to use the language of survival. We weather the storm. We endure. We persevere. We make it through. There is strength in all of that, of course. Sometimes surviving is the accomplishment.

But dancing is something different. Dancing implies that while life was happening to us, we were still living it.

I am old enough now to look backward and see plenty of lightning strikes. Some I saw coming. Most I didn't. There have been losses and disappointments, plans that changed, people I couldn't save, things I wanted that didn't happen, and things that happened that I desperately didn't want.

But when I look back, I don't only see the storm. There was dancing, too. Laughter around campfires. Babies and overdone birthdays. Trips taken when it would have been easier to stay home. Mornings when the sun came up over the trees and, for a moment, whatever I was worried about became smaller.

The lightning was real. So was the joy.

Subscribe

This Year's Lightning

I would like to tell you the lyric found me somewhere in the safe distance of hindsight, that I was thinking about storms I'd already survived. But the truth is less flattering. I heard it a week ago, on a trail in the early morning, on a vacation I had promised myself I would actually take.

I was up before sunrise because I am building something that has a deadline attached to it now, a real one, the kind with a number next to it and a date at the end of the year by which the number needs to work. I had told my family I would sleep in. Instead I was answering emails about a website before anyone else was awake, doing the quiet unglamorous work of trying to keep a business alive, on a trip that was supposed to be the opposite of that.

There is a particular irony in being a physician who tells people to protect their sleep, to guard their nervous system, to notice when their body is telling them something, and then lying awake at 4am anyway, running numbers that don't change no matter how many times you run them. My sleep, which I thought I had finally figured out years ago, has started slipping again. Not dramatically. Just an hour here, a restless stretch there, the kind of erosion you can talk yourself out of noticing until you can't.

And then there is an old fantasy that has started showing back up, one Ive mentioned before. It isn't dramatic either. It's smaller than that. It's the thought of just walking away from all of it. Not the medicine. The building. The website, the deadlines, the number at the end of the year. Just closing the laptop and not opening it again.

I don't say any of this for sympathy. I say it because I think it matters that the person writing to you about dancing through lightning is, at this exact moment, not entirely sure she's dancing.

Except that on the same trip, the same week, I did things I hadn't done in years. We built a fire on the beach one night, something I hadn't done since I was young enough that fires on beaches were just what you did. And after a hike, when the trail spit us out near the water and no one was around, I talked my daughters into skinny dipping with me. They were shocked their mother would even suggest it. The water was cold just like I like it.

So the lightning and the dancing weren't taking turns that week. They were happening at the same time, sometimes in the same afternoon. I could be up at dawn worrying about a spreadsheet and in the water by sunset, laughing at how scandalized my kids looked. Both of those were true. Neither one canceled the other out.

The Space Between

There is a well-known idea, often attributed to Viktor Frankl, that between what happens to us and how we respond, there is a space. And somewhere inside that space lies our freedom to choose what comes next.

The exact wording doesn't appear to be Frankl's, though the idea is deeply consistent with his work, and with what we understand about the nervous system. We don't get to choose every initial reaction. The body is faster than that. A deadline appears and the shoulders tighten before the mind has caught up. An old fantasy resurfaces and we don't get a vote in whether it shows up, only in what we do once it has.

None of that is a failure of mindset. It's just physiology.

But the first reaction doesn't have to be the final response, and lately I've been trying to remember that on the mornings when I catch myself back at the laptop before the coffee is even made. Some mornings I close it and pull out my journal like I used to. Some mornings I don't. I'd like to tell you I've solved this. I haven't. What I've done is notice it, which is smaller than solving it and is, some days, the only thing available to me.

Looking Forward

I've been thinking about this differently since that run.

At first the lyric made me look backward, at storms already survived, and I liked the generosity of imagining that maybe I hadn't simply endured them. Maybe, in places, I had danced.

But the more interesting question is the one I don't have a tidy answer to yet: can I remember this while the lightning is actually striking? Not afterward, once the deadline has resolved one way or another and I can tell a coherent story about it. Right now, in the middle of it, with the number still unsettled and the sleep still uneven and the fantasy of walking away still occasionally showing up uninvited.

I don't know yet how this particular storm ends. I don't know if the business will find its footing before the year does, or what I'll decide if it doesn't. I don't know if the 4am thoughts will keep receding or if they're the beginning of something I'll need to take more seriously.

What I know is that somewhere in the space between the deadline and my response to it, there is still a small amount of room. Not enough to make the lightning stop. Enough, maybe, on the better mornings, to choose the journal over the laptop.

I still think about the cold water that evening , and my daughters' faces, and the fire we didn't want to put out. Those are the parts I'm sure count as dancing. The rest I'm still finding out.

Subscribe

Comment

“Have you heard of the Barbie peptide? My hairdresser uses it and she looks so good. Should I do that?”

She’d already decided, mostly. I could hear it in the “should I,” which wasn’t really a question about safety. It was a question about permission. As I opened my practice I get calls about “peptides” constantly, and here it was again.

I asked her what she thought it did. Tan, she said. Also appetite, sort of, and something about libido. She wasn’t wrong. She also wasn’t right in the way that matters.

The Barbie peptide is melanotan II, a synthetic version of the hormone that tells your skin to make melanin. It was developed at the University of Arizona in the 1990s as a sunless tan in a syringe, a way to get color without the DNA damage of UV exposure. It never made it through FDA approval. It exists now the way most of these compounds exist: sold online as “research chemical, not for human use,” while everyone involved in the transaction understands exactly what it’s for and who’s injecting it.

Here’s the part worth sitting with. Melanotan II does have real human trials behind it. Small, but real, randomized, placebo-controlled. They just weren’t testing tanning. They were testing erectile dysfunction, and one of its close chemical relatives went on to become an actual FDA-approved drug, bremelanotide, sold as Vyleesi, for low sexual desire in women.

Subscribe now

So there’s a peptide here with legitimate biology, a real trial, and a real regulatory pathway. It’s just attached to the wrong claim. Somebody found a compound that did one interesting thing in a lab, and a completely different industry picked it up and sold it for something nobody tested it for. That’s not a story about a shady chemical. That’s a story about how a legitimate finding gets separated from the question it actually answered, and sold back to you as something else.

This is the part I wanted my patient to understand, and the part most peptide marketing depends on you never asking: a mechanism is not the same thing as evidence that the mechanism does what you’re hoping for, in your body, for your reason.

Why the FDA process exists at all

I understand why the approval process reads as bureaucratic friction when you’re standing in front of a mirror wanting a tan without the sun damage. It is friction. That’s the point.

Drug approval isn’t one test. It’s a sequence, and each phase is answering a different question. Phase 1 asks: is this safe in a small number of healthy people, at what dose, with what side effects. Phase 2 asks: does it actually do the thing we think it does, in the people who have the condition. Phase 3 asks the harder question: does it do that thing better than what already exists, in enough people, for long enough, that we can trust the result wasn’t luck.

Most compounds fail somewhere in that sequence. That’s not the system malfunctioning. That’s the system working. A compound that looks elegant in a petri dish or an animal trial or convincing in a small trial for one condition can still turn out to be useless, or actively harmful, for the thing it’s actually being sold for. Melanotan II’s own history makes the case: real signal in one context, no formal safety or efficacy data at all for the context it’s being marketed in now, which is cosmetic tanning in otherwise healthy people injecting themselves with no medical oversight.

The gray market exists specifically to route around that sequence. “Research use only” is not a safety category. It’s a legal label that lets a compound get sold without ever clearing the bar that would tell you whether it’s safe or effective for you.

People sometimes ask why I don’t offer peptides in my practice. The answer isn’t that I have some philosophical objection to using medicine to change biology. I prescribe GLP-1 medications, hormone therapy, and other treatments when the evidence and the person in front of me support them. Medicine is supposed to help.

What makes me wary is the idea that we can keep adding interventions while skipping the foundations underneath them. There is something deeply appealing about being handed a vial for recovery, muscle, energy, body composition, or longevity. It feels more sophisticated than sleep, strength training, protein, aerobic fitness, and time. Sometimes medicine can change what is biologically possible. But if I’m going to ask you to inject something into your body, I want considerably more than an elegant mechanism and a before-and-after photo. I want evidence that it actually helps humans do the thing we’re asking it to do.

She wasn’t the only one with a question that day. Once I laid out melanotan II’s actual history, she wanted to know about the others, the ones her hairdresser had also mentioned, the ones showing up in every wellness clinic within driving distance. So here’s how I’d walk through any of them, using the same test: is there a trial for this use, and what did it actually measure.

BPC-157

Sold for tendon, joint, and gut healing, and it’s the most commonly requested peptide in this entire category. It’s a synthetic fragment loosely based on a protective compound found in gastric juice, proposed to support blood vessel growth and tissue repair. There is no published, peer-reviewed, randomized controlled trial in humans, for any indication. I am going to repeat that a little louder THERE IS NO PUBLISHED, PEER-REVIEWED, RANDOMIZED CONTROLLED TRIAL IN HUMANS FOR ANY INDICATION. Nearly all of the supporting literature traces back to a single research group connected to the compound’s patents. There’s unpublished phase 2 data in ulcerative colitis and a real body of interesting animal work, but interesting animal work is not a reason to inject something into a human shoulder. Gray market, “research use only,” never progressed through FDA phases. The peptide with the most cultural buzz and the least human data of anything on this list.

TB-500 (Thymosin Beta-4)

Sold for the same territory as BPC-157, tendon and muscle recovery, often marketed alongside it as a stack. It’s a fragment of a naturally circulating protein involved in cell migration and wound repair. The human evidence here is thinner than people assume. The strongest human data is for an entirely different formulation and route, a topical eye-drop version of the full-length parent molecule, tested in phase 2/3 trials for dry eye and corneal healing, with real positive results. That is not TB-500. There is no published randomized controlled trial in humans testing the injected fragment sold as TB-500 for muscle, tendon, or joint recovery. Real biology, real trials, just not for the compound or the use it’s actually being sold for.

CJC-1295

Sold for muscle gain, fat loss, and recovery, usually paired with a “GHRP” like ipamorelin. It’s a long-acting analog that stimulates the body’s own growth hormone release, and it does what it’s designed to do at the hormone level, raising growth hormone and IGF-1 in a small trial of healthy adults. What it doesn’t have is any trial measuring the outcomes it’s actually sold for, not muscle mass, not fat loss, not recovery. A biomarker moving is not the same as an outcome changing. Gray market, no FDA approval for any use.

Ipamorelin

The same muscle, fat, and recovery claims as CJC-1295, often stacked with it. It’s a ghrelin mimetic that also stimulates growth hormone release. It has one real efficacy trial in humans, for restarting gut motility after bowel surgery. It failed. Regulators reviewing the broader class of human peptide studies have flagged safety concerns, including deaths recorded across trials, with causation unproven but enough signal to warrant scrutiny. The one trial that exists on a real clinical outcome didn’t work, and the safety signal is the most concerning of anything on this list.

GHK-Cu (copper peptide)

Sold for skin firmness, collagen, and anti-aging, both as a topical and, increasingly, as an injectable. It’s a naturally occurring tripeptide-copper complex that activates enzymes involved in collagen crosslinking and antioxidant defense. This is the outlier worth naming as one. Multiple small randomized controlled trials of topical GHK-Cu show real, measurable improvements in skin density, collagen content, and photoaging scores over 8 to 12 weeks. The evidence is genuinely better here than for almost anything else in the peptide world. What it doesn’t have is trial data supporting the newer injectable, systemic version at the same standard. The rare case where the marketed use and the actual trial evidence line up, as long as you’re talking about the cream, not the syringe.

Epitalon

Sold for longevity and lifespan extension. Proposed to activate telomerase, the enzyme that maintains telomere length. The human evidence is a petri-dish finding of telomerase activation, plus a mortality claim that gets cited constantly and doesn’t hold up on inspection. It comes from an unblinded cohort study of a completely different substance, a pineal gland extract rather than the synthetic peptide, run by a single research group, never independently replicated. The mortality claim people repeat isn’t even about the compound being sold.

SS-31 / Elamipretide

Sold for mitochondrial function, energy, and general anti-aging claims in the wellness market. It targets and stabilizes mitochondrial membranes, a genuinely well-characterized mechanism. This is the most instructive case on the list, because it shows what happens when a peptide with real biology meets a real, blinded trial. SS-31 is FDA-approved for Barth syndrome, a severe mitochondrial disease, but its randomized, placebo-controlled trial missed every primary and secondary endpoint. The encouraging numbers everyone quotes come from the open-label extension, where every patient knew they were on the drug. Its larger phase 3 trial in a related mitochondrial muscle disease also failed outright. If a peptide this well-studied, this well-funded, and this mechanistically sound can barely clear its own blinded trial, that tells you something about the odds for the ones with no trial at all.

The comparator: GLP-1s (semaglutide, tirzepatide)

Sold for obesity, and now cardiovascular risk reduction. This is what the finished version of the process looks like. Tirzepatide has shown large, consistent reductions in body weight across trials. Semaglutide reduced major cardiovascular events by 20% in a trial of over seventeen thousand people, followed for years. Fully FDA-approved, for specific, tested indications, at specific, tested doses. These are peptides too. They’re proof the bar can be cleared. They are not evidence that the untested ones deserve the benefit of the doubt. They’re the reason not to extend it.

What I told her

I didn’t tell her not to do it. I told her what I actually knew, which is different from what her hairdresser knew, which is different from what the listing on the website implied.

I gave her four questions I use for myself, on every peptide anyone asks me about:

1. Is there a human trial for this use, the one you’re actually being sold, not a related one?

2. What did that trial actually measure, an outcome you’d feel and care about, or a number on a lab report?

3. Is there an approved version of the same underlying idea, and if so, why would you take the unregulated one instead?

4. If it doesn’t work, or it works differently than advertised, what’s the actual downside, a couple hundred dollars, or something you can’t undo?

She still might do it. That’s her decision, not mine. But she’ll do it knowing that the biology is real and the claim isn’t proven. Those are two very different sentences, and the peptide industry has gotten very good at making them sound like the same one.

Subscribe now

Share

Leave a comment

Sources:

Dorr RT, et al. Evaluation of melanotan-II, a superpotent cyclic melanotropic peptide in a pilot phase-I clinical study. Life Sci. 1996, and subsequent Phase 2 trials of the related analog bremelanotide for female sexual dysfunction, leading to FDA approval as Vyleesi (2019).

Sikiric P, et al. Stable gastric pentadecapeptide BPC 157: novel therapy in gastrointestinal tract. Curr Pharm Des. 2011 — review noting the absence of independent, peer-reviewed human RCT data.

Sosne G, et al. Thymosin beta 4: a potential novel therapy for corneal wound healing and dry eye. Prog Retin Eye Res. — trial data for the ophthalmic formulation, not the injected fragment marketed as TB-500.

Sigalos JT, Pastuszak AW. The safety and efficacy of growth hormone secretagogues. Sex Med Rev. 2018 — on CJC-1295/ipamorelin hormone effects without outcome-level trial data.

Pickart L, Margolina A. Regenerative and Protective Actions of the GHK-Cu Peptide in the Light of the New Gene Data. Int J Mol Sci. 2018 — review of topical GHK-Cu RCTs.

Karasek M. Melatonin, human aging, and age-related diseases — cited source of the epitalon/pineal extract mortality claim, using a different substance than the marketed synthetic peptide.

Daubert MA, et al. Novel Mitochondria-Targeting Peptide in Heart Failure Treatment: A Randomized, Placebo-Controlled Trial of Elamipretide. Circ Heart Fail. 2017 — the SS-31/elamipretide trial that missed its primary endpoints.

Lincoff AM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes (SELECT trial). N Engl J Med. 2023.

I wake up every morning looking forward to my coffee. Not because I need the caffeine, although I’m sure it helps after years of emergency medicine. I look forward to it because over time it has become something much more than a drink.

The whole house is quiet. I hear the grinder before I smell the coffee as the water percolates. I scoop the grounds into my French press and settle into the same corner of the couch I’ve claimed for years. In the winter, I light a fire or sit beside the glow of the Christmas tree. In the summer, I open the windows and listen to the birds as the first light reaches the pines. I press the plunger down slowly, pour the first cup, inhale deeply, and reach for my fountain pen and journal. The next hour has become my favorite part of the day, a small sanctuary for contemplation and creation before the world asks anything of me.

When I miss it because of an early flight or sleep through it after a night shift, I don’t just miss my coffee. I feel unmoored in a way that’s more profound than missing a workout. It took me years to understand why.

What I had always called a routine had become a ritual.

I’ve been thinking a lot about that distinction lately.

We tend to reserve the word ritual for religion. We think of weddings, funerals, baptisms, or Sabbath dinners. But I don’t think rituals belong to religion alone. Every culture has them, and every family has them, whether we call them that or not.

A routine is a repeated action that helps organize your day. A ritual is a repeated act to which we’ve intentionally assigned meaning. Routines help us get things done. Rituals help us remember why those things matter. They remind us who we are, what we value, and where we are trying to go. A routine organizes your day. A ritual orients your life.

Subscribe

As a physician, I spend much of my time helping people build better habits. We talk about movement, sleep, nutrition, strength training, and stress. Habits matter because consistency changes health. But lately I’ve found myself wondering if the habits that truly last don’t remain habits at all. Perhaps the ones that endure are the ones that eventually become rituals.

When a habit carries no deeper meaning, it remains something we do. When it becomes connected to our identity, our values, or the person we’re becoming, it transforms into something much more enduring. That’s what happened with my morning coffee. It isn’t really about coffee anymore. It’s about creating one hour every day before I become a physician, a mother, a wife, a business owner, or anyone else’s problem solver. For a little while, I simply get to be myself.

I love when modern science catches up to something humans have practiced for centuries. Anthropologists have long recognized that rituals exist in every known culture. They mark births and deaths, harvests and weddings, the changing of the seasons and the passing of generations. Though they vary across cultures, they serve remarkably similar purposes. They mark transitions, strengthen relationships, reinforce identity, and remind us that life isn’t simply passing by. It’s unfolding.

Psychologists are beginning to understand why these practices have persisted for so long. Research suggests that rituals help us navigate uncertainty, restore a sense of control during stressful moments, deepen social connection, and give structure to life’s biggest transitions. The ritual doesn’t change the circumstance. It changes how we experience it.

That makes intuitive sense to me. Our bodies already live by rhythm. Cortisol rises with the morning light. Melatonin rises with darkness. Our hormones, immune system, metabolism, body temperature, and even the microbes in our gut follow daily and seasonal cycles. Health isn’t static; it’s rhythmic. Perhaps rituals are the psychological expression of those same rhythms, helping our minds move through time and transition as naturally as our bodies already do.

As I’ve thought more about rituals, I’ve found myself thinking less about the ones I inherited and more about the ones I want my daughters to inherit. We’re not a particularly religious family, but I still want my girls to feel grounded in time, in nature, and in something larger than the endless stream of ordinary days that can all blur together.

So we’ve started creating our own.

In the fall, we make caramel apples from the fruit we harvest from the tree in our backyard. Throughout November, a glass jar sits on our kitchen counter. Whenever one of us notices something we’re grateful for, we write it on a scrap of paper, fold it up, and drop it inside. On Thanksgiving, before dinner, we read every one aloud, my favorite one over the years is for a bbq sauce “sweet baby rays.” On the winter solstice, we turn off every light in the house except one candle. Each of us cups our hands around the flame and shares something we’re hoping for in the season ahead.

Last year, the wishes were exactly what you might expect.

An iPhone.

A better score in gymnastics.

Then my youngest daughter looked into the candle and said, “I hope Mommy has more Mommy Time.”

That wasn’t the answer I expected.

But maybe that’s the point of rituals. They create a space where the things that matter have a chance to surface. The candle wasn’t the ritual. The ritual was the meaning we chose to place around it. Without that moment, lighting a candle is just lighting a candle. With intention, it becomes something entirely different.

That realization has changed the way I think about our family traditions. The caramel apples, the gratitude jar, the Christmas tree hunt, the Easter egg gathering along the river, a New Years cold plunge. None of those activities are extraordinary on their own. What makes them memorable is that we’ve decided they mean something. We return to them year after year, and in doing so they become part of our family’s story.

I spend a great deal of my professional life talking about the markers of longevity. ApoB. VO₂ max. Grip strength. Muscle mass. These things matter. They tell us something important about how long and how well we may live.

But lately I’ve been wondering about the markers of a well-lived life.I don’t think they’re found in something you can measure. I think they’re found in something you live.

The smell of coffee before dawn.

A fountain pen gliding across the pages of a journal.

Caramel apples made from the tree in your backyard.

A candle burning on the darkest night of the year.

Little scraps of gratitude unfolded around the Thanksgiving table.

Those are the moments we remember. Those are the moments our children remember. If health is measured in years, perhaps a life is measured in rituals. Not because rituals make life longer, but because they remind us what we’re living for.

Maybe that’s what Returning North has been about all along. Not adding one more habit to optimize or another task to complete, but returning, again and again, to the people, places, and practices that remind us who we are.

So I’ll leave you with the question I’ve been asking myself.

What ritual could you begin today that someone you love might still remember fifty years from now?

Subscribe

Comment

Share

“How much should I exercise?”

It’s one of the most common questions I hear in clinic, and I’ve stopped answering it with a number.

Guidelines are a reasonable floor. One hundred and fifty minutes a week. Two strength sessions. But they don’t tell me what’s actually missing for the person sitting across from me. After years of asking patients about their real week, not just their workout log, I’ve stopped believing there’s one gap to close.

Fitness isn’t one thing. It’s strength, power, mobility, balance, stability, two different kinds of cardio, the steady kind and the hard kind, the movement that happens without deciding to move at all, and whether any of it brings you joy. Most people have built up two or three of these without ever deciding to. The rest go untrained the same way, by default, not by choice.

Here are six patients. See which one is you.

Subscribe now

The Gardener

She’s been active her whole life, gardening, walking, always outside, never a gym person. Her days are steady effort, the kind that would count as textbook cardio if anyone ever wrote it down. But ask her to sprint thirty feet to catch a bus, and she has nothing left to give it. Decades of steady work, and nobody ever asked her body for a burst.

The Desk Worker

He wants to lose the weight. He wants to be who he was in his twenties. He wants to keep up with his kids without being the one who has to stop.

He’s not lazy. He’s just busy, deep in work most of the day, no real routine around movement outside of it. When I ask about his day between meetings, he doesn’t have much of an answer, not because he’s avoiding it, but because it’s never occurred to him that the gym three times a week and the rest of his hours are two different questions. The gym is exercise. What’s missing is the movement that happens without deciding to move at all, walking to a colleague’s desk instead of a chat message, parking farther away, standing to think. None of it feels like training. All of it adds up.

The Runner

He runs fifteen miles at a time. On a hike together, we came to a stream crossed by a scatter of rocks. He couldn’t do it, stood at the edge recalculating, while I hopped across. “Need to work on that,” he said. He’s said it every time since.

It wasn’t one thing. His ankle doesn’t have the range to angle onto a tilted rock, and even if it did, his balance isn’t quick enough to correct once he’s committed. Running in a straight line trained neither.

He hates gyms. Hates lifting. Loves his morning routine exactly as it is, the same route, the same watch beep at the same mile markers, the same quiet before the rest of the world is awake. Real work here would mean giving some of that up. So the rocks stay a story he tells, not a problem he fixes.

The Chronic Dieter

Mid-fifties, decades of Pilates and spin, four mornings a week since her twenties. She calls herself disciplined, and she’s right to. She’s never lifted anything heavier than a grocery bag on purpose.

The scale keeps creeping up no matter what she cuts. She’s started to assume it’s just her hormones now. It might be part of it. But she’s also spent thirty years training her heart and never once asked anything of her muscle, and muscle is exactly what her body has been losing the whole time.

The Caregiver

Forty-seven. A four-year-old and a sixteen-month-old, both after years of infertility. She’s up before them for a vigorous yoga class, the one thing she’s kept for herself, and calls it enough, because it has to be. There’s no bandwidth left to ask whether it actually is.

All day she’s asymmetric: a toddler on one hip, twisting into the back seat to buckle a car seat, a laundry basket carried sideways because both arms were already full of something else. She wonders if the ache in her back is just this life stage. It might be. But nobody ever trained that trunk to hold steady. It’s only ever had to react.

The Faller

Retired now. She’s fallen twice, for no reason she can point to. The second time, she fractured her wrist on her way to a “bones and balance” class.

She came to see me afterward, not for the wrist. For what the fall told her: that her world had started narrowing without her noticing, and she wasn’t ready for that yet. She wanted to get stronger which is great. What she also needed was the ability to react fast enough to catch herself, and no one had asked her body to move quickly in years.

Which one are you

• Can you carry two full grocery bags up two flights of stairs without stopping? (strength)

• If someone stepped in front of you right now, could you shift your weight fast enough to avoid a collision? (power)

• Can you touch your toes, or get up off the floor without using your hands? (mobility)

• Could you stand on one leg for ten seconds with your eyes closed? (balance)

• Could you carry something heavy and lopsided, a bag, a child, a box, without your whole body compensating? (stability)

• In the last week, did anything raise your heart rate for twenty minutes straight? (zone 2)

• In the last two weeks, did you do anything hard enough that talking became difficult, even for a few minutes? (VO2max)

• On an ordinary day, is most of your movement inside a workout, or spread through the hours around it? (NEAT)

Wherever you hesitated, that’s your gap.

Where I land

For years I didn’t want anything to do with lifting. Moving metal around a room felt boring and beside the point when I could be outside instead. I thought of it as time stolen from the thing I actually wanted to do.

What changed my mind wasn’t a study. It was noticing what strength actually bought me. My knees don’t complain on the way down from a hike the way they used to. When I go down hard snowboarding, and I still do, I get back up without a production. I didn’t start lifting because I finally believed the research. I started because I got tired of my body being the reason I had to stop.

Mobility is still mine to work on. Power and plyometrics too, if I’m honest, though I’m getting there. I bring this up not because I’ve solved it, but because I haven’t and exercise is an evolution.

From my prescription pad

Rx: find the capacity your life isn’t asking of you, and go ask your body for it on purpose.

Why it matters isn’t complicated. Each of these capacities fails differently, and they fail on different timelines. Lose strength and you notice at the suitcase, the jar lid, the stairs. Lose power and you notice at the curb you didn’t quite clear. Lose mobility and stability slowly enough that you adjust around them without ever naming what changed, until the day you can’t. The gap doesn’t announce itself. It just narrows what you’re willing to attempt.

How you close it isn’t complicated either, but it is specific. Two grocery bags and stairs is not the same prescription as a bike trail with your kids, and neither is the prescription for a fractured wrist on the way to a balance class. The exercise that fixes one gap can leave another completely untouched, sometimes for years, which is exactly why I stopped handing out the same program twice.

You don’t need to train all of them at once. You need to know which ones you’re already getting for free, and stop assuming the rest will follow along.

None of this works long-term as another item on a list. The people who keep it up find some version of it they actually enjoy, not just tolerate, the hike over the treadmill, the pickup game over the reps. If you can’t find joy in any of it yet, that’s worth solving before you solve the rest.

If you want more than recognition, paid subscribers can download the North 360 Self-Assessment below and start training for life with intention. If you’re not a paid subscriber yet, drop a comment, tell me which patient was you, and I’ll send it over.

Leave a comment

Subscribe now

My middle daughter said it while I was folding laundry, not looking up. “Mommy, you never play with us.”

I started to argue. I was there constantly, driving them to practice, packing lunches, solving whatever had gone wrong that day. But she wasn’t wrong. I did things for my kids. I rarely just played with them.

So I opened my calendar and blocked fifteen minutes a day. I called it Mommy Time. One child, no phone, no TV, whatever they wanted to do. Cards, paint, coloring, nothing in particular. The only rule was that they picked, and I showed up with nothing else pulling at me.

It felt absurd to schedule time with my own children. Shouldn’t that happen on its own? Maybe. But I already knew that if I didn’t protect it, something else would take the slot without asking.

Subscribe

My daughters are preteens and teenagers now. We still have Mommy Time, not every day, not always fifteen minutes, but the ritual outlasted the reason I started it. What I didn’t expect was that the same blind spot would show up again, in a different room, with no one there to say it out loud to me.

Years later, I found myself asking a version of the same question, except this time it was about my own life.

It was COVID, and I was working three hours from home, in stretches I still don’t fully have words for. I’d leave for days at a time. Every shift in the ER was the same math problem with worse numbers each day. Not enough beds, not enough answers, not enough of whatever it was people needed from me.

Then I’d drive three hours back. Pulling into my own driveway felt almost magical, like surfacing. This is my real life, I’d think. My family was, in their way, thriving, tucked into their own small world, a rhythm that had nothing to do with what I’d just left. Walking in the door some nights, I didn’t know which version of reality was the real one. The one falling apart three hours away, or the one that had gotten along fine without me in it.

What I knew, standing in that doorway, was that I was giving too much of myself to one and not enough to the other. And that whatever this was, the driveway, the magic of it, I had to protect at all costs.

That’s when the question showed up, uninvited: what the hell am I doing with my life?

Not dramatically. Not as a breakdown. Just a persistent math problem of my own, one where the answer kept coming out wrong no matter how I ran the numbers.

I’d gotten good at telling people I was fine. Busy, but fine.

Eventually I hired a life coach. I remember feeling almost embarrassed booking the first call. I’m the one people come to for help, not the one who goes looking for it. But session after session, she didn’t fix anything. She just kept asking me what I was actually thinking, until I started noticing my own thoughts instead of just having them.

That noticing is what led me to the Monk Manual. It wasn’t a magic planner. It just asked, every morning, what actually mattered that day, and if it mattered, why wasn’t I protecting it?

I know how that sounds, like I’m about to tell you a journal changed my life. But it did. Being intentional with my time didn’t adjust my life at the margins. It rebuilt it. Eventually I built my own version of it, folding in everything the Monk Manual taught me alongside what I now call my North framework. It sits next to my coffee every morning, and at the top of every page, before the schedule, before the to-do list, is one small section: today’s non-negotiables. Not goals. Not tasks. The handful of things that make me feel like myself. It is, without exaggeration, my lifeline.

There’s a reason this isn’t just a feeling.

The prefrontal cortex, the part of the brain responsible for planning, weighing tradeoffs, choosing what matters over what’s merely loud, is metabolically expensive and easily outspent. Every decision draws on the same limited reserve, whether it’s what to make for dinner or whether a patient’s chest pain is cardiac. By the end of a long day, or a long stretch of long days, that reserve is thin. Under thin reserves, the brain defaults to whatever is urgent, immediate, and demanding a response right now, not necessarily whatever matters most. Researchers call this decision fatigue. I’d lived it in the ER for years without ever calling it that. It was just Tuesday.

What COVID did was strip away any illusion that this only happens under exceptional stress. Chronic stress floods the body with cortisol, and cortisol doesn’t just make you feel depleted. It actively impairs prefrontal function, the very system responsible for intentional choice. The parts of your brain built for reacting to threat get stronger. The parts built for deciding what you value get weaker. It’s not a metaphor. It’s physiology.

Stephen Covey called the result “the tyranny of the urgent” decades before anyone had cortisol assays to back it up. He was right without needing the blood work.

The urgent will always out-argue the important, because the urgent comes with a deadline and the important rarely does. No one’s chest pain is your mobility work. No one codes because you skipped dinner at the table. The bill for that only ever comes due later, quietly enough that most people never trace it back to its actual cause.

This is, I think, the real case for writing things down before the day gets a vote. Not because a to-do list is virtuous. Because the brain making that list at 6 a.m., before urgency has had its say, is a fundamentally different brain than the one making decisions at 4 p.m. after twelve hours of triage. Protecting time isn’t a lifestyle preference. It’s an attempt to let the better-resourced version of your brain get a vote at all.

I see what happens when that vote never gets cast.

Not long ago, a patient sat across from me. A mom, a business owner, mid-forties, the kind of relentless that built everything she has. “People notice my muscles,” she told me. “That feels good.” Then, almost in the same breath: “But I don’t. I want to be shredded. I can’t do CrossFit like I used to. I have to modify everything.”

She is injured in a way that means pushing harder right now is exactly the wrong prescription. What she needs is to back off and recover.

She does not want to hear this.

She wants a supplement. She wants her testosterone checked. She wants a referral to a new physical therapist, someone, anyone, who might finally clear her to push again.

What I want to hand her is a journal and fifteen minutes of coffee before the day starts. A walk in the woods with no agenda attached to it. Nothing that shows up on a lab panel.

I understand her more than she knows. She is not chasing a supplement because she’s vain. She’s chasing it because modifying feels like losing, and losing is not a language her nervous system speaks fluently. I know that language too. I have spent years prescribing action to people, myself included, because action feels like control, and control feels like safety.

But I’ve started to wonder if physicians are complicit in this. We are trained to solve. We have a pad to write on and a panel to order and a referral to make, and all of it is easier, for both of us, than sitting in a room and saying: the thing you actually need, I cannot give you in a prescription.

I didn’t write her a script that day. I told her what I actually thought. I don’t know yet if she’ll listen. I’m not sure I would have either, at her age, in her position, with her business and her body both demanding she keep pushing.

Maybe she’ll come back in a year with the same shoulder, no more healed, wanting the same referral. Maybe something in her will shift the way something shifted in me, standing in my own driveway, finally admitting I was giving too much to one life and not enough to the other.

My non-negotiables now are almost embarrassingly small. Move my body. Make something. Sit with the people I love, without my phone in my hand. Some weeks I miss all three. Emergency medicine doesn’t care what I wrote in my journal that morning.

But most mornings, before anything else gets a vote, I write them down anyway.

Not because I’ve figured out how to protect them perfectly. Because I’ve finally stopped pretending my calendar and my values are telling two different stories, and I’d rather they lied together than lie separately.

Comment

Subscribe

Share

Ready to define your nonnegotiables? Download this worksheet and get ready to live more intentionally.

Non Negotiables Worksheet

24KB ∙ PDF file

Download

Download

She has a trainer. A nutritionist. A functional neurologist. She trains consistently, eats with more precision than most physicians I know, and still, month after month, the scale refuses to move.

"It isn't fair," she told me. She's right. It isn't.

When I pulled her labs, her insulin was significantly elevated, well before her glucose ever would have raised a flag. She has polycystic ovary syndrome, diagnosed a decade ago, and in ten years of appointments, not one provider had mentioned that it might be the reason her metabolism was working against her.

I think about her every time I meet a woman who tells me she's "tried everything." Some of them have a diagnosis already and were never told what it actually meant. Others have never been diagnosed at all, because nobody looked past their fertility.

This spring, the medical field did something rare: it admitted the name was wrong. In May, The Lancet published a global consensus, backed by 56 medical and patient organizations and more than 14,000 people living with the condition, officially renaming polycystic ovary syndrome to polyendocrine metabolic ovarian syndrome, or PMOS. Nothing about the diagnostic criteria changed. What changed is that, for the first time, the name tells the truth: this is not primarily a disease of the ovaries. It's a disease of hormones and metabolism that happens to show up on an ovarian ultrasound.

Subscribe

That distinction is not academic. It's the reason women spend decades being treated for the wrong thing.

Here is what was actually happening in my patient's body, and quite possibly in the bodies of women reading this who have never been told any of it.

Insulin's job is to move glucose out of the blood and into cells. When cells become resistant to it, most of the body responds by simply working harder, less efficiently, more sluggishly. But the ovaries never lose their sensitivity to insulin. So when the pancreas floods the bloodstream with extra insulin to overcome resistance elsewhere, the ovaries receive that flood in full, and they respond exactly as insulin tells them to: by producing more androgens. That excess insulin also signals the liver to make less sex hormone-binding globulin, the protein that normally keeps testosterone locked up and inactive. Less binding globulin means more free testosterone circulating, even when a standard lab report shows testosterone in the "normal" range. This is one of the quieter reasons the disease gets missed. The number on the page looks fine. The picture underneath is not.

There's a second loop running in the brain. The hypothalamus speeds up its release of the hormone that governs the reproductive cycle, tipping the balance toward luteinizing hormone and away from the one that helps follicles mature. Follicles start growing each month and then stall, unable to finish. Those stalled follicles are what show up on ultrasound as the "polycystic" pattern, and they are not cysts at all. They're arrested eggs, sacs that never got the signal to complete the job. And they produce their own hormone that further disrupts the cycle, which is how a single hormonal imbalance becomes a loop that reinforces itself for years.

None of this requires a woman to be overweight. Insulin resistance shows up in a majority of lean women with PCOS too, along with elevated inflammation and less favorable cholesterol, even when nothing about their size would suggest a metabolic problem. And none of this requires her to still be trying to conceive. The androgen excess and the insulin resistance don't resolve when her cycles regularize or when she reaches menopause. They often become more pronounced as estrogen declines, at exactly the point when most women, and most of their doctors, have stopped thinking about PCOS entirely.

I don't say any of this to make you anxious. I say it because I trained the same way every other physician did, in separate boxes: gynecology here, endocrinology there, metabolic health somewhere else, as though the body respects those divisions. It doesn't. A woman can walk out of three specialist appointments with three pieces of an answer and never hear the whole thing, and that isn't only a failure of the system. It's a failure of how we were taught to look.

If you were told years ago that you had PCOS and given a birth control pill and a pamphlet about fertility, ask your doctor about your insulin, not just your glucose. If you've never been diagnosed but you've spent years with irregular cycles, acne that never fully resolved, or a weight that won't respond to real effort, it's worth asking whether anyone has ever looked at this as a whole picture rather than a set of unrelated complaints.

That question is bigger than PCOS. Almost every diagnosis you'll ever receive comes from a specialist looking at their piece of you. Ask what the endocrinologist would say about the ovaries, and the gynecologist about the metabolism, and whether anyone in the room has ever been asked to hold both at once. Most of the time, the answer is no, not because anyone failed you on purpose, but because the system was built in boxes and your body was never going to fit neatly into one of them.

My patient is not cured. Her weight has not suddenly cooperated. What's changed is that she finally understands what she's fighting, and that the fight was never a matter of effort in the first place.

Paid subscribers get the downloadable PMOS Action Plan: the exact labs to request, what actually moves the needle, and a tracking worksheet to bring to your next appointment.

Share

Subscribe

Comment

Pmos Action Plan

44.9KB ∙ PDF file

Download

Download

I know the sound of it before someone finishes the sentence.

It’s the same job, the same house, the same routine as last year and the year before. A plan mentioned so many times over a decade or more that it’s become almost conversational: the property that never gets bought, the job that never gets left, the business that never gets started, offered up with just enough conviction that you think this might finally be the year. Then another year passes and it wasn’t.

Nothing is wrong, exactly, which is what makes it so hard to name.

Subscribe now

Years ago I wanted to move abroad. My family didn’t. I let the idea go, because sometimes the people you love matter more than the version of yourself you’d imagined becoming. I don’t regret that decision, but I understand the quiet ache of a dream you stop mentioning out loud. It doesn’t disappear. It becomes part of the landscape of your life, something you learn to step around without noticing you’re doing it.

So when a friend tells me, for the fourth or fifth year running, that this is finally the year she’ll make the move, leave the job, or build the business she’s been sketching on napkins longer than either of us can remember, I don’t hear ambition anymore. I hear familiarity. I hear the sentence I stopped saying myself.

One of the stranger parts of being a physician is that I rarely meet people in this stage of their lives. Patients don’t usually come to me because nothing is happening; they come after something has already shifted, a diagnosis, a frightening symptom, a birthday that lands with unexpected weight, a body that finally says something the mind had been ignoring for years. By the time someone sits across from me, they’re often already moving. Something cracked the stillness open. The people who stay still rarely make appointments. There’s no chief complaint for I’ve wanted something different for over a decade and haven’t changed a thing. Vitals normal, labs reassuring, nothing to treat.

Lately I’ve found myself thinking about this through the lens of exercise physiology.

One of the most reliable principles of endurance training is that adaptation doesn’t come from repeating the same effort indefinitely. It comes from giving the body an actual reason to become something different. Zone 2 training has become deservedly popular because it builds the aerobic engine that supports nearly everything else: at a sustainable, repeatable intensity, the body builds more mitochondria, gets better at using fat for fuel, and improves how well it delivers oxygen where it’s needed. For most adults, something like 150 minutes a week forms a genuinely strong foundation for long-term health.

But a foundation is only a beginning. If every workout looks identical, even a good one, the body eventually adapts to that exact demand and stops changing in response to it. The signal stops being new. That’s why athletes deliberately layer in short periods of much higher intensity, the kind of interval that pushes the heart, lungs, and legs past what feels comfortable, and just as deliberately schedule real recovery, not as the absence of training but as the window in which the adaptation actually takes hold. The body grows through contrast, through stress paired with restoration, and it grows fastest when that contrast is chosen on purpose rather than left to chance.

I wonder sometimes whether our lives run on the same biology.

Take the friend with the decade-long plan. Her life isn’t lazy. It’s full. She works hard, takes care of the people around her, keeps the machinery of everyday life running well enough that nothing looks obviously wrong from the outside. But nothing new is being asked of her either. No uncomfortable conversation, no leap that might fail, no real season of rest where she stops carrying everything for everyone else. Just enough effort to maintain what already exists, repeated at the same intensity, indefinitely.

The body is remarkably efficient this way. Once it learns that today’s demands look exactly like yesterday’s, it stops spending energy becoming something new, because adaptation is metabolically expensive and biology waits until it has a real reason to pay for it. I think we do something similar. If Tuesday keeps looking like last Tuesday, we slowly stop expecting anything different of ourselves, and we mistake maintenance for progress because both require effort and, from the inside, they can feel almost the same. Maybe that’s why so many of us wake up one day wondering where the last decade went, not because we chose the wrong life, but because we stopped giving ourselves any real reason to adapt

.

I’ve started asking myself a different question lately, not whether some particular dream will finally happen, but whether this season is actually asking me to push or to recover. Sometimes the honest answer is recovery, a real one, a day without producing, fixing, optimizing, or proving anything, because that’s exactly what growth requires right now. Other seasons call for the opposite: a difficult conversation, a risk, a decision that’s been sitting in the background for years, the interval I’ve been avoiding because it will leave me breathless for a while.

A body doesn’t get stronger by living at either extreme forever, and I don’t think a life does either. It gets stronger by moving between push and recovery with some real intention behind the choice, often enough that neither one becomes the whole story on its own.

There may be nothing here to diagnose, nothing to medicate, nothing, strictly speaking, to treat. But something in most of us is still waiting for permission to believe that tomorrow doesn’t have to look exactly like today, and that permission, it turns out, is usually ours to give.

Download the Push or Recover Quiz below to help determine if you are stuck in the middle or ready for some change.

Leave a comment

Push Or Recover Quiz

35.2KB ∙ PDF file

Download

Download

Of all the numbers on a lab report, cholesterol might be the most argued-about in medicine. Ask ten people what to do about a high LDL and you’ll get ten confident, contradictory answers.

My prior health coach told me recently that she’s keeping her cholesterol high on purpose. Good for her brain, she said.

I promised an ApoB piece last week, and that conversation is exactly why I’m writing it now. So let’s look at the actual evidence. When we weigh all of it (and there is a lot), is there a right answer? And does it look the same for everyone?

What cholesterol actually is

Cholesterol isn’t a poison and it isn’t optional. It’s a waxy lipid built into the membrane of every cell in your body. It’s the raw material for estrogen, testosterone, and cortisol, for vitamin D, and for the bile acids that let you digest fat. You would not survive without it.

Most of what’s circulating in your blood isn’t coming from your plate. Your liver makes roughly 75-80% of it. Diet contributes the rest, but the two dietary levers aren’t the same thing. Dietary cholesterol is the cholesterol you actually eat, in eggs, shellfish, organ meat. Saturated fat is a different nutrient entirely, found in butter, red meat, and full-fat dairy, that contains no cholesterol but signals your liver to make more of it. For most people, that second lever, saturated fat, moves blood cholesterol more than eating cholesterol directly does (spoiler alert, probably ok to eat the yolks). Because cholesterol is fat and blood is mostly water, it can’t just float free in circulation. It has to be packaged and shipped.

Subscribe now

ApoB: the trucks, not the cargo

This is the part that gets lost in most cholesterol conversations. Cholesterol and triglycerides are cargo. They’re carried through your bloodstream inside particles called lipoproteins: LDL, VLDL, IDL, and Lp(a). Each one of those particles has exactly one molecule of a protein called apolipoprotein B stitched into its surface, like a single license plate bolted to each vehicle. One lipoprotein truck, one ApoB plate. Count the plates and you've counted the trucks.

A standard cholesterol panel measures LDL-C, which is the total weight of cholesterol cargo inside your LDL trucks. It says nothing about how many trucks are actually on the road. Two people can post the identical LDL-C number and carry very different risk: one has fewer trucks, each stuffed full of cholesterol; the other has many more trucks, each carrying less. Same cargo weight, very different number of vehicles that can get into your artery walls. The second person is carrying more risk despite the “normal” LDL-C.

ApoB is a direct headcount of those trucks. A growing stack of comparative studies, including a 2024 National Lipid Association expert consensus, shows that when ApoB and LDL-C disagree, ApoB is the better predictor of who actually goes on to have a heart attack or stroke.

How the trucks cause damage

Atherosclerosis starts when an ApoB-carrying particle slips through the lining of an artery and gets trapped inside the vessel wall, where it binds to structures called proteoglycans, oxidizes, and calls in immune cells that eventually build a plaque. This is called the response-to-retention model, and it’s the mechanistic backbone of everything that follows.

Smaller particles cross the arterial lining more easily than larger ones, which is why “small, dense LDL” got a reputation as the dangerous kind. But once you account for how many particles someone has, particle number is the stronger driver of risk, not size on its own. The relevant question isn’t really how big the trucks are. It’s how many of them are circulating, day after day, for years.

That accumulation is slow. A truck getting lodged in an artery wall doesn’t cause a symptom that day. It’s the compounding of thousands of small events over decades that eventually produces a blockage, which is why the exposure over time, not any single lab value, is what actually predicts your risk.

What about HDL?

You’ll notice HDL hasn’t come up yet. That’s deliberate. HDL particles don’t carry ApoB, they carry a different protein called ApoA-1, and they move in the opposite direction, ferrying cholesterol out of tissues and back to the liver instead of depositing it in artery walls. For decades HDL was marketed as “the good cholesterol,” on the assumption that a higher number was protective on its own.

That assumption ran into trouble when researchers actually tried to raise HDL with medication. Niacin, and later a series of drugs called CETP inhibitors built specifically to boost HDL, failed to reduce heart attacks or strokes in large randomized trials, even when they raised HDL substantially. One of them, torcetrapib, increased deaths. The one CETP inhibitor that eventually showed a modest benefit, anacetrapib, turned out to work by lowering ApoB-carrying particles, not by raising HDL. A low HDL is still a useful marker that something metabolic is off, but pushing the number up with a pill hasn’t translated into fewer events. It isn’t a lever the way ApoB is.

Why physicians push this so hard

The case for treating ApoB isn’t built on one study. It’s built on several independent lines of evidence that all land in the same place.

Randomized trials of drugs that lower LDL/ApoB through completely different mechanisms, statins, ezetimibe, and PCSK9 inhibitors, all reduce cardiovascular events in proportion to how much they lower ApoB, regardless of how they get there. When different mechanisms produce the same dose-dependent outcome, that’s a strong signal of causation rather than coincidence. The Cholesterol Treatment Trialists’ meta-analysis, pooling over 170,000 patients across 26 randomized trials, found that each 39 mg/dL (1 mmol/L) reduction in LDL-C cuts major vascular events by roughly 20-25%, with no threshold below which the benefit stops.

For a sense of what happens without treatment, familial hypercholesterolemia is the closest thing to a natural experiment: a genetic condition that produces very high LDL and ApoB from birth. Left untreated, roughly half of men with FH have a coronary event by age 50. That’s a lifetime of unopposed exposure playing out on an accelerated timeline, because the starting point is so much higher than average. It’s also the clearest illustration of why physicians treat this as cumulative rather than a single number to fix once.

No study has yet found a lower limit below which reducing LDL/ApoB stops helping

.

Why influencers anchor on weaker evidence

My health coach’s comment deserves a direct answer, because it’s a real and common claim. Your brain does hold about 20% of your body’s cholesterol, and it genuinely needs it for myelin and synapse function. But the brain makes almost all of that cholesterol itself, behind the blood-brain barrier, and doesn’t meaningfully import it from your blood. Most statins barely cross into the brain at all. Your circulating LDL or ApoB level tells you almost nothing about what your brain has access to. Recent, rigorous reviews haven’t found a meaningful link between statins and cognitive decline; if anything, preventing strokes tends to protect brain function over time. Keeping blood cholesterol high doesn’t feed your brain more cholesterol. It just leaves more trucks on the road.

The other study circulating in low-carb and carnivore circles right now is the Keto-CTA trial, which followed 100 “lean mass hyper-responders,” a specific and unusual metabolic phenotype (very high LDL, very high HDL, very low triglycerides) that emerges on some ketogenic diets. It’s a single-arm observational cohort over one year, with no control group and no hard outcomes like heart attacks or deaths. Plaque still progressed substantially in this group, and it tracked with how much plaque people already had at baseline more than with their ApoB. That’s an interesting and worth-watching finding. It is not evidence that ApoB doesn’t matter, and treating it that way requires ignoring a much larger, internally consistent body of trial and genetic data to lean on one small, short, uncontrolled study.

That’s the general pattern worth naming: contrarian claims often lean on a single small study, a personal anecdote, or an old mechanistic hypothesis, while setting aside the accumulated weight of trials, genetics, and cohorts that all agree. It’s also, frankly, better content. “Everything you’ve been told is wrong” gets shared more than “the guidelines were right.”

How to be curious instead of certain

Before adopting a claim that cuts against the mainstream, it’s worth running it through a few questions. What’s the actual study design, a randomized trial, an observational cohort, or a small case series? Does the claim require throwing out a large, consistent body of evidence, or does it add to it? Is there a plausible mechanism, and has that mechanism actually been tested against real outcomes rather than a surrogate marker? Who benefits if you believe this? And does the population in the study look anything like you, or is it a lean 35-year-old on a niche diet when you’re a postmenopausal woman with a family history of early heart disease?

The most reliable signal isn’t a credential or a platform, it’s convergence. When trials, genetics, and decades of independent cohorts all point the same direction, that agreement is worth more than any single expert, study, or influencer telling you otherwise.

Treatment options: diet

Diet can meaningfully move ApoB, typically in the range of 10-20% for most people, though individual response varies.

Swap saturated fat for unsaturated fat. This has one of the largest effects of anything on this list, with meaningful ApoB reductions from even modest swaps, in the range of 5% of total calories.

Add soluble fiber. 8-20 grams a day of psyllium is the best-studied form. It binds bile acids and pulls LDL particles out of circulation to replace them.

Add plant sterols and stanols. Around 2 grams daily from fortified foods or supplements blocks cholesterol absorption in the gut and lowers LDL by 6-15%.

Shift toward a Mediterranean eating pattern. Clinical trials show 5-15% reductions in ApoB, and in the PREDIMED trial, roughly a 30% reduction in cardiovascular events in high-risk people.

Lose excess weight and cut back on refined carbohydrates. Both help, especially for the triglyceride-rich particles.

Treatment options: medication

When diet isn’t enough, or the starting risk is high enough that diet alone won’t get there in time, several drug classes are available, usually layered rather than used alone.

Statins remain first-line for most people.

Ezetimibe blocks cholesterol absorption in the intestine and is typically added next.

Bempedoic acid is a newer oral option that works through a different pathway and doesn’t cause the muscle pain some people get on statins, useful for people who are statin-intolerant.

PCSK9 inhibitors are injectable antibodies that help the liver clear far more LDL from the blood and can produce large additional reductions on top of a statin.

Inclisiran works on the same PCSK9 pathway but only requires an injection twice a year, which solves the adherence problem for people who struggle with daily pills.

Not everyone needs all of these; the choice depends on your starting risk, your goal, and how your body responds to each step.

What the medical societies say

The newly released 2026 ACC/AHA multisociety dyslipidemia guideline, which replaces the 2018 version, sets risk-based targets rather than one number for everyone.

Very high risk (established cardiovascular disease, highest-risk features): LDL-C under 55 mg/dL, non-HDL-C under 85 mg/dL.

High risk (disease present but not meeting very-high-risk criteria): LDL-C under 70 mg/dL.

Borderline or intermediate risk (primary prevention): LDL-C under 100 mg/dL.

ApoB mirrors these tiers, roughly under 55, 70, or 90 mg/dL depending on risk category. The guideline recommends using it to fine-tune therapy once LDL-C and non-HDL-C goals are met, particularly for anyone with elevated triglycerides, diabetes, or a mismatch between their LDL-C and how they’re actually doing on treatment.

Europe’s 2025 ESC/EAS update lands in a similar place: under 55 mg/dL for very high risk, under 70 mg/dL for high risk.

How I practice

I tend to treat toward the lower end of these ranges rather than the minimum needed to clear a cutoff, particularly for people who have decades of exposure ahead of them rather than a crisis to manage right now. The genetic and trial data both point the same direction: less lifetime exposure is better, and no one has found a floor. I think of it less like a pass/fail lab value and more like blood pressure, something you manage on a trend line over years, because the damage from years of high exposure is already done by the time it shows up as an event.

That said, one size doesn’t fit all here, and I want to be honest about that instead of flattening it into a slogan. The direction of the evidence, lower ApoB generally means lower risk, holds broadly. Where exactly you land within that direction is a real conversation: your family history, your other risk factors, your actual disease burden if we’ve imaged for it, and what tradeoffs you’re willing to make. Someone with no family history, favorable everything else, and a low calculated lifetime risk is in a different conversation than someone with familial hypercholesterolemia or existing plaque.

I didn’t argue with my health coach in the moment. I did go back and pull the studies afterward, which is this entire article. She’s welcome to keep her cholesterol high for her brain. Mine’s headed the other way.

Leave a comment

Sources

• Role of Apolipoprotein B in the Clinical Management of Cardiovascular Risk: NLA Expert Clinical Consensus (2024)

• Apolipoprotein B Outperforms LDL Particle Number as a Marker of Cardiovascular Risk, UK Biobank

• Effect of Long-Term Exposure to Lower LDL Cholesterol Beginning Early in Life on CHD Risk: A Mendelian Randomization Analysis, Ference et al., JACC

• The Impact of Sustained LDL-C Elevation on Plaque Changes: Keto-CTA Study, medRxiv 2026

• Do Statins Affect Cognitive Health? A Narrative Review, PMC

• 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia, Circulation

• 2025 Focused Update of the 2019 ESC/EAS Guidelines for the Management of Dyslipidaemias

• Dietary Therapy for LDL Cholesterol Reduction: Evidence-Based Patterns, StatPearls/NCBI

• Plant Sterols and LDL-Cholesterol: DESCO Randomized Clinical Study, PMC

She was twenty. Her mother sat in the chair by the door with her coat still zipped, like she’d left the house so fast she forgot to take it off.

“It’s been a year,” the mother said. “Tonight it just got bad enough.”

Abdominal pain, on and off for twelve months, worked up twice already by a primary care doctor and once by a gastroenterologist with a waitlist so long she’d waited four months just to be told her labs were normal and to follow up in six. Tonight it had crossed some line at two in the morning that made “follow up in six months” feel like a joke, and she’d ended up in my emergency department instead, where my entire job was to answer one question. Is this dangerous right now?

It wasn’t. I could tell within the first few minutes, and the workup confirmed it. No appendicitis, no obstruction, nothing that needed a surgeon tonight. Which meant I was about to do the thing that I know, from the other side, feels like being handed nothing. Not an emergency. Follow up with your doctor. Here’s a paper with a phone number on it.

Subscribe now

She wasn’t asking for pain medication, which I mention because I’ve learned to notice when someone isn’t, and how much that changes the room. She wasn’t angry. She was just tired in a way that had nothing to do with the hour.

So before I said any of the discharge language, I asked her something that isn’t on any template. How has this affected your day to day. Your life. What has it taken from you?

She looked at me like I’d asked something illegal. Then she told me she’d stopped going out with friends because she never knew which nights would be bad ones. That she’d turned down a promotion at work that would have meant more time on her feet, and never told her boss why. That her mother had started sleeping in the room next to hers, just in case. None of it went into my note. None of it changed the plan, which was still going to be a normal workup and a referral back to a specialist with a four-month wait. But something in the room changed anyway. Her mother’s shoulders came down an inch. The girl said, “Nobody’s asked me that.”

I didn’t fix anything. I want to be honest about that, because I think this is where doctors let ourselves off too easily, myself included. I didn’t solve her pain. I sent her home with the same plan she would have gotten from me on any other night. The only thing that was different was ninety seconds of a question that has no billing code and changes no lab value.

And I keep thinking: that’s the whole thing. That’s what we’re withholding, most nights, not because the system took it from us, but because we’ve slowly decided it isn’t ours to give anymore.

It’s not lost on me that the question I asked her is one I ask almost every day now in the practice I’ve built outside the emergency department, where a visit is an hour instead of nine minutes and asking what someone has lost is the whole point of the appointment rather than something stolen from it. I didn’t expect that work to change how I show up at two in the morning. It has. The two worlds aren’t as separate as I thought they’d be when I built the second one.

Years ago I came home furious about a shift. Someone had come in demanding antibiotics for a cold, gotten angry when I said no, filed a complaint about my bedside manner. I was ranting to my husband, who has never worked a day in medicine, about how entitled patients had become, how little anyone understood what we actually do, how exhausting it was to be blamed for things that weren’t remotely our fault.

He listened for a while and then said something I wanted to dismiss immediately. “Yeah, but she’s not a doctor. She doesn’t know what you know. Maybe cut her some slack.”

I remember being irritated that he’d even offer an opinion. He had no idea what it was like to stand in that room. But I have never stopped thinking about that sentence, which is a strange thing to admit about something your husband said in passing over dinner more than a decade ago. It comes back to me constantly now, usually at the exact moment I’m about to feel superior to a patient, or to another doctor’s patient, or to the version of myself that used to roll her eyes at “difficult” people in triage.

Cut them some slack. Not because the system isn’t broken. It is. But because most of the people caught in it don’t know that it’s broken, they only know that they hurt and nobody seems to be able to help them, and being handed to yet another specialist with yet another waitlist feels a lot like being told their pain isn’t real.

I want to be careful here, because I am not interested in writing another essay that lets doctors off the hook by blaming an abstraction called “the system.” I’ve written that essay. Reasonable people would nod along to it, and it would be true, and it would also be a way of not saying the harder thing, which is this.

We are doing some of this to ourselves.

I hear colleagues talk about patients the way I used to talk about that woman in triage. Frequent flyer. Somatic. Anxious. Words that let you close a chart without opening the story inside it. I’ve watched a consultant walk into a room, glance at imaging, and walk out without ever really looking at the person on the table, and I’ve made the same call myself on a bad night, telling myself it was efficiency when it was closer to fatigue wearing efficiency’s clothes. The system built the conditions for this. Fifteen-minute visits, productivity targets, waitlists that stretch for months, a reimbursement model that pays for a procedure and not for a question like the one I asked that girl at two in the morning. All of that is real and none of it is an excuse for what we’ve let it turn us into.

Patients feel this. That’s why so many of them arrive furious before they even open their mouths, why an ER complaint can be about a cold and antibiotics but is really about a hundred earlier appointments where nobody looked up. They ping-pong from primary care to specialist to urgent care to my department and back again, each stop answering one narrow question and shipping them to the next, and somewhere in that loop the person gets smaller and smaller until she’s just a folder of ruled-out possibilities with nothing that says what she’s actually lost. Medicine has become a collection of handoffs. Primary care owns prevention. Gastroenterology owns the stomach. Emergency medicine owns tonight. Surgery owns the operating room. Everyone owns a piece. No one owns the story.

And maybe that’s what patients are grieving without having language for it. Not that nobody ordered the CT scan. That nobody is carrying the thread from one appointment to the next.

Nobody in that chain is required to ask what she’s lost. That’s not a diagnostic finding. It doesn’t move her toward a cure. But it is, I think, the only thing that tells a person she hasn’t disappeared inside her own case.

I don’t have a tidy answer for the parts of this that are structural. I don’t know how you build fifteen minutes back into a system optimized to remove them, or how you pay a physician for the minute that has no code, or how you ask an emergency department already drowning in genuine emergencies to also hold space for a year of abdominal pain that will never be dangerous enough to justify admission. Those are real constraints and I’m not going to pretend my one good question fixes any of them.

But I keep coming back to the fact that asking it cost me nothing. Not money, not time I didn’t have, not a resource anyone had to approve. It cost ninety seconds and the willingness to stop treating the workup as the whole visit. My husband’s sentence and that girl’s face in the same night, fifteen years apart, keep landing in the same place for me: most of what patients are actually begging for isn’t more medicine. It’s someone willing to notice that a year of pain is also a year of a life, and to say so out loud before handing them the discharge papers.

I don’t think that absolves the system. I think it’s smaller and harder than that. It means some of the fix isn’t waiting on policy or reimbursement reform or the next specialty pipeline. Some of it is just deciding, shift after shift, patient after patient, not to be the person who looks at the labs and misses the person attached to them. I fail at this more than I’d like to admit. I still think it’s the job.

She’ll go back to that gastroenterologist in a few months, and I have no idea what he’ll find or whether he’ll ask her what I asked her. I only know that for one night, in a room that had nothing else to offer her, someone did. I don’t know if that’s enough. I know it’s not nothing.

Leave a comment

Subscribe now

Share

“My doctor said everything was normal.” Then the pause. “So why don’t I feel normal?”

I hear some version of this every week. And most of the time, the labs really are normal. They’re just incomplete.

Twenty years in emergency medicine trained me to look for what’s acutely wrong: the stroke, the sepsis, the thing that will kill you today. Preventive medicine trained me to ask a different question, not “is this person sick” but “where is this person headed.” Those require different labs.

I still order the standard panel. CBC, CMP, a basic lipid panel. Those aren’t optional. They catch anemia, kidney and liver dysfunction, electrolyte problems, the baseline. But over the years I’ve added a set of tests that tell me things the standard panel misses entirely.

ApoB. For most of my training, LDL cholesterol was the number that mattered. ApoB measures something more specific: the actual count of atherogenic particles in your blood. Two people can have identical LDL and very different ApoB, and the person with more particles carries more risk, regardless of what the LDL number says. I now order this on almost every patient over 40, and it changes my treatment threshold more often than LDL does. Full post on this next week.

Lipoprotein(a), or Lp(a). This one is mostly genetic. Diet, exercise, and weight don’t move it. I check it once, because it doesn’t change what’s modifiable, it changes how hard I push on the parts that are. If your Lp(a) is high, I’m more aggressive about blood pressure, ApoB, and everything else in your control.

ApoE genotype. I like knowing this one. It doesn’t change what I recommend for diet and exercise; that advice is good for everyone regardless of genotype. But knowing someone’s ApoE status shapes how I think about their long-term brain and cardiovascular risk, and how seriously we take the modifiable pieces.

Fasting insulin or HOMA-IR. By the time A1c or fasting glucose move, insulin resistance has usually been present for years. Fasting insulin, or better, HOMA-IR, which combines fasting insulin and glucose into one number, catches it earlier, when diet and exercise changes still make the biggest difference. It also connects to more than diabetes risk: fatty liver, cardiovascular disease, and changes in body composition all track with rising insulin resistance long before glucose does.

Hemoglobin A1c. Still useful, still worth ordering. But it’s an average, and averages miss things. Early insulin resistance can hide underneath a normal A1c, and certain conditions that affect red blood cells can throw the number off in either direction. I use it alongside fasting insulin or HOMA-IR, not instead of them.

Liver enzymes, looked at through a metabolic lens. ALT and AST are usually ordered to rule out liver disease, but I read them differently, as an early window into metabolic health. A slowly rising ALT, even within the “normal” range, can be one of the first signs of fatty liver and insulin resistance, often years before someone’s glucose or lipids look abnormal. This is one of the more underused signals sitting in a completely standard panel.

Homocysteine. This one gets overlooked. Elevated homocysteine is tied to cardiovascular risk and, often, to B vitamin status: B12, folate, B6. It’s inexpensive, easy to check, and when it’s high there’s usually something straightforward to do about it.

Uric acid. Most people only think of uric acid in the context of gout, but I read it as a broader metabolic marker. Elevated levels track with insulin resistance, fatty liver, and cardiovascular risk, even in people who will never have a gout flare in their life. It’s a number worth knowing well before it becomes a problem you can feel.

Ferritin. One of the most underused labs in medicine. I’ve seen countless patients with a completely normal CBC and profound fatigue, hair loss, restless legs, or exercise intolerance, because iron deficiency starts well before anemia does. This matters most in menstruating women, endurance athletes, and anyone on a restrictive diet. If a patient tells me they “just can’t recover anymore,” ferritin is one of the first things I check.

Vitamin B12. B12 does more than make red blood cells. It’s involved in nerve function and DNA synthesis. Deficiency is common with certain medications (metformin, long-term acid blockers), restrictive diets, and some GI conditions. It’s cheap, easy to fix, and easy to miss if no one’s looking for it.

hs-CRP. A marker of systemic inflammation you can’t feel. It’s not a diagnosis on its own, it’s a clue that adds context to cardiovascular risk, recovery, sleep, and stress. I use it to round out a picture, not to make a decision in isolation.

Omega-3 Index. Instead of guessing from a diet history or trusting a supplement label, this measures the actual EPA and DHA incorporated into your red blood cell membranes over the past few months. It’s not part of standard screening guidelines the way cholesterol is, but it’s one of the few markers that gives you something concrete to track after you change your diet or start supplementing.

Vitamin D. Probably the most over-tested, over-discussed lab in medicine. I don’t think everyone needs it checked repeatedly, and I don’t think it’s a cure-all for vague symptoms. But in the right context, limited sun exposure, malabsorption, documented deficiency, bone health concerns, it’s worth knowing.

Hormones, it depends. This is the one area where I don’t have a standard panel I run on everyone. What I check depends entirely on the person in front of me: where they are in perimenopause or menopause, what symptoms they’re having, whether we’re considering hormone therapy, whether testosterone or thyroid function is part of the picture. I’ll write a separate post on how I actually approach this, because it deserves its own space rather than a bullet point here.

DEXA. Not a blood test, but it belongs in this conversation. Most people think of it as a bone density scan, and it is, especially important after menopause. But depending on the type, it also gives body composition data: lean mass, visceral fat. Sometimes the most important finding isn’t in the blood at all. It’s watching someone lose muscle and gain visceral fat years before they’d feel either.

I didn’t start ordering any of this to run up a bill or chase a number for its own sake. Most of it came from watching the same story repeat in my exam room: normal labs, a person who doesn’t feel normal, and no test in front of me built to explain the gap. Some of these markers I check on nearly everyone. Some I only reach for when the story calls for it. I’m still adjusting that line as I learn more, and I’d rather tell you that honestly than pretend the list is finished.

This is also the start of a new Monday series here, From the Physician’s Desk, where I’ll walk through the decisions I make every day in preventive medicine: what I order, what I skip, and why. Next week we’ll start with ApoB, the single lab that’s changed my thinking about cardiovascular risk more than any other.

For paid subscribers, these posts will also grow into something bigger over the next year: a working handbook covering biomarkers, movement, nutrition, sleep, hormones, and the rest of what preventive medicine actually looks like in practice. Not a stack of PDFs, something you can keep coming back to as it grows.

Subscribe

Share

Comment

Why go from one half-passion to another, when you could have a career you actually love?

So I wrote a book. A middle school fantasy novel about a woman named Diana and her twin brother Apollo, separated at birth, each living in a different world, one of them real, one of them not. It took me months. I finished it.

Then one person read it and didn’t like it, and I put it in a drawer and decided it was irresponsible to be a writer. Writing would never support me and my family.

I still think about that book sometimes. Not with regret exactly. More like you think about a room in a house you used to live in. You know it’s still there. You just don’t know yet whether you’re going back.

What I know is this: three children read it and didn’t want to stop. A paid editor read it and found everything wrong. I believed the editor, because that’s what we’re trained to do, defer to the authority, the credential, the person who does this professionally.

But I’ve been thinking lately about what it means to let one voice be louder than all the others. In medicine we call it anchoring. It is when the first piece of information shapes everything that follows, even when better information comes later. You lock onto the initial diagnosis and stop seeing what doesn’t fit.

I anchored to that editorial letter in 2021 and stopped seeing everything else.

I decided I was someone who liked writing but didn’t like what came after. So I built something instead. Something with metrics and deliverables and a business plan. Something that looked, from the outside, like a responsible choice.

It was. It also wasn’t the whole truth.

This week I was reading about William Kent Krueger, the author of one of my favorite novels, This Tender Land. In the introduction he describes spending three years writing a book he believed would be his next novel. It never was. He put it aside and started again. Three years later, This Tender Land existed.

I couldn’t stop thinking about those first three years.

Were they wasted? From the outside, maybe. There was no published novel to show for them. But I don’t think those years were really spent writing the wrong book. I think they were spent becoming the writer capable of writing the right one.

I’ve been a physician for twenty years. I know how to sit with a patient who is grieving a diagnosis and help them find the thread that leads forward. I know how to hold two true things at once: this is hard, and you will be okay.

I am not always good at doing that for myself.

The responsible choice and the wanted choice have been sitting on opposite sides of a room in me for four years now, longer if I’m honest. I built the responsible one carefully. I tend it. I believe in it.

But the wanted one is still there. Still waiting. Not demanding anything. Just present, the way a book in a drawer is present.

I wrote a book about two worlds and then spent four years telling people how to live longer in this one. I’m not sure those things are as separate as I made them.

I don’t know what I’m going to do with that.

What I know is that I’m writing. Every week, more honestly than the week before. And somewhere between the health essays and the personal ones, between the physician and the person, I’m becoming something I couldn’t have predicted in 2021.

Maybe that’s what the first years were for.

Not building the thing.

Building the person who knows what she actually wants to build.

Last night I opened the drawer.

I don’t know what happens next. But I looked.

Leave a comment

Subscribe now

She walks ten thousand steps a day. Has for years. She doesn’t miss days, and if anything, she’s more disciplined about it than most people are about anything. But her body hasn’t changed in all that time. Same strength, same shape, same plateau she can’t explain and can’t walk her way out of. The same question, “I’m doing everything right but not seeing results?”

The answer, I think, starts on the Oregon coast.

My daughters and I were wandering through Lincoln City on a trip we hadn’t planned very carefully, ducking into shops mostly to get out of the wind. We found ourselves watching a glass artist work through a studio window and didn’t leave. The shelves were lined with floats that seemed to hold light inside them, blues and greens and deep ambers. Twenty minutes later we were wearing safety glasses and debating colors for glass floats we hadn’t known we were going to make that morning.

We spent an absurd amount of time on those colors. Tiny jars of crushed glass lined the shelves around the studio. Blues that looked like the Pacific just outside. Greens like the hills coming down to the coast. Each of us had a strong opinion and couldn’t entirely explain it.

Subscribe now

I thought I understood glassblowing. Like most people, I assumed it involved a person blowing through a tube while molten glass expanded at the other end. It doesn’t, not anymore. The instructor shapes the glass with tools and gravity and turning. What struck me more than anything was that the turning never stopped. Not while she walked, not while she talked, not while she moved between furnace and bench. Every motion was unhurried, but the rod was always moving. Stop turning and gravity immediately had its say.

Before anyone touches the glass, the furnace has already done the essential work. You can’t shape cold glass. The furnace heats it to the point where change becomes possible, where the material can actually become something different than it was a few minutes before. Without that heat, all the skill in the world just bounces off.

Building muscle works the same way, and most people never know it. The body has no real interest in carrying extra muscle just because we’d like it to. Muscle is expensive. It costs energy to build and to keep. If the body can already meet the demands of ten thousand steps, it has no reason to invest in more. It will hold the line at “enough” indefinitely, no matter how many days in a row “enough” gets repeated.

A strength workout changes the equation. Not because of the effort itself, but because of the question it asks. Mechanical tension in the muscle fiber sends a signal: should we be stronger than we currently are? Without that specific signal, repetition, however faithful, however many days in a row, doesn’t get answered. The body just keeps doing what it already knows how to do.

Reading the Glow

None of us could shape much in that first half hour. Our hands didn’t know what the glass would do until it had already started doing it: we turned the rod too late, gathered too little, panicked when it started to sag. The instructor wasn’t reacting to what the glass looked like. She was responding to what it was about to become. She could see when the material was approaching a state where it could be shaped, recognizing possibilities that were completely invisible to us.

By the end of two hours, something had shifted in us too. Not skill exactly. More like the beginning of attention. We’d started to read the glow: to see the difference between glass that would hold a curve and glass that was about to slump. The pieces we’d made were still obviously beginner work. But our handling of the glass had already changed.

In the first weeks of a new strength program, most of the improvement isn’t muscle at all. It’s the nervous system learning to recruit fibers it already had, firing them harder and in better sequence, well before any of those fibers have grown. The lift gets easier before the muscle gets bigger. The body is learning before it is growing. This is one reason people become discouraged too early: we expect visible change before appreciating invisible adaptation. Yet invisible adaptation is usually the prerequisite for everything that follows.

Back to the Furnace

Every time my daughter’s float started looking finished, the instructor sent her back to the furnace.

At one point her piece didn’t hold. I don’t remember what went wrong, only that it didn’t take, and she had to start the shape over without much ceremony. No one treated it as a setback. It was simply what came next. The glass had changed since the last time it went in. What worked ten minutes earlier wasn’t enough now. Standing at room temperature admiring what had already been accomplished wasn’t going to move the piece forward.

After a workout, the body repairs itself slightly stronger than before. The weight that felt heavy starts to feel normal. This is the goal, and it’s also why progress stalls. Once the body has mastered a demand, it stops spending resources on further change. To keep adapting, it needs another invitation: more resistance, another rep, a heavier load pulled from the same fire. Not because the last round failed. Because it succeeded, and in succeeding, used itself up.

There’s a wrong way to do this too. Leave the piece in the furnace too long and it stops cooperating. The glass goes from workable to runny, sagging out of whatever shape you’d just given it. Not enough heat and it won’t move at all. The instructor was reading a narrow window where the glass would actually do what was asked of it. Muscle has the same window. Too little challenge and the cells never get the signal. Too much stress without recovery between sessions and the system breaks down instead of building up. The dose is the whole art.

The Part Most People Miss

At the end of class, our floats looked done. The colors had settled into their final patterns. We were ready to take them home.

Instead, the instructor placed them in the annealing oven and told us to come back tomorrow.

Glass cools unevenly. Cooled too fast, it traps stress inside itself, invisibly at first. It can look flawless and still carry a fracture that surfaces days later for no reason anyone in the room would notice. Annealing lets that stress release slowly, overnight, while nothing visible is happening at all.

We came back the next morning. The floats looked different than I remembered. The color had shifted, settled somewhere I hadn’t expected. One of my daughters held hers up to the light and turned it over, looking for what she’d put in. It wasn’t exactly what any of us had pictured. The most important changes had happened while we were away.

The workout is only the request. The growth happens later, overnight mostly, while we’re doing nothing that looks like training. Muscle protein synthesis rises. Damaged fibers repair. Growth hormone increases. We chase the next workout instead of protecting the night that would let the last one matter.

This holds further into life than most people expect. Research following people well into their seventies and eighties found the capacity to build new mitochondria in response to training stayed fully intact: not diminished by age, not diminished by menopause, not diminished by a body that had already been through a lot. The biggest predictor of how much someone improved wasn’t how old they were. It was how unconditioned they’d been to start. The less fit going in, the more room to change. The furnace still works. The glass still moves. The question is only whether the heat is high enough to ask anything of it.

I think about my patient’s daily walk, faithful and unbroken, ten thousand steps logged for years. It’s not wasted. Her heart and her longevity are better for it. But none of it has ever asked her body the specific question that changes shape. What she’s missing isn’t effort or discipline. It’s a different kind of signal: something hot enough to demand a new answer, followed by the recovery that lets that answer settle into something durable.

The instructor called it reading the glow.

I think she was talking about more than glass.

Subscribe now

Leave a comment

Share PeakMD

A few miles into my run, my hip started talking to me again.

Not enough to stop. Just enough to remind me it was there.

The ache has been hanging around for months now. Some days it’s barely noticeable. Other days it feels like a small hitch in my stride, a reminder that at fifty my body occasionally has opinions of its own. As I ran along the trail, I found myself looking down at my shoes and wondering if maybe they were the problem.

Maybe I need new shoes.

It was an appealing thought because it came with a straightforward solution. Research a few models, head to the running store, spend some money, and walk out feeling optimistic. Runners love new shoes. They smell like possibility. They offer the comforting feeling that improvement might be just one purchase away.

But somewhere between one bend in the trail and the next, another thought arrived.

The truth was I hadn’t been doing the things I already knew mattered. My stretching routine had become sporadic. The mobility work I usually do had quietly disappeared from my mornings. The strength training that helps keep my hips and glutes resilient had slipped down the priority list. The fascial work that helps me move well had been replaced by a mental note that I should really get back to it someday.

In other words, I was hoping the answer might be found at the bottom of my feet when it was far more likely to involve my entire body.

Subscribe now

As often happens on runs, my thoughts drifted from my own life to my patients. Because I see this pattern everywhere, and if I’m being honest, I see it in myself too. We all want the thing that will fix us. The supplement. The gadget. The diet. The medication. The planner. The wearable. The new pair of shoes. We are drawn to solutions that feel tangible and immediate because they offer something we all crave: hope.

Sometimes those things help. Sometimes they help tremendously. But they are rarely the whole story.

I see this most often in conversations about menopause hormone therapy.

She came to me in March, for her first visit, and cried before we’d even finished her history. Not the kind of crying that comes from one bad day, the kind that comes from a body that has been overruled for a long time finally getting a vote. I don’t think anyone had asked her how she was doing, not really, in longer than she could remember. She told me she was doing everything right and not seeing results. She runs her own business. She’s raising kids. She trains hard, harder than her body has been asking for, and when the word overtraining reached her something in her face shifted. A loosening, like she might let herself stop gripping for a second.

Then, almost in the same breath, she asked about adding testosterone. About getting leaner.

“It’s already March,” she said, “and I haven’t done anything different this year.”

As if the failure was that she hadn’t added enough yet. As if the answer was always going to be one more thing.

Maybe the testosterone will help. Maybe the leanness will come. But I don’t think either one will touch the thing that actually brought her to tears in my office before we’d gotten through her intake form.

Sometimes hormones are the missing piece. I prescribe menopause hormone therapy regularly, and I have watched it change lives. Women who haven’t slept through the night in years finally rest again. Hot flashes disappear. Mood improves. Brain fog lifts. Some women tell me they feel like themselves for the first time in a decade. Those experiences are real. The benefits are real. The science is real.

But the longer I practice medicine, the more convinced I become that most health transformations happen when we stop looking for a single answer and start understanding how many different pieces work together. Hormones can be an important piece of the puzzle. Sometimes they are the missing piece. But they are rarely the entire puzzle.

Part of the confusion comes from the way we talk about health. We love breakthrough stories. We love before-and-after photos. We love hearing that one thing changed everything. Occasionally that happens. Medicine has produced remarkable advances that truly transformed lives.

But many of the challenges we face in midlife don’t work that way. They’re not caused by one thing, which means they’re rarely solved by one thing.

Midlife is complicated. Many women are simultaneously building careers, supporting aging parents, raising children, navigating changing relationships, and trying to care for themselves somewhere in the margins of an already crowded life. The hormonal transition of menopause is happening at the exact same time many of life’s other demands are reaching their peak.

I don’t think we search for easy fixes because we’re lazy.

I think we search for them because we’re tired.

We’re carrying a lot. We’re making decisions all day long. We’re trying to meet expectations at work, at home, and in our communities. By the time we finally turn our attention toward our own health, of course we want the new shoes to solve the hip pain. Of course we hope the supplement, the wearable, or the prescription might be the missing piece. Sometimes they are. But sometimes what we’re really longing for is relief from carrying so much.

Estrogen receptors live in nearly every system we depend on — brain, bone, muscle, blood vessel — so it’s no mystery that losing estrogen can unsettle the whole body at once.

The evidence supporting hormone therapy for bothersome menopausal symptoms is strong. For many women, it remains the most effective treatment we have for hot flashes and night sweats. It can improve sleep, quality of life, and overall wellbeing when used appropriately.

At the same time, hormone therapy cannot strength train for you. It cannot build cardiovascular fitness. It cannot create muscle without resistance. It cannot undo years of chronic stress. It cannot create meaningful relationships or help you reconnect with a sense of purpose if you’ve lost touch with it. Hormones can improve the terrain, but you still have to walk the path.

This is one reason I’ve become increasingly interested in precision medicine. Many people hear that phrase and think of advanced laboratory testing or genetics. Those tools can be useful, but to me precision medicine is something simpler: asking what’s actually driving someone’s symptoms, finding the real leverage points, and being willing to discover that the missing piece isn’t the one they came in hoping for.

For one woman, hormone therapy may truly be the key intervention. For another, the biggest opportunity may be rebuilding muscle. For someone else, it may be sleep, nutrition, stress, loneliness, purpose, or movement. Most often, it’s some combination of all of the above.

The goal is not to find the one thing. The goal is to see the whole picture.

The fundamentals haven’t changed nearly as much as the wellness industry would like us to believe. Sleep still matters. Strength still matters. So do movement, nutrition, meaningful relationships, time outdoors, and a sense of purpose. These are not particularly exciting answers, which may be part of the reason we keep searching for something else.

Yet when I look at the healthiest people I know, I rarely find a secret. I find a collection of ordinary practices repeated consistently over time. They have built lives that support their health rather than asking a supplement, medication, or device to compensate for the absence of a foundation.

By the time I finished my run, I still hadn’t decided whether I needed new shoes. I may.

But I also knew that before I spent another dollar searching for the next solution, I needed to return to the foundations I already knew mattered. The stretching. The strength work. The mobility. The small habits that quietly support everything else.

The irony is that tools often work best when the foundations are already in place. The right running shoe helps a runner who is training consistently. Hormone therapy helps a woman who is also rebuilding strength, protecting sleep, managing stress, and caring for herself. The best outcomes rarely come from a single intervention. They emerge from many pieces working together.

The next morning, before I researched new shoes, I spent ten minutes stretching.

Not because stretching is exciting. Not because anyone posts before-and-after photos of a mobility routine. But because sometimes the fix isn’t the next thing we buy, or the next thing we add.

I still don’t know what my patient will decide, whether the testosterone helps, whether the leanness comes, whether she ever lets herself stop gripping long enough to notice what her body has been asking for all along. I think about her more than I probably should. I recognize the grip.

Sometimes the answer is already in us, underneath all the reaching. The hard part isn’t finding it. It’s being still enough to feel it.

Share

Leave a comment

Subscribe now

The Metolius was moving quickly that morning, cold and clear as it wound through the pines near my home. I was out for an easy run, following a familiar trail, when I found myself watching the river and thinking about uncertainty.

A river never doubts its next step.

It doesn’t know what lies around the next bend. It doesn’t know when a fallen tree will redirect its course or when spring runoff will reshape its banks. It simply responds to the terrain in front of it.

I have never been quite that comfortable with uncertainty.

When I was growing up, we knew where to find the best moving boxes. Liquor stores, mostly. The cardboard was thicker. We learned which neighborhoods had them and when they threw them out. My parents had a system.

The lights went out sometimes. Not a storm, just the bill. You learned to notice the particular silence of a house when the refrigerator stops humming. You learned to do keep a flashlight in your room.

I don’t say this for sympathy. I say it because it explains something. When the ground is unreliable for long enough, you spend a lot of your life trying to find solid footing. You start looking for roads that are clearly marked. Paths that other people have already walked.

Medicine looked like that to me.

Do well in school. Get into college. Go to medical school. Complete residency. Find a job.

The road was difficult, but it was legible. Someone else had drawn the map. And I was very, very good at following it.

For years I simply took the next step. Then the next. Then the next.

Eventually I arrived exactly where I had planned.

Or so I thought

Subscribe now

Starting my business PEAKMD has been one of the most uncertain experiences of my life.

There is no syllabus. No attending physician. No board exam at the end reassuring you that you’ve done enough.

I remember one particular stretch, my third massage therapist had just left, and I hadn’t seen a new patient in a month. I was sitting at my desk doing the math I didn’t want to do. Not metaphorical math. Actual numbers. Runway. Months. I kept rearranging them, as if a different order might produce a different answer.

It didn’t.

Around that same time, my daughter said something I haven’t been able to put down. She told me that sometimes it felt like I was more present when I was physically gone than when I was home. That when I was home, I wasn’t really there.

She wasn’t wrong.

I was always somewhere else in my head, solving something, planning something, trying to outrun the uncertainty by thinking faster. The lights were off in a different way than they used to be, but I recognized the feeling.

The discomfort makes sense. Neuroscientists often describe the brain as a prediction machine. Every second of every day, our brains are trying to anticipate what comes next because prediction conserves energy, and uncertainty does the opposite. When we don’t know what comes next, the brain pays attention. Stress hormones rise. We scan for threats. We search for answers.

It is one reason major life transitions can feel so exhausting, even when we chose them. The uncertainty itself is a physical experience, not just an intellectual one. Perhaps this is one reason nature feels so restorative. A river is not trying to control its future. A forest is not resisting change. Every season is an exercise in adaptation.

For years, I assumed confidence came from reducing that discomfort.

Now I’m not sure that’s true.

Recently, a patient asked me which supplements I take. She told me she wanted to take the same ones because I had probably already researched them all and figured it out.

I smiled, because I understood exactly what she was hoping for. She wasn’t really asking about supplements. She was asking if somewhere, there was a person who had made the uncertainty stop. A right answer. A perfect protocol. A map. And isn’t that what we all are asking for in perfect exercise routines or following a new diet, the certainty that this one will work.

I remember feeling that way myself early in my medical training. I imagined that experience would eventually eliminate uncertainty. That one day I would know enough to always know the answer.

Instead, something unexpected happened.

The longer I practice medicine, the more comfortable I have become saying, it depends.

Not because knowledge is unimportant but because biology and disease is complex. Human beings are complex. The most honest answer is often not certainty but probability. The best physicians I know are not the most certain ones. They are the most comfortable navigating uncertainty.

Wisdom and certainty are not the same thing.

Psychologists draw a distinction between goals and values that I keep returning to. Goals are destinations: they can be achieved, abandoned, or changed. Values are directions. You never finish being curious. You never complete courage. You never arrive at integrity.

The distinction matters because goals often depend on circumstances we cannot control. Values remain available regardless of what the future brings.

A compass doesn’t tell you exactly where you’ll be in five years. It doesn’t eliminate obstacles or smooth the terrain. It simply helps you stay oriented when the landscape shifts.

These days, when I feel lost, I ask a different question than I used to.

Not: Where will this lead?

But: Am I facing North?

Am I moving toward the things that actually matter to me? Toward the people I love? Toward the work that feels like mine?

When my daughter told me I wasn’t really there, I was facing the wrong direction. I was oriented toward control, toward certainty, toward solving the unsolvable. None of it was bringing me home.

I built PEAKMD around a simple question I ask every patient before we ever discuss labs or medications or exercise: What is your North?

The irony is not lost on me that it took me nearly five decades to answer that question for myself.

I spent most of my life confusing the map for the destination. Assuming that if I followed the right path long enough, certainty would eventually arrive like a reward. That the ground would finally hold.

What I have found instead is something quieter and, I think, more true.

The ground never fully holds. But I trust myself more than I used to, and I am still working on it.

As I ran beside the river that morning, I thought about what it would mean to move the way the Metolius moves, not knowing what’s around the next bend, but responding to whatever comes. Not resisting the fallen tree. Not mourning the old channel when the banks shift.

I grew up in houses where the lights went out. I learned early that stability was not something you could take for granted. What I didn’t learn until much later was that the instability itself had given me something: evidence. Evidence that I could navigate uncertainty when it arrived. That I had done it before and would do it again.

Perhaps that is what confidence actually is. Not the absence of fear. Not the presence of a plan. Just evidence, accumulated quietly over time, that you can keep moving even when you don’t know where you’re going.

The Metolius doesn’t know what lies around the next bend.

Neither do I.

A compass, after all, was never meant to predict the future.

It was meant to help us keep moving.

Subscribe now

Leave a comment

Share PeakMD

A few months before my 50th birthday, I canceled my party.

Not immediately. First I scaled it back. Then I scaled it back again. What had started as a community celebration with hiking, yoga, cold plunges, portable sauna, line dancing, a DJ, and a bonfire slowly became smaller until eventually I convinced myself I didn’t have the bandwidth for any of it.

At the time, the decision felt reasonable.

I had just returned from Uganda. A tragedy had touched people close to me. I was pouring enormous energy into launching a new business. Life felt meaningful, exciting, uncertain, and exhausting all at the same time. Somewhere through all of this, the party stopped feeling like a celebration and started feeling like one more thing to manage.

So I canceled it.

The truth is that I wasn’t struggling with turning fifty. If anything, I was looking forward to it. What I was struggling with was everything else. Looking back, I think that’s one of the things stress does best. It narrows our vision. Not dramatically. Quietly. It convinces us that the things that bring us joy can wait. The hike can wait. The dinner can wait. The gathering can wait. Slowly, without realizing it, we begin making our world smaller.

Subscribe now

For a brief period this year, I found myself returning to an old escape fantasy.

Mine happens to be Ireland.

A small cottage. A slower pace. Long walks. Fewer responsibilities. A life that existed mostly in my imagination.

I wasn’t seriously planning a move. What I was really longing for was relief.

Over the years, I’ve seen versions of this play out in exam rooms. People assume they need a different job, a different routine, a different relationship, or a different town. Sometimes they do. But just as often, what they’re experiencing is exhaustion. When we’re depleted, it’s easy to mistake fatigue for unhappiness and overwhelm for evidence that something is fundamentally wrong.

Looking back, I can see how easy it is to mistake exhaustion for dissatisfaction and overwhelm for misalignment. When life feels heavy enough, the problem can begin to look like the life itself.

It wasn’t.

I wasn’t unhappy.

I was tired.

Thankfully, the people who love us sometimes see more clearly than we do. When I told my daughters I was canceling the party, they looked at me with genuine confusion. “But Mom,” they said, “you love parties.”

They were right.

Not because I enjoy being the center of attention. What I love is gathering people. I love introducing friends who don’t yet know each other. I love watching conversations unfold around a table, on a trail, or around a fire. I love seeing a collection of individual relationships become a community.

Somewhere beneath the stress, grief, travel, logistics, parenting and pressure of building something new, I had temporarily lost sight of that part of myself.

So I changed my mind.

Not completely. The giant celebration was gone. The DJ disappeared. The elaborate plans never happened. What remained was something much simpler: close friends, family, food, music, and a backyard fire.

What followed may have been my favorite birthday I have ever had.

The day began exactly as I hoped it would. I went for a run and later rode my bike. The weather was perfect. By evening, friends and family began to gather.

At one point during the night, my daughter and a close friend and neighbor’s son picked up their instruments and began playing songs I love on guitar and banjo. The entire performance had been quietly orchestrated by my neighbor, one more thoughtful act I never saw coming.

We gathered around the fire and listened.

As I watched them play, I realized I wasn’t simply watching two talented teenagers perform. I was watching children who had grown up together. Kids whose lives had crossed through school events, sleepovers, campfires, community projects, and all the ordinary moments that rarely seem important while they’re happening.

Yet sitting there that evening, they felt anything but ordinary.

I looked around the circle and saw people who had entered my life through completely different doors. Medicine. School board meetings. River trips. Raising children. Community projects. Some friendships stretched back decades. Others were newer. One friend had driven from Portland simply to be there. My husband had quietly helped create an evening that felt effortless despite knowing how much work goes into making something feel easy.

And somewhere between the music and the firelight, I had a realization.

I wasn’t looking at a birthday party.

I was looking at a life.

A life built so gradually that I had almost failed to notice it while I was living it.

As the evening went on, one of my friends laughed and said, “You know what I’ve noticed about you? When you’re waffling, you usually feel really good once you’ve decided to do it.” I laughed. Mostly because it was true. And because everyone standing there had just watched me spend months debating whether I should celebrate my birthday at all.

What fascinated me most as I reflected on all of this was not the science of connection, although that matters. It was the science of perception. Psychologists have shown that humans are remarkably poor at predicting what will make us happy in the future. Researchers call this affective forecasting. Again and again, studies show that we overestimate the effort required for meaningful experiences and underestimate how good they will feel once we’re there.

We don’t feel like going to the workout, the gathering, the concert, the dinner, or the hike. Then we go, and afterward we find ourselves wondering why we hesitated in the first place.

The older I get, the more I think wisdom may involve learning to recognize those moments. Stress has a way of drawing our attention toward what is unfinished, uncertain, and demanding. It convinces us that the answer is to simplify, withdraw, or postpone joy until a more convenient season arrives.

Sometimes that instinct is correct.

But sometimes the thing we are most tempted to cancel is the thing we most need.

That birthday party I almost canceled turned out to be a reminder. Not that life is perfect. Not that we should always say yes. But that when life becomes overwhelming, we can lose sight of the very things that make it meaningful.

Then I found myself sitting around a fire, listening to my daughter and a lifelong friend play music together while surrounded by people I love. I looked around at friendships that had accumulated over decades, children who had grown up together, neighbors who had become family, and a community that had been built so gradually I almost failed to notice it.

In that moment, I realized I wasn’t looking at something I wanted to leave behind.

I was looking at something I was profoundly grateful to have built.

Sometimes the thing we need most is not a different life.

It’s a clearer view of the one we already have.

Subscribe now

Leave a comment

A patient stood in front of me recently during a longevity assessment, someone most people would immediately describe as healthy. Lean, active, a longtime runner, the kind of person who does all the “right” things and probably gets told all the time how fit he looks. During part of the assessment, I asked him to stand on one leg. He laughed a little at first, like most people do, assuming this would be the easiest station of the day. Then he started wobbling almost immediately. Arms reaching out. Foot dropping down. Trying again and losing balance even faster the second time.

What struck me wasn’t that he struggled. Most people do, especially once visual compensation is removed. What struck me was the look on his face afterward. Genuine surprise. As physicians, we spend so much time talking about cholesterol, weight, blood sugar, and exercise minutes, but very few people have ever been told that balance at midlife predicts far more than they realize. In a 2022 study published in the British Journal of Sports Medicine, adults unable to stand on one leg for ten seconds had an 84% higher risk of death over the following seven years. Not because balance itself is magical, but because balance reflects the integrated function of multiple systems that quietly change as we age: vestibular function, proprioception, neurological coordination, reaction time, lower extremity strength, even cognitive processing.

Subscribe now

I found myself thinking afterward about how differently we define fitness versus resilience. Many people who are objectively fit are still undermeasuring the capacities that most predict how well they will age. We tend to focus on the visible things: pace, weight, aesthetics, workout frequency, resting heart rate. Meanwhile, the body is keeping score somewhere else entirely. In grip strength. In recovery speed. In the ability to generate force quickly enough to catch a stumble. In whether the nervous system can actually shift back into recovery after stress has passed.

One of the things that has surprised me most as I’ve gone deeper into longevity medicine is how often the most meaningful predictors are not the glamorous ones. They are not hidden inside some futuristic technology or expensive supplement stack. Many are remarkably simple, almost deceptively so. Grip strength, for example, has emerged as one of the strongest biomarkers we have for overall health and longevity. In the PURE study, which followed more than 140,000 people across 17 countries, grip strength predicted cardiovascular mortality more strongly than blood pressure. Every 5-kilogram decrease in grip strength was associated with a 17% increase in cardiovascular mortality risk.

There is something almost poetic about that to me. The idea that the body records years of movement, muscle maintenance, metabolic health, recovery, and aging in something as simple as the strength of your hands. Grip strength is not really a hand test. It is a window into total-body muscle quality, neurological integrity, and physiological reserve. The body has been adapting to how we live for decades, and eventually those adaptations become measurable.

The same is true for power, which may be one of the least appreciated aspects of aging. Most people understand strength. They notice when lifting groceries becomes harder or when they can no longer do what they once could in the gym. But power is different. Power is the ability to generate force quickly, and physiologically it declines earlier than strength, often beginning in our forties and fifties even in highly trained people. This matters because so much of real life depends on rapid response rather than slow force production. Catching yourself when you trip. Stepping quickly off unstable terrain. Recovering balance before momentum carries you to the ground.

I think this is why some of the simplest tests become the most revealing. A broad jump. A kneeling-to-standing jump. Watching someone who looks outwardly fit suddenly realize their body does not move through space the way they assumed it did. Not because they are unhealthy, but because aging often begins quietly. We lose quickness before we lose strength. Adaptability before incapacity. The changes are subtle enough at first that most people never notice them until something forces them to.

Working in emergency medicine has probably made me more aware of this than most. In the ER, I often see the final chapter rather than the beginning of the story. The fall that leads to the hip fracture. The hospitalization that changes the trajectory of someone’s independence. The moment when resilience finally runs out. What interests me more now are the decades before that happens. The quieter physiological shifts that begin long before anyone considers themselves old.

Cardiovascular capacity tells a similar story. Cardiorespiratory fitness remains one of the strongest predictors of all-cause mortality we have, with studies showing dramatically lower mortality rates in people with higher aerobic fitness levels. But I’ve become increasingly interested not just in output, but in recovery. How quickly does the heart rate come down after exertion? How efficiently does the nervous system shift out of activation? How much reserve does the body actually have?

Because reserve is really what many of us are trying to preserve as we age, whether we realize it or not. The reserve to recover from illness. To travel without exhaustion. To spend an active day outside and still have enough energy left for connection at the end of it. To remain fully engaged in your own life rather than progressively narrowing it around your limitations. VO₂ max, heart rate recovery, and autonomic health are not simply performance metrics. They are reflections of vitality.

This is also where heart rate variability, or HRV, becomes so interesting to me. HRV reflects autonomic nervous system flexibility — the ability to move between stress and recovery efficiently. Higher HRV generally reflects greater resilience and adaptability, while persistently low HRV can signal chronic strain, inadequate recovery, inflammation, poor sleep, or nervous system overload. In many ways, HRV becomes a running record of modern life itself. How much pressure we are carrying. How little stillness we allow. Whether we ever truly come back down after living in a near-constant state of activation.

What I find compelling is that all of these measurements are really asking variations of the same question. Not simply how strong you are or how fast you can run, but how adaptable your system remains. Can you stabilize yourself when something unexpected happens? Can you recover after stress? Can you generate enough force quickly enough to protect yourself? Can you tolerate challenge without completely depleting your reserves afterward?

That question is part of why I started building the Longevity Lab at my office at PeakMD. Not because I think people need more health anxiety or another layer of optimization culture, but because I think there is something clarifying about looking honestly at the systems that actually determine long-term vitality. Not just whether we can perform well today, but whether we are building bodies capable of staying adaptable, capable, and independent decades from now. I run these sessions in small groups, and the moment I find most meaningful is always the same — not the data itself, but the look on someone’s face when they finally have an honest picture of where they actually are.

In other words: are you strong enough to catch yourself?

I don’t think the answer is obsessive self-tracking or turning longevity into another perfectionistic pursuit. Most people do not need more shame or more optimization pressure layered onto their lives. But I do think there is value in honest data. Not data used to judge ourselves, but data that helps us stop guessing. Data that closes the gap between how we think we are aging and what our physiology is actually saying.

Because the body has been honest with us the whole time. We just haven’t always been asking the right questions.

Leave a comment

Subscribe now

Sources

Leong DP et al. Prognostic value of grip strength: findings from the PURE study. Lancet. 2015.

Araujo CG et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. Br J Sports Med. 2022.

Mandsager K et al. Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing. JAMA Network Open. 2018.

Cole CR et al. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med. 1999.

Thayer JF et al. The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. Int J Cardiol. 2010.

Reid KF & Fielding RA. Skeletal muscle power: a critical determinant of physical functioning in older adults. Exerc Sport Sci Rev. 2012.

For paid subscribers, I’ve included the full Longevity Lab assessment and scorecard below, these the exact tests I run in session, covering balance, power, recovery, strength, and cardiovascular capacity, along with the age-referenced norms I use to interpret each result. These are the measurements that most often reveal the quietest signs of aging first. If you’ve been curious what your own numbers might look like, this is where to start.

Some of these tests are surprisingly humbling, even for people who consider themselves fit. That’s the point. Print it, find a friend, and be honest with yourself.

If you want my eyes on your results, I run Longevity Lab sessions in small groups at PeakMD in Sisters, Oregon. Reply to this post and I’ll also comment here on your results!

Download the pdf below.

Subscribe now

Peakmd Longevity Lab — Self Assessment Scorecard

1.91MB ∙ PDF file

Download

Download

The first night on the river, we sat around a campfire while smoke drifted into the Ponderosa pines. One woman had brought good wine (she always does) and the guides passed around dessert under headlamps. There were no curated introductions. No networking. No bios. Just women slowly unfolding into conversation the way humans probably have for thousands of years around fires like this

Our guides this year were all women in their twenties. Strong, sunburned, funny, capable. One had just spent six weeks traveling through Sri Lanka, another just completed a yoga training before returning to guide for the season. Another was working through AmeriCorps while trying to decide what came next. They carried heavy gear over rocks, read rapids with calm precision, and moved through the river with the confidence that comes from living close to uncertainty.

Around the fire sat another generation of women in their forties and fifties. Women balancing careers, aging parents, marriages, teenagers, college applications, businesses, stress, reinvention. Women who had once also believed life was almost infinitely wide.

Subscribe now

Two women had canceled before the trip. One because her sister’s cancer had returned and she was starting palliative chemo. Another because she had just received her own breast cancer diagnosis. I thought about them while we floated through canyon walls and slept under stars. Loss was already present at the edges of this trip before any of us got in the water.

At one point, the conversation turned toward aging in that honest, slightly vulnerable way that sometimes only happens outdoors. One woman said quietly, “Sometimes I get sad because I used to feel like I could become anything. Now I think… I’ll never be a river guide.”

Everyone understood what she meant.

It was not really about river guiding.

It was grief for unlived versions of ourselves. For doors that quietly closed while we were busy building lives. For identities we never tried on. For younger bodies that recovered faster. For the strange realization that possibility is no longer endless in the way it once felt at twenty-five.

And yet the irony of that conversation was that earlier that day these same women had charged through class IV and V rapids, helped pull each other back into rafts, laughed until they cried, carried gear across uneven rocks, and disconnected from their devices more completely than most of us do all year. On the final day, several of us climbed a cliff and jumped into cold river water below. Not gracefully. Not fearlessly. But willingly.

We looked profoundly alive. Not preserved. Not performing youth. Just fully present inside our own bodies and our own lives, which is rarer than it should be.

In the airport afterward, I kept thinking about another part of the conversation around the fire. Several of the women had once been highly competitive athletes. Some no longer participated in the sports they once loved because comparing themselves to younger versions of themselves hurt too much. It was easier not to play at all than to confront what had changed.

I understood that instinct immediately.

Some people stop participating in their own lives long before their bodies actually fail them. Not dramatically. Quietly. They stop taking risks. Stop trying new things. Stop gathering. Stop playing. Stop entering spaces where they might feel uncomfortable, inexperienced, uncertain, or vulnerable. Life becomes increasingly optimized, efficient, safe, productive, and disconnected. And somewhere in that process, many people slowly lose contact with the part of themselves that feels fully awake.

What struck me most on the river was how biologically human the entire experience felt. Cold water. Physical exertion. Shared challenge. Storytelling. Laughter. Awe. Unstructured conversation. No constant notifications. Just presence. As a physician I know that these are not small things. I understand shared physical challenge and unstructured human connection are among the most potent inputs for the nervous system we have. We just don’t prescribe them because they don’t come in a bottle. It felt ancient in the best possible way.

The next morning, after the trip ended and we were back in a hotel reconnecting to phones and regular life, I saw a text from a close friend. Her husband had died suddenly and violently. The emotional whiplash of that moment is hard to describe. Less than twelve hours earlier we had been laughing around a campfire under stars, jumping off canyon cliffs into cold water. Suddenly life felt fragile and unbearably sharp.

But in a strange way, the text clarified something I had already been feeling all weekend.

Aliveness is not guaranteed by achievement, optimization, productivity, or even success. We can build beautiful lives on paper while becoming increasingly disconnected from ourselves inside them. And the cruelest part is how quietly it happens. How reasonable each small withdrawal feels at the time.

The women who seem most vibrant in midlife are rarely the ones desperately trying to stay young. They are usually the ones still participating fully in life. They remain curious. They challenge themselves physically. They nurture friendships. They laugh loudly. They gather around campfires. They try things they might fail at. They continue entering the river even after life has taught them how dangerous the water can be.

The goal was never to stay young. That was never possible anyway.

Maybe the real goal is simpler and harder than we make it.

To stay alive inside yourself for as long as you can. To keep getting in the water.

The water is cold but it is absolutely worth it.

Leave a comment

Share