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Cardiologist and author Eric Topol discusses his article, “What super agers can teach us about longevity and health span,” which is an excerpt from his new book, Super Agers: An Evidence-Based Approach to Longevity. He introduces the critical difference between lifespan (total years lived) and health span (years lived in optimal health). Eric shares the surprising results of his “Wellderly” study, which sequenced the genomes of over a thousand healthy adults over age eighty. The study found that their exceptional health was not primarily due to protective genes, but was instead strongly correlated with lifestyle factors like being thinner, exercising more, and having robust social connections. Contrasting this group with the 60 percent of U.S. adults who have at least one chronic disease, he argues that the goal shouldn’t just be a long life, but a long and healthy one. The conversation clarifies two paths to this goal—slowing aging itself or delaying disease—and makes the case that focusing on preventing and delaying chronic illness is the most evidence-based approach we can all take to maximize our health span.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Eric Topol, cardiologist and founder-director of the Scripps Research Translational Institute and author of the new bestselling book, Super Agers and an Evidence-Based Approach to Longevity. And we’re going to talk about that in today’s episode.

Kevin Pho: Eric, it’s wonderful to finally speak with you.

Eric Topol: Kevin, the same here. I really enjoyed it. It’s been too long since we last had a chance to connect.

Kevin Pho: All right, well congratulations on the book. I just saw on X that it is a New York Times bestseller. And for people who don’t know who you are, which is very few, I’ve followed you on X for a while. I’ve read many, many of your op-eds in The New York Times, but just give us a brief synopsis for those who don’t know who you are.

Eric Topol: Well, I’m still in the practice of cardiology. I love doing that. But most of the time I spend is on research, trying to come up with better ways to provide individualized care using things like genomics and digital and AI.

Kevin Pho: And you’re of course the author of the book Super Agers, and we’re going to talk about that today. There are so many of these longevity books written by physicians from reputable institutions. So what led you to add on to that? What led you to write this book when there’s so much knowledge and so many books on longevity already?

Eric Topol: Well, one of the reasons, of course, is that there hasn’t been much that went to hardcore evidence. You know, this was a problem we have with pseudoscience, and you had a lot of promotion and marketing of longevity. And also the term longevity: I didn’t even want that in the subtitle because the book is about health span and preventing age-related diseases.

But there are companies out there, as you know, Kevin, that are marketing longevity, charging clinics $250,000 to get plasmapheresis and stem cells and, you know, hyperbaric chambers. I mean, this is really a very polluted area. Even though there’s a lot of great science, it’s enlightening the process of aging, you know, the biology.

So the idea is that we’ve learned so much about the science of aging that we can use it to prevent diseases along with the research that we’ve done that was dedicated to health span, the so-called Wellderly study. That’s really what prompted putting a book together that I think is very distinct from the prior work.

Kevin Pho: So we’re going to, of course, talk about your Wellderly study. Now, for those patients, they always ask me, how can you tell these physicians apart? Because some of these longevity books or wellness books are written by MDs, and they come from big-name institutions. And patients always ask me, so what separates your book, Dr. Topol, from another MD who also has impeccable credentials? Like, why should they listen to someone like you?

Eric Topol: Well, they can listen to whoever they want. I mean, I’ve had a long career in medical research, and I think the track record speaks for itself. You know, I don’t need to get into things like h-indexes and citations and whatever, but the book has over 1,800 citations. So it’s really grounded with the evidence. There’s nothing in there that isn’t, in my view, either fully validated or positioned that it isn’t and needs to be. So I’ve taken a very hard line on what the data are, what the evidence is.

And I think that’s why I do a Substack, Ground Truths, which is about getting ground truth in life science and medicine. We can’t get enough of that. So some of the books that you’re referring to were not written by people with impeccable credentials. So I would take issue perhaps with that too. Some are MDs for sure, but I think you have to evaluate the source. And it’s good to get different opinions, but opinions are one thing; facts, data, and evidence are another.

Kevin Pho: So your book, like you said earlier, was launched by your Wellderly study. Now, you distinguish, of course, between lifespan and healthspan. So just give us some context and some definitions just to start us off.

Eric Topol: Yeah, so lifespan, of course, is longevity. And that is irrespective of the health of a person. So healthspan is the maximum number of years that is free of significant diseases. And in this case, we’re talking about age-related diseases: cardiovascular, neurodegenerative, and cancer.

Eric Topol: So the Wellderly study was dedicated to finding 1,400 of these people. It took seven years, Kevin, to find all these people who had never been sick, who had no chronic diseases, and were on no medications. And we did whole-genome sequencing of all these people, and we found, compared to the elderly—the people over 65 where 95 percent have a chronic disease by that point in our population—there was no real genetic, genomic difference from their whole-genome sequences between the Wellderly and the elderly, which led us to the conclusion.

Eric Topol: That this is not a genomic story. You know, if you look at the people, like for example, Lee Rual, the patient of mine I presented at the very beginning of the book and refer to throughout, she is 98. And her brothers and her parents all died in their fifties and sixties. And that was very typical of the Wellderly: that they were often the last person standing in their family, with their closest relatives dying at much younger ages.

This is not purely genetics; that plays a small role in health span. But the big role is likely beyond luck, which is probably contributing a bit, but it’s the immune system. Everything we’ve learned is that the immune system being resilient, being intact as we get older, is essential to give us health span.

Kevin Pho: Do those findings surprise you?

Eric Topol: Yeah, I think in some respects, because I think the myth, if you will, or the dogma maybe, is that our health span would be indexed to our DNA. And the fact that it wasn’t was surprising. And for those of us like me who have a terrible family history, it’s liberating in some respects.

And then I think, as you know, there’s so much data reviewed in the book that if you have the lifestyle factors that you incorporate at a young age, like at just 50, you get seven to 10 years of healthy aging. So we do know that lifestyle factors play a very prominent role. The earlier you start with them and the more you keep with them, the longer a health span extension you get.

So perhaps it’s not as surprising, but most of us have been thinking—certainly I did all these years until we did this study—that this was kind of fatalistic, deterministic by your DNA as to what’s going to happen to you with major health issues. But I think we’ve learned that that’s not really true for the most part.

Kevin Pho: So knowing the findings of the Wellderly study, let’s talk about some of the changes that you made in your own practice. Like how did that affect how you cared for patients?

Eric Topol: Yeah, I think it’s changed quite a bit because, for example, for exercise, when my patients would come in and they’d tell me about all their weightlifting, I discouraged them from doing strength training or resistance training because I was so much into aerobic exercise. But now, of course, the data shows that they’re both important. That’s, I think, enlightening for a lot of patients, particularly as we get older, to preserve muscle mass. And balance training is also, you know, right up there.

Other things include the emphasis on sleep. I talk to every patient about, you know, what is their characteristic sleep pattern. And beyond just ruling out sleep apnea, it’s really important to find out about if people are having trouble sleeping, are they doing anything to track it? If they do, what is it showing? But trying to promote particularly deep sleep and regularity of sleep, which has a big influence on all three major age-related diseases. Surprisingly, I think most people wouldn’t realize that a regular schedule of sleep is so critical.

And then, you know, the diet story, it’s really come a long way in recent years with respect to what’s anti-inflammatory, which is a more largely plant-based diet, Mediterranean diet, versus what is pro-inflammatory, not just ultra-processed foods, but overdoses of protein, particularly animal-derived protein. So we’ve learned a lot about the basic three lifestyle factors, and there’s many more, as I allude to in the book, is lifestyle-plus, you know, things like social engagement and being out in nature and, you know, all sorts of things that we had not considered as core lifestyle factors.

Kevin Pho: So I want to dig deeper into those core lifestyle factors: exercise, sleep, and diet. So we talk about exercise. As you know, I’m an internal medicine, primary care physician, and certainly the evolving research. And like you said, strength training plays just as important of a role as cardiovascular exercise. So what do we mean by strength training? Like, that means so many different things. Like what does that mean?

Eric Topol: To me, it’s really that most of the activities are aerobic. Like, walking, bicycling, et cetera. They’re really lower-body strength. So we’re not doing anything for upper-body or core muscles, you know, abdominal. So, you know, things like sit-ups and pushups and planks and lunges and, you know, just a band for strengthening. These are things that are, you know, inexpensive or cost-free. But spending 30 minutes a couple, few times a week doing those things. Also, balance training, you know, for as we get older, standing on one foot, whether that’s, you know, on the floor or on a foam pad or that sort of thing. You can get much better at your balance by training. I certainly learned that too.

So those things I think need to be encouraged, especially, you know, as we get past age 60. That’s when we start to lose muscle mass. And that strength, you know, hand-grip strength is a proxy for really upper-body strength, and the relationship that it has, and resistance training, to health span is really striking. So these are things to keep in mind that, you know, not to neglect. I mean, you can get bands, you know, rubber bands that you would use for resistance training for less than $10. And I advocate that to patients, and they can just progress from, you know, one color to the next to get better workouts and, you know, just doing a couple sessions of 10 reps. So those alone are something that’s helpful, no less the other things. So I think this is something to emphasize, which I had not been doing until I really reviewed all the research.

Kevin Pho: And I want to emphasize that the barrier to strength training doesn’t need to be so high. Like you said, there’s a ton of body-weight exercises. You don’t even need any equipment for them. Bands cost less than $10. Of course, going to the gym and lifting weights, that’s always good. But in terms of talking to patients who may be intimidated by going to the gym or buying a set of weights, we don’t necessarily need to go that far. Just what you said: body-weight exercises, simple balance training exercises, simple equipment like bands. That is plenty enough, right?

Eric Topol: Oh yeah. No. If you’re doing a whole workout session with pushups and sit-ups and bands and, you know, planks, I mean, you are, you’re getting a great workout. Just like you said, it’s basically, you know, no cost whatsoever. You don’t have to join a gym to get a lot out of that. Then you can go for a nice brisk walk or bicycling and whatever, and then you kind of get the whole package.

Kevin Pho: Now let’s talk about sleep in the primary care setting. What kind of questions should I be asking patients to measure how good or what quality their sleep is?

Eric Topol: Yeah. Firstly, I want to probe, what is it like during the day? Are they feeling like they’re going to nod off or they actually nod off? Just not feeling, you know, energized throughout the day. And then during the night, are they getting interrupted sleep? You know, are they going to bed at a similar time each night? Is there any indication from their partner of stopping breathing? You know, is anything that would suggest the possibility of sleep apnea? Because it’s more prevalent than a lot of people are aware.

So, you know, just asking some simple questions about particularly the pattern of sleep. I think what, you know, as mentioned earlier, a lot of people have very irregular patterns. And that isn’t good. And, you know, sticking to a time that’s probably going along with your chronotype, which is, you know, if you’re a morning person, you’re going to bed kind of early. You’re trying to get seven hours of good sleep. But of course, that quality is hard to know just by time. And that’s why even just a few weeks of tracking, whether it’s through a smartwatch, fitness band, a ring, even mattress sensors, it can be very instructive, even on the short term, to learn about your quality of sleep, like deep sleep versus, you know, REM sleep. So, you know, learning about this, I think we’ve learned that sleep health is fundamental. It, of course, helps us deal with anxiety and stress, helps to mitigate depression. All these things are interdependent with our physical health too.

Kevin Pho: Now, other than sleep apnea, what are some of the common reasons why people have poor-quality sleep?

Eric Topol: Yeah, I mean, I think, you know, for men getting older, it’s, they have the prostate curse and they’re getting up a lot during the night. And so learning about that. Also, you know, what you eat, when you exercise, you know, these are things that have interactions with our sleep. And so, you know, not exercising too late in the day or eating too late, you know, when you’re hydrating. People think it’s important to hydrate throughout the day, but probably if you’re having interrupted sleep, you might want to do that earlier in the day.

So lots of things we can learn about that. But, you know, I think this is something that is worth the attention because getting into a groove with sleep, learning about, for example, interactions with alcohol intake. These are all crucial because that investment of getting into that groove will pay off great dividends for helping to prevent things like neurodegenerative diseases and also cardiovascular and even cancer. So the relationship with sleep has been underestimated, and I was really struck by the data.

Kevin Pho: Now the third part of these lifestyle modifications I want to address, of course, is diet. And there’s just so much misinformation when it comes to diet. After combing through all that research, what would you say are some of the biggest misconceptions that we have about diet?

Eric Topol: Well, for one, there’s this protein craze right now. Yeah. Which is unfounded. Nat who wrote a, you know, this is like bro science, and he went through all the data and he took it apart. There’s nothing to support this massive amount of protein, you know, one gram per pound, which has been navigated in other books on this topic.

So if you look at the data, you know, as you get older, you might want to increase the protein from the recommended allowance of 0.8 grams per kilogram per day to one or 1.2 grams per kilogram per day, but not double that. And that would be a huge amount of protein intake. What we’ve seen, though, is that does promote inflammation. In experimental studies, it promotes atherosclerosis, not the kind of thing you want to do. So that’s one thing.

Particularly, you know, animal protein, which ties into the validation of the Mediterranean or Mediterranean-like diets that are more plant-based, anti-inflammatory. The data there is so compelling, Kevin. You know, just recently there was a study of 105,000 people followed for 30 years, and only 9 percent reached age 70 with intact health span, no age-related diseases. What did they eat? They ate a Mediterranean diet. So that, along with randomized studies, has iced it, in my view. You know, nutrition science has had its problems with respect to, you know, using food diaries and recall by individuals. But when you look at the totality of the data, it is very supportive, no less looking at inflammatory markers in the blood for the diets. And again, you see that a largely plant-based diet, you know, pescatarian-type diet or even, you know, low amounts of red meat, just not high quantities, is really a healthy diet. Optimal.

Kevin Pho: And when we talk about an anti-inflammatory diet, like that’s certainly in vogue, Tom Brady has an anti-inflammatory diet. So are there foods that have been shown by evidence to be quote-unquote anti-inflammatory?

Eric Topol: Yeah, well that diet I just described, it’s, you know, rich in vegetables and fruits, plant-derived proteins. You know, this diet has the dose validation. And yes, indeed, if you look at people that have inflammatory markers like cytostatin A and interleukin-6 and CRP, they go down with that diet, whereas, you know, diets that are rich in fried foods and red meat and other things, certainly ultra-processed foods, that’s the worst for promoting inflammation. So it’s hard to eliminate ultra-processed foods from our diet, but that is the chief offender. And I think there’s really strong support that we need to get on this here in the United States because this is now 70 percent of the American diet, is this ultra-processed food. And many of those constituents are really pro-inflammatory.

Kevin Pho: Now when you go on these podcasts and contradict by name some of these physician influencers on longevity, do you get any feedback or blowback from their team when you, because I’ve heard you on other podcasts, call them out by name. So what kind of responses do you get?

Eric Topol: I haven’t gotten any response from the individuals. I mean, there are only a couple involved here, but I think, you know, one of the key points is if you are selling or hawking supplements or if you have companies that are promoting longevity, then this is a real conflict regarding, you know, trying to be objective. So, you know, I think this is a problem if you’re going to be a person that is an expert in trying to advise others, there shouldn’t be a profit motive involved in the things that you’re either talking about or writing about. And so this is a problem we have right now, as some of the people in this field are very active in selling things, and without data. And that’s not good, in my view.

Kevin Pho: Sometimes I listen to your competitors and they always say it’s data, right? But you and I know that there are different qualities of data, and sometimes you could always find a study or evidence that fits a preconceived notion. Now, for the layperson, patients who listen to these influencers, and these influencers say that whatever supplement is backed by data, so how can patients differentiate the data that they’re talking about?

Eric Topol: Well, I mean, I’ll give you an example. There’s a supplement, AG1. It’s very popular, this green powder. It costs about a hundred dollars a month. You know, it just keeps coming every month. And it claims it has, it claims it’s the only supplement with data, but when you look at the studies they’ve done, they are tiny studies that the company has run itself. So you can look them up and you say, well, where’s the study done by independents? Where’s the robust data that has any effect on health outcomes?

And one of the problems that you’re getting at, Kevin, is for supplements in particular, those that are claiming health outcomes or promoting health span or longevity, there’s no regulation here. There’s no oversight by the FDA. It’s completely unregulated. So this is a real problem for consumers. How do they differentiate? And when you have celebrities that are standing up for these supplements, that doesn’t help matters because people do believe in them, you know, if they like the celebrity, they tend to, you know, want to believe in this stuff. So my advice is, you know, if you’re trying to get to the truth, try to look through the data that’s available, and you’ll find it doesn’t exist or what is being claimed as data to support claims is very shaky.

Kevin Pho: So a rule of thumb, if a physician influencer, perhaps, is selling what they’re promoting or talking about on their podcast, consumers should look at that skeptically.

Eric Topol: I would concur with that. Yes.

Kevin Pho: Now, through your research, there’s a lot of tests like whole-body MRIs that are certainly being heavily advertised. Is there anything new that’s come up from a screening standpoint that you’ve uncovered through your research that is somewhat surprising or unexpected?

Eric Topol: Yeah, so this is another area. So not just supplements and not just doing all sorts of, you know, blood tests that are unwarranted in people who are healthy, but also advocating total-body MRI. This is a really big mistake because we have no data, I mean no data to show that that is beneficial, not harmful. So the whole-body MRI is a really difficult issue because so many people are having incidental findings, whether it be a liver nodule or a lung nodule that requires biopsies and complications. And Dr. Lair, who’s a physician at Cornell and writes for The New Yorker, wrote a column about his prostate that was discovered, some type of nodule. Now he has frequent prostate biopsies. Still doesn’t know what this is. He is going through a tremendous amount of anxiety, as I wrote about in the book, unnecessarily.

And this is the problem right now. It’s expensive. The company, Prenuvo, which is the main one promoting this, is making all sorts of claims, and there are no data to support this. So if you want to test for occult cancer instead of looking for a mass that might be cancer, that’s billions of cells, in a high-risk person who has not just family history but genomic risk factors, polygenic risk scores that are high, other reasons—not just because they’re 50 years old, which is, you know, or even younger—you go ahead and you can get a multi-cancer early detection blood test as a way to get at it, microscopic cancer, not macroscopic on a scan. So I don’t see the total-body MRI. There are no data to support it at this point. If you have evidence of microscopic cancer and by AI, it doesn’t tell you where it’s coming from, yeah, total-body MRI then would be a very reasonable step. But, you know, this is just another example of where these longevity, some longevity influencers are pushing this and have companies built around it, and it’s just not supported by any clear evidence.

Kevin Pho: Now, do you find that argument resonates with the patients? Are you able to convince them in the exam room? Because I completely agree with everything that you say. There’s a problem of overdiagnosis and leading to unnecessary tests for things that ultimately may not be dangerous. But sometimes I find that argument pales in comparison to some patients who may have heard that a whole-body MRI picked up pancreatic cancer in one of their friends, and, oh, yeah. That to them is a much more powerful argument. How successful are you in convincing patients about the overdiagnosis arguments when it comes to these whole-body MRIs?

Eric Topol: Yeah, it’s a big issue, Kevin. You’re right on. Because some people, they just feel like they have to get these scans. You know, there’s a very big expense, out of pocket. These are not covered by insurance. And no matter what you say, you know, they’re going to want to go ahead and get this because they think it’s, they know somebody like you said. And they say it saved their life, but of course that may not be true at all. So, most of the time, my patients that I see are the ones that had the scan. They’re now concerned about the, like for a calcium score of their heart arteries or a total-body MRI. And now they’re very anxious and they’re trying to get opinions about what they should do. So I’m seeing them mainly after they’ve had scans. I’m not usually in a position where I get to talk to them to talk them down from having this scan, although I do that when I can.

Kevin Pho: So what’s on the horizon from an evidence-based standpoint? What do we have to look forward to from a super-ager standpoint?

Eric Topol: Well, that’s where the excitement lies, and that is, as you well know, and the medical community knows, we’ve never been able to achieve the fantasy of primary prevention of cancer, neurodegenerative diseases, and even cardiovascular. But we have a path to do that now by taking the high-risk person that we can identify through layers of data—genes and proteins and interpretation of scans, things like retinal photos and electronic records—we can identify who is at high risk for one of these three age-related diseases and get all over it with surveillance and prevention. And that’s what’s so exciting. We didn’t have a way to do that before.

We could say somebody’s at higher risk for a certain condition, but we couldn’t say when, like having a risk for Alzheimer’s at age 98 versus 68 is quite a difference. Now we can say when, and we can say with much more certainty. And we can do things like we never had before. Not just lifestyle factors, but we have much more potent anti-inflammatory drugs in the pipeline. One of them is the GLP-1 drugs like the Ozempic family, but a lot more is coming. So it’s a whole new day for prevention.

And that’s what I think is the real theme of the book, is that by the science of aging, we have things like organ clocks and new plasma biomarkers and new AI interpretation of medical images, like for example, a mammogram. Now recently, the FDA approved that from a normal mammogram you can pick up through AI that a woman has in the next three or four years a very high risk for developing breast cancer. Or from a retinal photo that a person in the next seven years is going to develop Parkinson’s or Alzheimer’s disease. So we just didn’t have that kind of forewarning in the past and to nail it with respect to timing.

Kevin Pho: Now, for those patients, again, who are inundated with super-ager and longevity advice, we talked about what they should be looking for when it comes to supplements. Any other things they should be looking for to separate what is truly beneficial for them versus what is promotional?

Eric Topol: Well, I think, you know, everyone has got to keep their guard up as to, you know, what is objective, you know, what is evidence that they can count on. And, you know, if helpful, multiple sources. You can always check if you have a physician, if somebody is a go-to for you that you can get to and, you know, discuss it. That’s great. But, you know, I think this is something where each individual will have to decide what is truthful, what is objective.

But one thing I think to emphasize is that going back to what we discussed earlier on the Wellderly study, we do have a tremendous amount of control over healthy aging. All the things that we talked about, whether it’s diet, exercise, sleep, and on and on, have effects on our immune system and on inflammaging. And so if we do those things and keep our immune system at top-level protection and not going haywire off the rails with respect to dysregulation, that’s the goal, and we can do it.

And so, you know that it doesn’t have to cost anything. These things, when it starts to cost a lot of money, that should be a red flag, right? We can do this for, you know, minimal cost. The data is strongly supportive of that. And if you’re going to put an outlay of funds for, you know, getting tests or supplements that you know, aren’t backed up by evidence, you probably should, you know, question that and think twice or three times.

Kevin Pho: We were talking to Eric Topol, cardiologist and author of the bestselling book, Super Agers and an Evidence-Based Approach to Longevity. Eric, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Eric Topol: Well, I just think, you know, we are at a propitious time in medicine that we are on a precipice of being able to prevent the big three age-related diseases that account for most of our cutoff of health span, also lifespan. And so let’s, you know, build on this. It’s not at a good moment with respect to biomedical research funding. Of course, we’re seeing that getting gutted. It’s a real mismatch of the opportunity with what’s happening right now. But eventually, we’ll get this right. And eventually, we will be able to flip the elderly, where most people over 65 have at least one chronic disease, to Wellderly, the super-agers, who have reached the age of 85-plus and have never had one of these three age-related diseases. That should be the goal right now, and I’m hoping over the years ahead, we’ll achieve it.

Kevin Pho: Eric, thank you so much for sharing your perspective and insight. Congratulations on the success of your book, and thanks for appearing on the show.

Eric Topol: Oh, thanks for having me, Kevin. Great to be with you today.