Recently, I interviewed Dr. Florence Comite, and we talked about healthy longevity and hormone optimization. If you would prefer to listen to the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
I am very excited to chat with Dr. Florence Comite. We are going to be talking about precision medication, optimizing hormones. It’s going to be a really fascinating call here.
Let me go ahead and give Dr. Florence’s bio here, as Dr. Florence Comite is a clinician, scientist, and innovator in the field of precision medicine. She is world-renowned for her expertise in predicting, preventing, and reversing chronic disease and the disorders associated with aging.
In 2005, Dr. Comite founded the Comite Center for Precision Medicine and Health, where she practices a clinically proven, academic approach to personalized health care, structured as a clinical trial in Groq Health, a mobile app with science-backed AI and ML-backed systems to identify treatment and lifestyle changes to reverse and prevent the diseases of aging.
Groq Health, a revolutionary new app that delivers personalized precision medicine to reverse biological aging. It’s currently in beta testing. The application offers Dr. Comite’s patients highly personalized health care that interprets their genomic, metabolic, phenotypic, and digital health data into individualized action plans. The AI-powered app is being developed with the intent to expand the impact of precision medicine and empower people to take control of their health. Check out that app.
I think I listened on a previous podcast that it won’t be out until sometime in 2024, which we are pretty close to as of recording it.
Very excited. Thank you so much for being here, Dr. Comite.
Dr. Florence Comite:
Appreciate being here. Florence is fine. Can I call you Eric?
Dr. Eric:
Without question.
Dr. Florence:
Great. Since we’re both from Brooklyn and Queens, I think we’re related probably.
Dr. Eric:
Florence, can you dive a little bit into your background? When you graduated from medical school, were you a more conventional doctor? Did you always want to be more integrative, functional medicine? Give more of your background.
Dr. Florence:
I’d love to. I actually did start when I graduated. Maybe not quite in the way we’re thinking. My father asked me when I graduated medical school, “Can you now help me be healthy?” I looked at him a little confused and said, “Medicine is about treating disease.” He said, “That doesn’t make sense. Shouldn’t you try to keep people healthy?” I said, “That’s a great idea.”
I think I went through training subsequently after graduating from Yale. I stayed at Yale doing residency in internal medicine and hit several fields: a deep dive into adult specialty, pediatrics, and women’s health, which also incorporated men’s health but more from the fertility point of view.
Then I was at NIH, where I became a clinical scientist and worked hard to look at research and how you bring a research, scientific mindset. I did a lot of research. I published a fair amount. I went back to Yale and stayed on the faculty for 20 years.
I began to realize about 20 years ago that we all start aging in our 30s. Why don’t we pick up on that and stop disease from happening before you get symptoms? That started me on this path of proactively wanting to stop people aging, which is a big risk factor for all diseases. I felt like if I could stop aging, it would also stop chronic diseases of aging.
If you think about it, diabetes for example is one great disease that happens more often than not as people get older, like in their 40s, 50s, and 60s. It’s really beginning way before that.
I felt that if people could stay physiologically younger and healthier the way my dad described it and wanted for himself, that would be a gift. Why get sick if you don’t have to? That’s how my work began in this field, from scientific and clinical applications.
Dr. Eric:
You still to this day then do quite a bit of research?
Dr. Florence:
I do. In fact, the center that I started in New York in 2005 was an outcome of that. What I designed was something we now call at this Comite Center for Precision Medicine and Healthy Longevity as an individualized study of each human being. We think of it as n of 1.
Most of medicine is population research, where you are looking at thousands if not millions of people. Then you are applying it almost as a one size fits all, not individually to each human being.
That came at the same time I had this epiphany. I was giving a dinner club at Yale. Why do we begin to fall apart in our 30s? We’re fine up until then. In our 30s, fertility. Men begin to get heart attacks in their late 30s if they have a proclivity to that. Women start more easily than men putting some weight around the middle, slowing down. In some ways, energy becomes a factor. Osteoporosis. That just begins to accumulate as you hit each subsequent decade of life.
I knew at the time being an identical twin that my twin and I were not exactly alike. I was always interested in genomics. It was around that time that the whole genome was described, looking at DNA. I felt that it wasn’t ready for prime time because you couldn’t really peer into function at a dynamic way.
I began to study metabolism and endocrinological, hormonal optimization to see how we stop people from getting older at the cellular level. How do we keep them in the best shape they can be in, which generally happens, not everyone but most people in our 20s? That is prime time.
I felt like if we could keep people physiologically in their 20s, or no more than 30, we wouldn’t be doing the Abby Hoffman thing, where we’re getting old in our 30s. Effectively, we are. Many of us blame it on having children, a family, being really busy, trying to make it in our career. Even if we did exactly the same thing as we did in our 20s- Marathoners or triathletes are great examples of it, but they still have heart attacks. Why? Those questions occurred to me.
Along with the fact that each one of us is unique. My identical twin and I are not even alike. For example, I could live on sushi and sashimi, and she doesn’t like fish at all, except for mackerel, which I always forget to say. We grew up eating herring, which is mackerel. It’s a very strong fish, so it’s unlike tuna and salmon and all the rest of that delicious stuff.
She is an amazing gardener. I can’t garden. Our teeth and eyes are different. Our guts are different. It didn’t make sense to me. If we’re identical twins, what’s changing?
What occurred to me at the time is it’s expression of genes. That’s what my research has been about for the last 15 years. How we define n of 1. What’s right for you, Eric, might not be right for your brothers, if you have brothers. I don’t know if you have siblings. Or your cousins. Even if the genes look alike, they don’t always act alike. That’s identical twins.
Dr. Eric:
That is tying into precision medicine. Everybody is different from what you’re saying. Not everybody requires the same diet. Not everybody requires the same stress management skills. We could go beyond and beyond. Supplementation. Maybe you could give a better definition of precision medicine.
Dr. Florence:
Exactly. You got it right. I can delve a little deeper. The word “precision” for me comes from data. To me, without data about a human being and how they act at the cellular level, metabolically, hormonally, what their thyroid is doing, what their brain is doing, what their ovaries or testes are doing, you can’t tell people apart necessarily.
The data is what I think of as the personal health story. Instead of what we typically do in conventional medicine is very reactive. You have to get sick, and then we’re good at it. We jump all over you. That is reactive medicine. To me, it’s about being proactive.
I’m actually, unlike you, not trained in functional medicine although a lot of my functional medicine colleagues and friends think I know functional medicine. To me, the root cause of disease, which is the core of functional medicine, has to do with the etiology and how genes are expressed.
Precision to me is data married to somebody living life: how they sleep or don’t sleep, what their exercise is like, what they are willing to do to put effort into eating maybe a little differently. I don’t believe in suffering. If we get this right, we’ll live even longer, maybe to 120 or 150, in great shape and enjoying life. It’s not about suffering to do everything perfectly. It’s not about fasting all the time or living on paleo or keto. It’s about what’s right for that singular human being.
The Comite Center has been called a living n of 1 lab, meaning that it is really about a collection of people and data and people who want to invest in their health and own their own health trajectory. How do we stay healthy for the rest of our lives and never get diabetes or have a heart attack or Alzheimer’s or a stroke or cancer or osteoporosis? That’s really what precision is about to me. The data to put into play actionable interventions that are fit for that specific human being, if that makes sense. I hope it does.
Dr. Eric:
It does. I guess you are going with the Groq app that’s coming out. Getting even deeper into genomics. I assume now, these days, you do genomic testing on patients?
Dr. Florence:
Yes, we do. I felt about a couple of years ago that we were beginning to reach a time where we could use genetic variance, meaning if your genes aren’t exactly functioning right, what are those variants telling us?
Can you detox mercury? I found out that I’m not a great detoxifier. That puts me at higher risk for certain kinds of cancer and accumulating bad toxins like mercury, which is at 38 for me when you want it less than 10. My twin sister is undetectable because she doesn’t live on fish the way I used to.
In one year, I was able to bring it down after identifying it. I didn’t learn until a couple of years ago when I looked at gene variance that we now have operational at the living n of 1 lab, which is the Center, that I knew that I don’t detox well. I need to be able to be careful what I do.
Another example which I’m not too good at, so I hope your audience can appreciate, as they may feel the same way. I don’t have Celiac, which would make it hard to digest gluten. It’s ubiquitous out there in every slice of pizza and great bread, which I could live on, too. Yet it’s hard for me to be gluten-free. I go through periods where I try to be my best at it. That inability to detoxify also affects me. There are lots of examples of that. Yes, we’re in genomics.
What Groq is, because you have connected the dots, is really taking a component of what we do at the center and delivering it to everybody on a virtual medical platform, using an app for people to be able to upload their own data to get a continuous glucose monitor to measure sugar, for example; to look at their bio markers and their five key ones, which I’m happy to jump into, that have come out of my research and make a difference in every single one of us.
We are all born as men and women with genes that may not be perfect. When they come together, it creates a unique human being. By figuring out how we live life and what we do, we can change your future state of health by stopping chronic disease and reversing aging, which people stop me when I say that. We have the data to prove it. I don’t know how much you’re into that, but I’m happy to point you in the right direction to hear more about it.
Dr. Eric:
I’m definitely interested. I would love to talk more about the biomarkers.
Before you dive into those, quick question: When it comes to reversing aging, I assume the earlier you make these changes, the better. For someone like me, who is 53, and someone else who might be in their 60s or 70s, is it ever too late to reverse the aging process?
Dr. Florence:
Great question. No, it’s not. If you look up RejuvenationOlympics.com, which is a site that was started by someone who has gotten out there because he is spending millions on his own health to try to reverse aging in every cell in his body. He is in his 40s, Bryan Johnson. Have you seen or heard about his work?
Dr. Eric:
I don’t think so.
Dr. Florence:
He created a website. I’m not sure if it’s a business, Blueprint.com. He also set up this site called RejuvenationOlympics.com. You’ll see that people are listed there who have reversed aging. As such, we are 25% of the leaderboard. Peter Diamandis and some of the other folks who believe in extending health and longevity are also part of it.
The Comite Center is 25% of the change. The top 20 of a couple of thousand people who have found it and uploaded their data. I am very proud of that because it’s independent validation, looking at biological aging. That is the point I want to make.
It’s far easier if you’re younger. Your system has more to it. You can burn the candles at both ends as a teenager and 20-something. It gets harder as a 30-something. It gets even harder every decade. Then I have seen 70-year-young people twice as healthy as 35-year-young people. It’s completely up to that n of 1 individual and what’s going on below the surface, in their health story, how they live life, their family history, the choices they’ve made. All of that is reversible and changeable.
With the exception of some genes that are known to be autosomal dominant, meaning they will express no matter what. A good example might be BRCA. 88% of people have a certain kind of BRCA gene that causes breast cancer, prostate cancer, and a few others. They are more likely to express it. It depends on how they live life and what they are doing to treat it.
There are other conditions that are supposed to be autosomal dominant that are not. Lewy body Parkinson’s, which Robin Williams had. Nobody diagnosed it. One of my cousins had it and sadly died at 70. You start with dementia and then get signs of Parkinson’s. Sometimes, it’s not diagnosed. It wasn’t in my cousin for about 20 years. It wasn’t in Robin Williams either. He was able to cover it up as an actor really well.
Most things though, believe it or not, are reversible. If you catch it at an early age, and even later, if you’re willing to put in some effort in juggling your life. Everybody has to make those decisions.
I told you about me and gluten. On the other hand, I’m at high risk for macular degeneration, which is an eye condition where you don’t have central vision. My father had it. I inherited the gene, as did my twin sister. It turns out that by limiting Vitamin A and not overdosing on Vitamin A in certain fruits and vegetables that I love, it will help me avoid macular degeneration because it helps to precipitate macular degeneration. By using sufficient amounts of Vitamin D and making sure I absorb it.
That’s kind of interesting, isn’t it? Vitamin A is great for the eyes. Tomatoes, anything red, red peppers, carrots. All three of them, I can live on. I munch on tomatoes all summer. I mentioned my sister is a gardener, and so was my mother. We grew up eating tomatoes like they were apples. They are a fruit, but we think of them as a vegetable.
I avoid a lot of Vitamin A now. I try to do it more in moderation. Instead of three packages of two pounds of carrots in the chicken soup I make, I try to limit it to one package of carrots. It’s sweet. I like sweets. That’s an example.
When you look at the Rejuvenation Olympics website, to go back to your question about being too early or too late, where the right time is, it’s never too late or too early. The age range for our clients (we don’t call them patients because we want them healthy, and in Groq, they’re members), is 15-73. You can see the span is great. We want it to be for everybody.
I think if people own their own health—that’s what Groq is about—then they won’t get sick in the same way. They will be able to protect aging and their health and their money. Being sick costs a lot of money, not only compromising life. That’s what should be stopped. I believe it can be in this century.
Dr. Eric:
That’s awesome to hear. It’s very interesting about Vitamin A. I would have thought the opposite, like you mentioned Vitamin A is known for eye health. If you have the gene that predisposes you to macular degeneration, you’d want more Vitamin A, not only through food but maybe supplements. It sounds like it’s the exact opposite, where you want to limit it. Beta carotene sources, not just active Vitamin A. Very interesting.
Dr. Florence:
You’re exactly right. There was even a study years ago in the New England Journal, where if you take Vitamin E, but only one type, it increases cancer. I like to keep people aware of what their nutrient makeup is. For example, you know as well as I do that fat soluble vitamins can be dangerous. Too much Vitamin A causes hair loss as well. You could overdose on Vitamin A.
It’s confusing out there. You go into any pharmacy, and how do you choose what supplements are good for you?
We believe in looking at the specifics that make up you as a human being to figure out if you actually need D to pull in more calcium and strengthen your bones, but D is also a hormone that is fat soluble. You can’t overdose on D almost. Most of us have too low D. I haven’t met a person with D that is greater than 50. A lot of people are in the 20s or even in the teens. We want Vitamin D levels to be 60-80 as a sweet spot.
It’s really good not just for calcium and bones, which we all know. But it’s actually a hormone that affects every cell in the body and protects the immune system, brain, heart, thyroid. You want to be able to know these facts to be able to apply them for yourself.
Dr. Eric:
Same here. I see a lot of people deficient in Vitamin D. Most people are lower. I’m guessing Vitamin D is one of those top biomarkers that you mentioned earlier that you are going to discuss?
Dr. Florence:
It actually isn’t. Here’s the thinking around it. Vitamin D is really important. The one group of people you want to be careful of is people who are stone formers and make calcium. That can be genetic. It can also be from dehydration and not drinking enough water. If you have it in your family, it makes the odds higher.
Vitamin D presumably is low in everyone. You can’t get enough from the sun. We have lost that ability. Darker-skinned people even more so. The data I have read and interpreted over the years has shown that if you want to absorb Vitamin D from the sun, you have to be nude for an hour near the equator, and you can probably get some Vitamin D. I follow people who live in NYC and go to Florida during the winter. I have only seen one person increase their Vitamin D level from sun alone.
You really need to take a supplement. That would be something that everybody should take, but not a lot of it. Maybe 1,000-2,000 a day of D3. We believe it should be taken with K2 because otherwise, you don’t channel the D or the calcium into bone. You need the K2, which acts in a coagulation sequence.
There are some complexities around that because if someone is on a blood thinner, you have to be careful when you take it. Vitamin D with K2 at a certain level and a certain kind of K2 is important to have enough calcium in bone, not to get the calcium in breasts or the heart or precipitating in the prostate or anywhere else in the body. That’s a good combination.
It’s not one of our top biomarkers because it is ubiquitous. I’m sure your followers who have had their Vitamin D measured have seen how low it is. Sometimes, the doctors don’t know that a Vitamin D of 30, just because it says it’s okay on a Quest or LabCorps range is fine. It’s not usually adequate. There are many people who have osteopenia and are at risk for osteoporosis who should have more calcium in their body as well.
We don’t actually prescribe calcium ever. I haven’t done that for 20 years. There is no need. If you have adequate D, you will mobilize calcium from your gut. Make sure you have calcium in your diet. Does that answer your question with a little bit more frills?
Dr. Eric:
It definitely does. Just to confirm, do you like to see in most people, if not everyone, the 25 hydroxy Vitamin D levels to be at least 50?
Dr. Florence:
At least 60 actually. 60-80. If they go up to 100, no problem. In people who are at risk of forming calcium stones, sometimes people know they have kidney stones, but they don’t know what kind. If they have had an immediate family member—a father, a mother, a sibling, even a child—just be aware that they need to undertake Vitamin D. Don’t take too much; take less.
People who don’t have stones can take 5,000 international units a day. People who have stones in their family or they themselves have produced a stone, I’d be careful and make sure to take 1,000-2,000 daily, no more. Make sure that they drink a lot of water to the extent that their urine is clear, that it looks like water. Forget counting. If you know that you’re peeing, and it looks clear, that’s a good sign. You’re staying hydrated, which helps to stop precipitation of stones.
Dr. Eric:
That sounds good. I could talk more about Vitamin D for a while. Definitely want to hit some of the other points, including those top biomarkers. Why don’t you talk about those five?
Dr. Florence:
There are five that we found are most critical in everybody. This is the part we based on research in that there is no one person I’ve seen, and I’ve seen thousands over the years who actually metabolize sugar effectively who aren’t on a trajectory to become diabetic at some point in their life. It could happen in their 30s or their 90s. That’s because it’s survival.
The five key biomarkers speak to hormonal optimization, cholesterol, and all the carbohydrate markers that can tell a person what’s happening today, and where they are headed for the future. No one wants to become a diabetic. It’s not a fun thing. If you can stop diabetes in your tracks, you’re stopping the risk of heart attack, stroke, even Alzheimer’s. You’re stopping the risk of kidney disease or eye disease, skin disease, things like neurological disease, like paresthesias of the hands and feet, which I have seen precede diabetes in people who don’t even know they are prediabetic or diabetic.
The millions and millions of people around the globe with prediabetes or diabetes is to me an understatement. It’s actually everyone. It’s a survival gene. If we couldn’t put on weight when we fasted or when there was a famine or when there was the Holocaust, we wouldn’t be able to pass on those genes because the folks who lived through being cavemen/cavewomen, which all of us must come from that era, had a survival winter that may not have fed them. Those genes are ubiquitous. There are at least 1,500 variants of sugar, metabolism, types of genes. We all have combinations of them.
We measure fasting sugar, fasting insulin, and hemoglobin A1C. I can talk more to the complexities and combination thereof if you’d like.
But the other two biomarkers that relate but also have other impact is free testosterone and what we call cholesterol risk ratio. That looks at a ratio of total cholesterol and HGL, or what a lot of people think of as “good cholesterol.” The lower that ratio is, if it’s less than 2, the safer you are. These are values that we consider critical biomarkers. In other terms, we call them lab tests. But biomarkers to me are data that help us define the state of your health today and where you’re headed tomorrow.
Dr. Eric:
Cholesterol risk ratio, less than 2. How about those other markers? The fasting insulin, hemoglobin A1C, etc.
Dr. Florence:
Fasting sugar or glucose, after an overnight fast, sugar should be between 70-80. That is a pretty tight range, but that’s optimal. That means your body has no insulin on board. Insulin should be undetectable, or less than 2 as well, which is the dimension of detectability in the lab studies.
Both of them speak to how well you manage and metabolize glucose in the system. We don’t need any insulin if we haven’t eaten for 8-10-12 hours. Actually, we don’t need insulin if we haven’t eaten for three hours. If we have too much insulin on board, even greater than 2, 2-5 is sort of target range but not optimal. Anything over 5 speaks to insulin resistance, which means the insulin has been overused in a way, and it’s not working as effectively as it should.
You really want fasting sugar to be between 70-80. Insulin should be undetectable at less than 2. Then when you eat, insulin does go up. It should mirror glucose. There are ways of eating to do that. Glucose should stay below 120.
Now, there are reasons glucose might shoot out higher to 150 or 180. They include some good reasons, like exercise. There are patterns that have to be interpreted. But if you eat a banana, and your sugar goes to over 200, that’s a risk factor. The fructose in a banana is not compatible with your system. It doesn’t mean you never eat bananas, but maybe there is a way you eat bananas that keep your sugar below 120. Between 70-120.
I didn’t mention this, but you don’t want your sugar to go below 70 either. That is a risk for diabetes. Sugar needs to be maintained in this tight zone to keep you optimal and to prevent chronic disease from appearing and sticking with you for the rest of your life. Sugar damages every cell of the body.
We have another trick to it that your followers may be interested in. That is we use continuous glucose monitors (CGMs), so people can really see, like I mentioned with a banana, and test it themselves. They can see singular foods, like what they might eat, what that does to sugar, whether it’s a carb or protein or fat or fiber. Then they can start mixing foods.
One of the ways we know that we can keep insulin and sugar in parallel together and protective of your health is by starting with a protein before you eat a carb, any carb. Protein, high fiber, or healthy fats, like avocado, olive oil, those in balance will keep your body’s absorbing and metabolizing sugar in a way that’s the healthiest and optimal.
Dr. Eric:
If you have an undetectable insulin, and your fasting glucose is between 70-80, is it safe to say that your hemoglobin A1C is most likely looking good? This should also be on the lower side.
Dr. Florence:
That’s a great question. It is, with one exception. If your sugar and insulin shoot up in patterns that are not healthy, like after a meal. Let’s say you sit down and have steak and potatoes and green beans with a nice salad on the side. You have your steak that fits in the palm of your hand, so it’s the right amount of protein. You want to have at least 20-30g of protein at each meal. It should add up to at least a gram of protein per kg per day. A kg for those who may not know is 2.2 pounds. If you weigh 60 kilos, which is about 130 pounds or something of that nature, for the women out there, you want to take in at least 60g of protein a day. That would be 20 at each meal if you’re a three meal per day kind of person. If not, keep track of it.
You absolutely want to see what your sugar does after that. That’s where the CGM can come in handy. I’m sure you’ve heard of all those companies that prescribe CGMs and follow your food. It’s not as simple as food alone, as you’re probably getting the idea from all the information I’m pouring out there.
If I’m doing too much too fast, tell me, Eric. I’m a New Yorker. We speak very fast here. You can relate. You’re more measured, so I’m impressed.
If you eat food, and your sugar jumps up to 250 having mashed potatoes, that’s a problem. You could look perfect fasting, but not necessarily what we call post-paranal, which means after food.
Here’s another tip: I don’t actually call diabetes “diabetes” anymore. I almost try never to call it “type 1” or “type 2.” Type 1 is an immunological disorder, and that is very different than what we think of as type 2.
I actually call this a disorder of carbohydrate metabolism because it is. All of us have one in one way or the other. As I mentioned, it is Darwinian. It’s about survival. If we couldn’t put weight on our bones and fat on our bones when times are lean, we don’t live through those times. Those genes don’t get passed down.
We owe it to our ancestors for why food is plentiful. There are golden arches on every street corner right? We can have those delicious French fries although they used to be more delicious; I have tried them recently, and they are not so good anymore. I think they made them healthier. I’m not sure, but I’ve heard they’re different.
It’s easier to put on weight. It’s easier to put on weight in our mid-30s and beyond because our hormones are shifting. You have to be careful. In order to be careful, you have to know what your body is actually doing. The more data you have about how you personally function, the better off a person is going to be. They will be able to judge accordingly.
Does that mean you avoid all food all the time that causes your sugar to go up to 180, 200, 250? Whether it’s a banana or a bowl of ice cream or a cookie or cake? Absolutely not. There are some people who can eat a banana, and their sugar stays at 80 or 100. There are some people who eat a bowl of ice cream, and their sugar stays at 110. Remember, ice cream has some protein in it.
There is a study out of Israel from the Weizmann Institute that showed very clearly, they compared two people out of the thousands they studied. I think they studied 1,600 or so. One person, sugar went sky high on a banana but didn’t do anything with a cookie. The other person had a cookie, and it went sky high, but the banana didn’t do a thing. It’s about learning about you individually as a human being, that whole n of 1 concept.
Dr. Eric:
That makes a lot of sense. Do you currently use a CGM on yourself?
Dr. Florence:
All the time. It’s right here. I have to feel for it because they’re so tiny. I can show it. I don’t know if people want to see it. Don’t look at my triceps though. They’re not the best. I work on it, but I’m convinced I was born without triceps. I am only kidding, but it’s so hard. See it right there?
Dr. Eric:
I do.
Dr. Florence:
My sister has amazing triceps because she did more swimming than I did years ago. I don’t swim because it gets your hair wet, and it’s hard to dry it when your hair is long. That’s one excuse anyway.
I love rollerblading, and she doesn’t rollerblade. She has great triceps, so she is able to wear sleeveless clothes and look much better than I do. I guess as an identical twin, I probably can get great triceps. So far, I’m working on it. It’s a work in progress.
Dr. Eric:
I’m sure you’ll get there. Tying into muscle mass, free testosterone. Testosterone is important for muscle mass. Protein also, which you mentioned. Free testosterone, another one of those biomarkers. What’s an optimal range for that? I guess it probably differs with men and women.
Dr. Florence:
It does, but we do have optimals. There is a spectrum, and we judge according to somebody’s health, how they feel, what they’re presenting with. In men, it’s a little easier than women. We women, as you men probably know, are very complex. Each woman is really her own thing.
In men, it’s still the n of 1, but you can look at change in men as they age over time. It’s more linear. In men, beginning in their 30s, just like women, testosterone falls by 1-3% a year. We women have far less testosterone than men. That’s why we’re at higher risk earlier in life for osteoporosis and fracturing our wrist or shrinking or curvature of the spine or hip fracture later in life. You’ve seen plenty of men walking around hunched over a walker because they have severe osteoporosis, and their spine has collapsed. 25% of all men and women will be osteoporotic. Men, it starts about 10 years later than women.
Women’s testosterone should be between 6-30. I’m talking about free testosterone. Why we women also put more weight around the waist, women who do everything pretty much perfectly and maintain their weight, frequently, they’re 35-45, and they come to see me because they have put on 2, 3, 4, 5, 6 pounds, which is almost nothing for some other women. In these women, they look great, they have done everything, they work out, they eat as well as possible, or they are just gifted genetically, which is a thing. That’s because their testosterone is low.
I think of a woman I just saw and spoke to a couple weeks ago, Sarah, who was in fabulous shape. She was turning 43, and she wasn’t happy because she had put on five pounds, and her clothes didn’t fit her right. We put her on testosterone. We also found out at the time that she was osteoporotic, and that was only by doing a bone density test, which I recommend strongly for everybody at least starting in their 20s but definitely in their 30s, when you can make a real dent in growing bone. Within weeks, her weight had dropped. It was definitely related to the fall in testosterone because everything else was pretty much in the sweet spot.
You really want to raise testosterone. Most women come in at less than 2, sometimes less than 1, which is tiny. We have 5-10% of what men have. In men, you want it over 180. I am talking about free testosterone, not total. I’ll tell you why in a second.
In her case, she went from 1-12 over a period of weeks to months. Her weight dropped almost immediately. She was doing other things she should be doing. When I say that, it’s not just eating protein, which I mentioned at least 1g per kg. For the 60kg women, let’s say it’s 60g. It could be more if you’re heavily into resistance training, which is a good thing because that’s how we grow muscle.
Those are the three elements that can really make a difference for aging. Without enough muscle, you can become sarcopenic. That allows disease to creep in, either from the outside in, like with COVID for people who have comorbidities and diabetes, or had heart disease. When they were sick, they didn’t have enough muscle and more fat and more visceral fat, so they got sicker, and they died more often than people without it.
If you were prediabetic, it was 8x as likely for you to die from COVID because of the comorbidity than if you didn’t have diabetes or prediabetes.
Testosterone, 6-30, free. Other labs may have other levels. Depends on the units that get measured. We happen to use Quest. LabCorps might measure it a little bit differently. Everybody could be a little different. You have to look at where that is in terms of optimal.
Make sure you’re taking adequate protein in your meal daily and doing resistance training at least 2-3x a week.
Dr. Eric:
Sticking to the topic of hormones, can you discuss the difference between hormone replacement versus hormone optimization? Does everybody with low testosterone or estrogen or progesterone need hormone replacement in your opinion?
Dr. Florence:
Let me start with what is hormone replacement, and what is hormone optimization? First, I started feeling uncomfortable with hormone replacement right from the beginning as an endocrinologist and a reproductive endocrinologist. Hormones was a very deep field of mine along with peptides. I did a lot of research in my earlier years at NIH and Yale in children who had early puberty, using peptides, and in adults, women with endometriosis and fibroids.
With respect to that, we are not Mother Nature. We can’t do what Mother Nature does and cause a woman- Week-to-week, women’s cycles change. Women’s symptoms change. In men, it’s more every hundred days, every three months, their system evolves. Sperm takes that long to be made. Testosterone goes up and down with response to what we call a negative feedback loop in the body. There is more consistency in it for men. That shifts as men hit their 30s and 40s when they don’t release as much testosterone. Their brain doesn’t recognize it. They are not making enough. In women, it shifts as well based on their ovulatory cycle, or if they are on birth control pills.
To me, optimizing hormones means we can start addressing what Father Time starts taking away from us. In our 30s, testosterone begins to fall. Even before menopause in women and andropause in men starts hitting us, where ovaries stop performing. You can’t make eggs. Men start drifting downward with their testosterone, but they are not recognizing it. Their brain hormones are low. They can make testosterone, but their testes are not being told, “This is how you make testosterone. This is the hormone.” Hormones start falling, particularly LH and FSH.
The optimization is how do we limit risk and improve health? The risk/benefit ratio to me is how I apply doing clinical research with dealing with a singular human being. When we do research, we look at risk/benefit for a whole group of people. How can we get them healthier by any intervention we’re doing or testing? How do we prevent side effects?
Hormonal optimization is limiting side effects but increasing response. What is the best benefit? As I mentioned with Vitamin D or the hormone D, that is what we do when we look at people at risk of stones. We don’t want them to have stones, but we want to maximize their health. We compromise on the dose of D. That’s the same way I approach any hormone, including testosterone, estrogen, progesterone, prednisone, DHEA, DHT, etc. That is how we look at hormonal optimization. Does that make sense? We want to get the best out of it with the least risk. If that’s what we need for that person.
Dr. Eric:
Yeah, that makes sense. One thing I heard with men and testosterone, because you said it starts declining in their 30s. Would you be cautious about giving a male in their 30s or 40s testosterone? I heard if they are still thinking about having children, you would not want to give testosterone.
Dr. Florence:
Actually, the opposite. Would you think twice about testosterone if a man wants children? The most common way of giving hormones in this country for now, maybe in the world, is testosterone itself. I have a unique approach to it. I actually use a hormone which is a peptide hormone, not a steroid hormone, called HCG. Have you heard of it?
Dr. Eric:
Yeah.
Dr. Florence:
HCG, Human Chorionic Gonadotropin. It acts like the hormone that comes from the brain, LH, which I mentioned earlier. It tells male testes to make testosterone. It triggers the lytic cells in the testicle and says, “Hey, wake up. It’s time to make more testosterone. You’re drifting to sleep.” The brain is not paying attention to low circulating testosterone.
That hormone actually increases fertility. We use it to help men become fertile. Testosterone can suppress the testes itself because you’re giving the hormone. You’re giving the hormone, the testes looks around, and says, “Hey, you might not need any testosterone because it’s on board already.”
It’s not perfect that way. Actually, men still make sperm. If it was perfectly shutting off the testes, then you’d be able to use it as a birth control. We have never been able to use testosterone as a birth control because it doesn’t really shut down.
For safety reasons, I would not give men testosterone if they were trying to conceive children. But a lot of men in their 30s are not. If they are at risk, which is less common than your 40s or 50s or 60s, we judge it accordingly based on those biomarkers.
If your T is low, whether you’re 35 or 45 or 55, we are going to look at starting with HCG if the rest of the numbers fill that pattern. I can give you examples. There is a whole group of men that we treat who has Ashkenazi Jewish background, or they’re Indian and Asian, that have very early heart attack and stroke in the family. A lot of times, relatives, men and women, died early, like by 60, of heart attack or stroke. They were sick beginning in their 40s. We have a whole group of people we treat gingerly, looking at risk/benefit to make sure that we don’t let them go down the path of having a heart attack at 40 or 45 and die in their 60s.
in fact, the very first person who tried Groq in February 2021 was somebody who had that history whose father was Ashkenazi and mother was Puerto Rican. His numbers looked like a 50-something-year-young man. Maybe this time, year-old man. He was already expressing symptoms of low testosterone, which we hear about, or hypogonadism, meaning his testes weren’t producing enough. His numbers were tested three times. They were quite low. His free T ranged from 50-70 instead of over 180. He was putting weight around the middle. He had less energy, less libido. It was completely reversed within a few months.
Dr. Eric:
Wow. Before we start wrapping things up, can you talk a little bit about thyroid? What do you test for in your practice with your clients?
Dr. Florence:
Yep. I do. I can. Thyroid is an important hormone as well. Our thyroid gland sits around our neck. It’s kind of like a bow tie, I guess. A little knot in the middle, but with two wings.
80% of people have abnormal thyroid function. As we age, it’s clear-cut. You can’t just measure TSH. You have to measure free T3 and free T4. Again, that system is interactive. We create TSH from our brain, the pituitary. The hypothalamus at a higher level makes TRF, thyroid releasing hormone, which tells the pituitary to make TSH, thyroid stimulating hormone. That in turn tells the thyroid to make T4. Interestingly enough, T4 is converted to T3, and T3 is the active thyroid hormone.
If you don’t measure TSH, free T3, and free T4 together, you don’t know the relationship. The range for TSH is 0.4-4 or 4.5. It’s a humongous range. Insurance companies sometimes only want that number, but you can have a high TSH or a low TSH, and your thyroid, your free T3 and free T4 can be abnormal, not the range we want. We look for a free T3 of 3-4ish. We look for a free T4 of about 1-1.5. The balance has to be there.
I have seen lots of variations on that theme. I think we’ve come too far in a way. Sometimes using lab tests. I have seen many women and men who complain of classical thyroid symptoms like hair loss, weight gain or loss, constipation, ends of the eyebrows losing hair, slowing down in their thinking, or speeding up heart rates. Those are variations on the theme of high thyroid/low thyroid.
In women, it’s actually interesting. It’s the opposite. If your menstrual cycle is too heavy, it’s usually related to low T3. If it’s high, you have higher thyroid hormones, you can stop your menstrual cycle, or you have a very light cycle.
You know better than me, I’m sure, that thyroid affects every cell in the body as well. It affects the brain for cognition and memory. It affects the heart for rhythm, muscle, and conduction. It affects muscle and bone.
Being in that optimal range for all three. I pay attention more to free T3 and free T4 than TSH because that could be anywhere.
The final thing is if we do see a disruption, particularly where we suspect something called Hashimoto’s thyroiditis, or an inflammatory process that is immunological, we will look at antibodies as well. That is an autoimmune form of thyroid disease. Does that help?
Dr. Eric:
It does. It’s important not to look at just TSH. I’m glad you test for the thyroid hormones, free T3 and free T4. If you’re suspecting autoimmunity, you will also look at antibodies.
I’m sure there is so much you could cover. Anything that I didn’t ask you that you wanted me to ask you?
Dr. Florence:
I’ll add one more thing for thyroid. I know we have to wrap up because it’s been fun, and we might be even over the hour.
With thyroid, be aware that you need to know what your free T3 is. A lot of folks do reverse T3. I don’t find it as helpful, except maybe when people are ill. 20% of people can’t convert T4 to T3. That is why if they are already taking thyroid hormone, but it isn’t doing as much as they hope, like Synthroid is the most common, which is a T4 or generic type, then they need T3. 20% of people cannot convert genetically T4 to T3. That is the active hormone.
Last words on this interview: I think everybody could take care of their health, so they become knowledgeable with not that much data. If they can follow along and really invest in their health, it will pay off in spades. Getting sick is very costly and not much fun. By understanding more about your personal history, your family history, your exercise and sleep, even your restorative stuff like yoga or meditation, which turns off cortisol, one can really preserve their health and actually get younger biologically as they age longitudinally and chronologically.
I just hope we can deliver this to everybody by scaling the Comite Center through the virtual app Groq Health.
Dr. Eric:
Speaking of which, can you let people know where they can find you? Also, how can they get on the waitlist for that app since it’s not officially out yet?
Dr. Florence:
They can find me on Instagram, Twitter/X, and LinkedIn, @DrFlorenceComite. We are posting there. We also post on Comite Center on Instagram, Facebook, and Twitter.
Groq Health, as far as signing up on the waitlist, it would be going to GroqHealth.com. The link may not be working right now, but we are trying to fix it. We have close to 20,000 people already signed up.
A little tidbit: Groq Health is out there on Android. We are collecting anybody who signs up, so when we are ready to open it up to direct to consumer, which will happen sometime in 2024, anybody who signs up on an Android will be at the top of the list. With the iPhone, you need an invite. With an Android, you don’t. You can go to Google Play and download the app.
Dr. Eric:
Good to know. Whether you have an Android or iPhone, Android, you’re on the top of the list if you sign up. iPhone, you need an invite. Either way, they will visit GroqHealth.com, correct?
Dr. Florence:
Yes.
Dr. Eric:
Wonderful. Thank you so much, Florence. This was an amazing interview. I really appreciate you taking the time to discuss how to reverse aging and optimize hormones.
Dr. Florence:
I appreciate it. You clearly know your stuff. It was great talking to someone who is an educated, informed physician who can help sort out these thorny questions for people. I think it’s really hard to understand medicine. We are so complex, all of us. Thanks for having me.
Dr. Eric:
Thank you.