Skin Care and Aging: Keeping Your Skin Healthy and Youthful

Skin aging is a complex process caused by both intrinsic (internal) and extrinsic (external) factors. Intrinsic aging is influenced by hormonal changes and is inevitable, while extrinsic aging is caused by exposure to environmental factors, such as UV radiation. 

Both intrinsic and extrinsic aging can lead to collagen degradation, dryness, loss of elasticity, and wrinkling of the skin. Skin aging is also associated with loss of skin moisture, due to decreased production of hyaluronic acid.

 How to Naturally Reduce Wrinkles with Food (YouTube link)

Skin Aging

Human skin aging is a complex biological process, not yet fully understood. It is the result of two biologically independent processes:^[1]

1. Intrinsic or innate aging
2. Extrinsic aging

Intrinsic or Innate aging

An unpreventable process, which affects the skin in the same pattern as it affects all internal organs
Is influenced by hormonal changes that occur with age.   It is well established that the deficiency in estrogens and androgens results in collagen degradation, dryness, loss of elasticity, epidermal atrophy and wrinkling of the skin.^[2]

Androgens^[2]

• Recent findings suggest that skin and its appendages are steroidogenic tissues that can be significantly affected by sex steroids, particularly androgens. 
• Androgens have been shown to modulate epidermal and dermal thickness, and changes in circulating androgen levels with age can alter key functions of the skin, such as epidermal barrier homeostasis, wound healing, sebaceous gland growth and differentiation, and hair growth. This can leave the skin susceptible to infections and several disease states.

 
Estrogens^[3]

• Estrogens improves the skin in a number of ways, including increasing collagen content and quality, increasing skin thickness, enhancing vascularization, and improving the extracellular matrix, which is responsible for the skin's tone and appearance.
• Skin aging is not entirely estrogen-dependent, as the ravages of time and the external environment also play important roles.

Extrinsic aging

The result of exposure to external factors, mainly ultraviolet (UV) irradiation, that is also referred to as photoaging.

• The sun's harmful UV radiation can damage telomeres, specialized structures found at the ends of chromosomes, and lead to the formation of free radicals, which can damage cells and contribute to aging.
• The most visible signs of photoaging, or premature skin aging caused by sun exposure, are wrinkling and pigmentary changes. Photoaging can also lead to various forms of skin cancer.

Loss of Skin Moisture: A Key Sign of Skin Aging

Skin aging is also associated with dryness, caused by the loss of a key molecule called hyaluronic acid (HA). HA has the unique ability to bind and retain water molecules, which helps to keep the skin plump and youthful. As we age, our production of HA decreases, leading to drier, more wrinkled skin.^[6]

Tips for Preventing Photoaging and Keeping Your Skin Healthy as You Age

Sun protection: Avoid the sun's harmful UV rays as much as possible

• Seek shade whenever possible, wear protective clothing, and apply a broad-spectrum sunscreen with an SPF of 30 or higher to all exposed skin every day, even on cloudy days. 
• Reapply sunscreen every two hours, or more often if you are sweating or swimming.

Retinoids:

• Retinoids can help to improve the appearance of photoaged skin. Apply a retinoid cream or serum to your face, neck, and chest every night.
• Using retinoids can reduce collagen breakdown and boost collagen production

Antioxidants: can help to protect your skin from free radical damage

• Include antioxidants in your diet by eating plenty of fruits, vegetables, and whole grains. 
• You can also apply antioxidant serums and creams to your skin.

Other tips:

• Stay hydrated
• Drink plenty of water throughout the day to keep your skin plump and hydrated.
• Eat a healthy diet
• Eat a variety of nutrient-rich foods to nourish your skin from the inside out.
• Manage stress
• Find healthy ways to manage stress, such as exercise, relaxation techniques, and spending time with loved ones.
• Don't smoke
• Smoking damages the skin and accelerates aging.
• Moisturize regularly
• Use a moisturizer that is appropriate for your skin type to keep your skin hydrated and protect it from the elements.
• For dry, cracked skin, Cetaphil Cracked Skin Repair Lotion is a good option.
• See a dermatologist regularly
• Have your skin checked by a dermatologist at least once a year to identify any potential problems early on.

By following these tips, you can help to prevent photoaging and keep your skin healthy and youthful as you age.

References

1. Hyaluronic acid: A key molecule in skin aging
2. Brincat MP. Hormone replacement therapy and the skin. Maturitas 2000; 35:107–117. 
3. Makrantonaki E, Zouboulis CC. Androgens and aging of the skin. Curr Opin Endocrinol Diabetes Obes. 2009;16(3):240–245.
4. Baumann L. Skin ageing and its treatment. J Pathol. 2007;211:241–51. doi: 10.1002/path.2098.
5. Skin Care and Aging
6. Hyaluronic acid: A key molecule in skin aging

Long COVID: Symptoms, Causes, and Risk Factors

A major new NIH initiative has been announced to identify the causes and ultimately the means of prevention and treatment of "Long COVID."

Symptoms

Acute COVID-19 is a highly inflammatory illness. 

Most people with COVID-19 recover within two weeks. Some, as reported in [30], with so-called Long Covid (symptoms lasting longer than three weeks), continue to experience excessive fatigue, breathlessness, headache, insomnia, muscle fatigue and pains, chest pains, persistent cough, intermittent fevers and brain fog.

Causes

In the post-acute phase, 

• Inflammation
• Immune activation
• Long-term dysregulation of virus-specific immune responses 

have been consistently identified in peripheral blood. 

These immune responses have been associated with a variety of factors including:

• Clotting dysfunction
• Reactivation of latent viral infections such as Epstein Barr Virus (EBV)
• Autoimmune responses

Importantly, there is a growing body of evidence that persistent SARS-CoV-2 RNA or protein can be detected in various tissue compartments for many months following acute infection. This may explain, at least in part, ongoing aberrant immune responses, inflammation, and clinical symptomatology.

Risk Factors

It’s unclear why some people develop long Covid and others don’t, but four factors appear to increase the risk:^[37]

• High levels of viral RNA early during an infection
• The presence of certain autoantibodies
• The reactivation of Epstein-Barr virus
• Having Type 2 diabetes

The study finds about 10 per cent had symptoms for a month, with between 1.5 and 2 per cent after three months. The median age of those with Long Covid is 45, and women are more likely to be affected.

Ongoing Research

It is important to note that the research on long COVID is still ongoing, and there is still much that we do not know about this condition.

References

1. Clinical and immunoserological status 12 weeks after infection with COVID-19: prospective observational study
2. Long-term COVID-19 symptoms in a large unselected population
3. The Tip of the Iceberg: Virologist David Ho (BS '74) Speaks About COVID-19
4. Even Mild Covid-19 Infections Can Make People Sick for Months
5. [WEBCAST REPLAY] COVID-19 Pandemic Update: Analysis From Neil Howe & Daryl Jones
6. Why U.S. hospitals see promise in plasma from new coronavirus patients
7. Virus May Spread Twice as Fast as Earlier Thought, Study Says
8. What Does Your Cough Say About Your Illness?
9. The COVID-19 vaccine development landscape
10. She spent 9 days in a coma and relearned how to walk. What this Covid-19 survivor wants protesters to know
11. If you’re hoping a vaccine is going to be a knight in shining armor saving the day, you may be in for a disappointment. SARSCOV2 is a highly contagious virus. A vaccine will need to induce durable high level immunity, but coronaviruses often don’t induce that kind of immunity (link)
12. Mutations map holds the key to bringing coronavirus under control
13. Virus Likely to Keep Coming Back Each Year, Say Top Chinese Scientists (Bloomberg)
• “The virus is heat sensitive, but that’s when it’s exposed to 56 degrees Celsius for 30 minutes and the weather is never going to get that hot,” said Wang Guiqiang, head of the infectious diseases department of Peking University First Hospital. “So globally, even during the summer, the chance of cases going down significantly is small.”
14. All the Covid-19 Symptoms You Didn’t Know About
15. Coronavirus: Can it affect eyesight?
16. What Troponin Tells Us About Myocardial Injury in COVID-19
• Clinicians then assess potential causes of troponin elevation, including hyperinflammation, which may respond to immunosuppressive therapy.
17. Strokes and mental state changes hint at how COVID-19 harms the brain
18. A family physician’s COVID story
19. A COVID-19 vaccine: 5 things that could go wrong
20. Studies detail conjunctivitis in kids, adults with COVID-19
21. A perspective on potential antibody-dependent enhancement of SARS-CoV-2
22. COVID-19 survivors suffer long term heart conditions
23. As evidence builds that COVID-19 can damage the heart, doctors are racing to understand it
24. Novel coronavirus survives 28 days on glass, currency, Australian researchers find
25. CDC Expands Covid Risk Warning to Include Overweight People
• Nearly 72% of American adults are overweight (25 < BMI < 30) or obese (BMI ≥ 30)
26. CDC Says Virus Can Spread Indoors in Air Beyond Six Feet
27. Covid may cause sudden, permanent hearing loss – UK study
• 16 of 121 patients admitted to hospital with Covid reported hearing problems about two months after discharge.
28. Long Covid: what we know so far
29. Living with Covid19
30. Long Covid casts a lasting shadow over workers
31. Interferon deficiency can lead to severe COVID
32. 'Brain fog' can linger with long-haul COVID-19, study says
33. New clues to the biology of long COVID are starting to emerge
34. Risk Factors for Covid-19
35. Kidney damage can result from coronavirus infection
• Kidney fibrosis, or scarring, is a serious long-term consequence that can occur virtually after any injury to the kidney and correlates with kidney function. Our work shows kidney scarring in COVID-19 patients, which provides an explanation why the virus might cause kidney functional decline as demonstrated in other studies
36. Kidney Outcomes in Long COVID
37. How Long Covid Exhausts the Body 
38. Study details immune cells vital to success of vaccines against coronavirus
39. Study identifies shared molecular mechanisms across SARS-CoV-2 variants that allow virus to thrive despite vaccination
• Similar to treatment regimens for HIV, we believe the future approach to managing pandemics will require a drug combination cocktail.
• Here, this could include a combination of vaccines and antiviral innovations to target the virus. Specifically, combination therapy approaches to target the adaptive immune response (e.g., vaccines, antibody treatments) and another inhibiting viral innate immune antagonist proteins (e.g., Orf6 and Orf9b) or activating the innate immune response, could be the most effective. Perhaps with this approach, we may be able to get ahead of viruses before they reach pandemic levels.
40. Impact of SARS-CoV-2 ORF6 and its variant polymorphisms on host responses and viral pathogenesis
• Impact of SARS-CoV-2 ORF6 and its variant polymorphisms on host responses and viral pathogenesis 
41. SARS-CoV-2 variants evolve convergent strategies to remodel the host response

Update on MSG (Monosodium Glutamate)

Update on MSG (YouTube link)

A frequent cause of post-dinner headaches, mono-sodium glutamate (MSG) is a food additive, enhancing flavor. MSG is often added to in prepared Asian food and soy sauce, but it’s also added to some prepared soups, soup mixes, fast foods, deli meat, and salad dressings. In some people, MSG activates two major pathways of chronic inflammation,^[11] and it also has a negative effect on liver health.

MSG has been associated with palpitations of the heart,^[8] muscle weakness, and numbness. To further prove the ill effects MSG can cause, a Japanese study found constant consumption of products that contain MSG can lead to obesity, inflammation in the liver based on mice studies.^[3]

MSG Symptom Complex

During years of using MSG as a food additive, the FDA has received many reports of concerning reactions that people have attributed to foods that had MSG in them. These reactions — called MSG symptom complex.^[5]

But researchers have found no clear proof of a link between MSG and these symptoms. Researchers admit, though, that a small number of people may have short-term reactions to MSG. Symptoms are often mild and don't need to be treated. The only way to prevent a reaction is to not eat foods that have MSG in them.

Watch Out for the Intake Amount 

Monosodium glutamate (i.e., the purest form of umami, the fifth taste) itself is not bad for your body, what you have to be careful about is the amount you eat. When you put too much salt in your food, it is too salty, if you put sugar too much, it is too sweet, but with umami, you can't taste if there is too much of it. 

That is why some people put too much of it and says it causes health problem, but it is same as eating too much salt or sugar. The right amount of MSG you should add is one pinch.

MSG Must Be Listed on the Label 

The U.S. Food and Drug Administration (FDA) has classified MSG as a food ingredient that's generally recognized as safe. But its use is still debated. For this reason, when MSG is added to food, the FDA requires it to be listed on the label.

 

Definite Sources of MSG

• Hydrolyzed Protein, Sodium Caseinate or Calcium Caseinate 
• Autolyzed Yeast or Yeast Extract 
• Gelatin 
• Hydrolyzed Oat Flour 
• Glutamic acid 
• Monosodium glutamate

Possible sources of MSG

• Textured Protein 
• Carrageenan or Vegetable Gum 
• Seasonings or Spices 
• Flavorings or Natural Flavorings 
• Chicken, Beef, Pork, Smoke Flavorings 
• Bouillon, Broth or Stock 
• Barley Malt, Malt Extract, Malt Flavoring 
• Whey Protein, Whey Protein Isolate or Concentrate 
• Soy Protein, Soy Protein Isolate or Concentrate 
• Soy Sauce or Extract

Other sources of MSG

• MSG is found in most of the food prepared by major fast-food chains.
• Binders and fillers for medications, nutrients, and supplements, both prescription and non-prescription, and some fluids administered intravenously in hospitals, may contain MSG.
• According to the manufacturer, Varivax-Merck chicken pox vaccine (Varicella Virus Live), contains L-monosodium glutamate and hydrolyzed gelatin both of which contain processed free glutamic acid (MSG).
• MSG is used as a plant "growth enhancer" (AuxiGro) that is sprayed on growing crops. AuxiGro Plant Metabolic Primer contains 29.2% by weight, pharmaceutical grade, L-glutamic acid.
• The most common source of MSG is molasses or sugar beet or cane.
• MSG and Aspartame(nutrasweet) are found in everything from soups, sauces, and juice to frozen entrees, candy, cigarettes, and anything with seasonings (e.g., potato chips, meat, ice cream).

Conclusions

In the old days, safe eating depends heavily on knowing how to read biological signals such as: 

This looks ripe; this smells spoiled; that's one slick-looking cow.

This is much easier to do when you have long experience of a food and much harder when a food has been expressively designed to deceive your senses with, say, artificial flavors, synthetic sweeteners, or flavor enhancer (e.g., MSG).

Foods that lie to our senses are one of the most challenging features of the Western diet.  

Using MSG as an example, it is regularly added to instant noodles.  Lots of people are addicted to eating instant noodles and in large amount because they taste good with added MSG.  However, it is low in nutrients and frequent consumption of it is linked to an increased risk of metabolic syndrome.

References

1. 10 Foods Proven To Aggravate Joint Pain
2. NEUROLOGICAL INFLAMMATION: AN APPROACH TO REVERSING THE PROCESS
3. Monosodium glutamate (MSG): a villain and promoter of liver inflammation and dysplasia 
4. AJINOMOTO MONOSODIUM GLUTAMATE. IS IT REALLY BAD FOR YOUR HEALTH?
5. Monosodium glutamate (MSG): Is it harmful? - Mayo Clinic
6. Monosodium glutamate - Wikipedia
7. Update on MSG (NutritionFacts.org)
8. Heart Palpitations After Eating - Cleveland Clinic
9. Tchkonia T, Morbeck DE, Von Zglinicki T, Van Deursen J, Lustgarten J, Scrable H, … Kirkland JL (2010). Fat tissue, aging, and cellular senescence. Aging Cell, 9(5), 667–684.
10. Fernstrom, John D. (2018). "Monosodium Glutamate in the Diet Does Not Raise Brain Glutamate Concentrations or Disrupt Brain Functions". Annals of Nutrition and Metabolism. 73 (Suppl. 5): 43–52.
11. Dietary food additive monosodium glutamate with or without high-lipid diet induces spleen anomaly: A mechanistic approach on rat model

The Link between a Common Variant in HLA Genes and Asymptomatic SARS-CoV-2 Infection

So far most global efforts have focused on severe illness in COVID-19, for example:

• The Link between TLR7 Variants and Critical COVID-19

However, examining asymptomatic infection provides a unique opportunity to consider early immunological features that promote rapid viral clearance. 

Asymptomatic COVID-19

At least 20% of people who become infected with the SARS-CoV-2 coronavirus never feel sick.^[4-7] Now scientists have identified a genetic mutation (i.e.,  HLA-B*15:01) that is linked to a higher likelihood of avoiding symptoms during infection.^[1]

Here variation in the human leukocyte antigen (HLA) loci may underly processes mediating asymptomatic infection was postulated.

Initially, scientists suspected that this genetic association is due to pre-existing T cell immunity.  After further study, now they show that:

The structural similarity of the peptides underpins T cell cross-reactivity of high-affinity public T cell receptors, providing the molecular basis for HLA-B*15:01-mediated pre-existing immunity.

 

What is HLA genes?

Among the many genes involved in human immune responses, Human leukocyte antigens (HLA) variants have among the strongest associations with viral infections.^[2]

HLA are genes in major histocompatibility complexes (MHC) that help code for proteins that differentiate between self and non-self.

They play a significant role in disease and immune defense. They are beneficial to the immune system but can also have detrimental effects.

T Cell Cross-Reactivity

Cross-reactivity is the ability of an antigen to bind with an antibody that was raised to a different antigen. It may arise by one of two mechanisms: shared epitopes on multivalent antigens, or conformational similarity of epitopes.

In the study, scientists sought to determine whether the T cell cross-reactivity observed previously in patients with infection could be observed in unexposed individuals.  Here are their observation:^[1]

T cells from a subset of healthy donors carrying HLA-B*15:01 who were never exposed to SARS-CoV-2 were reactive to the SARS-CoV-2 peptide NQK-Q8, and most of the reactive cells displayed a memory phenotype. The sequence identity between SARS-CoV-2 and seasonal coronaviruses peptides, except for a single amino acid substitution, could explain the T cell cross-reactivity.

Seasonal Coronaviruses

Based on a Croatia study on the role of seasonal coronaviruses, rhinoviruses, adenoviruses and bocaviruses in the etiology of respiratory infections, it states that:

An overall global prevalence in respiratory tract infections was found to be between 0.5 and 18.4% for seasonal coronaviruses, between 13 and 59% for rhinoviruses, between 1 and 36% for human adenoviruses, and between 1 and 56.8% for human bocaviruses. 

Pre-Existing Immunity to SARS-CoV-2

In the study of [1],  scientists concluded that pre-existing immunity to SARS-CoV-2 is found to reflect T cell memory to circulating 'common cold' coronaviruses:  Here are their findings and conclusions:

T cells from pre-pandemic samples from individuals carrying HLA-B*15:01 were reactive to the immunodominant SARS-CoV-2 S-derived peptide NQKLIANQF. The majority of the reactive T cells displayed a memory phenotype, were highly polyfunctional and were cross-reactive to a peptide derived from seasonal coronaviruses.

Finally, they have surmised that the structural similarity of the peptides underpins T cell cross-reactivity of high-affinity public T cell receptors, providing the molecular basis for HLA-B*15:01-mediated pre-existing immunity.

References

1. A common allele of HLA is associated with asymptomatic SARS-CoV-2 infection
2. Biochemistry, HLA Antigens
3. Seasonal Coronaviruses and Other Neglected Respiratory Viruses: A Global Perspective and a Local Snapshot
4. Meyerowitz, E. A., Richterman, A., Bogoch, I. I., Low, N. & Cevik, M. Towards an accurate and systematic characterisation of persistently asymptomatic infection with SARS-CoV-2. Lancet Infect. Dis. 21, e163–e169 (2020).
5. Oran, D. P. & Topol, E. J. Prevalence of asymptomatic SARS-CoV-2 infection. Ann. Intern. Med. 173, M20-3012 (2020).
6. Buitrago-Garcia, D. et al. Occurrence and transmission potential of asymptomatic and presymptomatic SARS-CoV-2 infections: a living systematic review and meta-analysis. PLoS Med. 17, e1003346 (2020).
7. Ra, S. H. et al. Upper respiratory viral load in asymptomatic individuals and mildly symptomatic patients with SARS-CoV-2 infection. Thorax 76, 61–63 (2021). 

Orchid Care for Beginners

Unveiling Life: A Petal-Painted Symphony of Renewal (12/19/2023)

(Updated on 12/19/2023)

This document details the full orchid life cycle, encompassing hibernation and the opening of a bud signifying a new cycle.

Figure 1.  Orchid varieties

Orchids are plants that belong to the family Orchidaceae, a diverse and widespread group of flowering plants with blooms that are often colorful and fragrant.^[1]

The orchid flower is typically has an outer whorl of three sepals, an inner loop of three petals, a single large column in the center, and an enlarged bottom petal called a lip or labellum (see Figure 2). The overall flower shape is characteristically bilaterally symmetrical (the left and right halves of the blossom are mirror images), a necessity for reliable pollination by bees.

Figure 2.  Basic structure of orchid^[1]

Orchid Care

There are more than 20,000 species of orchids, and contrary to popular belief, they are extremely easy to look after, yet many homeowners flounder by overwatering or putting orchids in the wrong place.

Lighting

Orchids do not like direct sun. They require low light levels, but they do need sunlight. It is possible for them to survive in offices but they may struggle. Avoid placing your orchid on windowsills because of the direct light.

Temperature

It is best to keep your orchid between 60 F and 80 F.

Fertilizer

It is not necessary to add fertilizer to your water or feed your orchid. At the greenhouse, the growers sometimes give low amounts of fertilizer and your orchid has plenty of energy to continue its bloom cycle.

For our orchid in 5 inch pot, we water them weekly using the cup shown

Watering

Orchids do not require water often and do not need a lot.^[2]

When giving water using the measuring cup (see Figure 1), be aware about the size of orchid you bought. Mini orchids in 2.5 inch pot need 1.5oz of water weekly. Orchids in 5 inch pots instead need 3oz of water per week.

Trimming Stems at the End of Bloom Life

At the end of your orchid's bloom cycle, the blooms will begin to wilt and fall off. This should start with the oldest (lower) flowers first. Based on grandmom's advice, this is the time for you to cut them down at the stem base.^[2]

To prepare your orchid for the flower break you should remove wilted flowers and keep the stems as long as they are still green. The plant will send all energy from the stems back into the roots. Only when the stems are getting brown you should cut them down at the stem base.

The following caring tips were given by a grandmom as you can see in the below pictures.  Note that she never repot her orchids.  If you plan to repot, be very careful not to damage the roots.

This orchid plant has been grown for around 7 years with each cut represents one year 

Yesterday (07/17/2023) grandmom had cut off two stems from the below orchid plant

To prepare this orchid for the flower break, trimming was done

A velvety green bonnet swells with anticipation, cradling a hidden surprise (12/10/2023)

Like a tiny sunrise, a vibrant bloom explodes from the bud, painting the air with its radiance (12/19/2023)

References

1. Anatomy of an Orchid
2. Orchid Care

13-Steps for a Long Healthy Life

Here are 13-steps for a long healthy life summarized from [1] by @ColinKeeley on Twitter:^[2]

1. Our Goal
• Lifespan is the number of years you live
• Health span is how long you’re healthy enough to do the things that matter to you
• Longevity means maximizing health span and lifespan
• Our goal is to live longer and live better and it all starts with prevention...
2. Avoid Icebergs
• Medicine 2.0 (medicine today) deals with problems after they present themselves.
• Medicine 3.0 focuses on prevention over cures.
• We are trying to avoid icebergs in the distance
• It is better and easier to avoid the first heart attack than treat it after
3. The 4 Horsemen
• There are four major killer diseases: 1. Cardiovascular disease, 2. Cancer, 3. Neurodegenerative disease, 4. Type 2 diabetes and metabolic dysfunction
• Metabolic health is the common thread
• Exercise is our best prevention
4. Exercise
• Exercise is "by far the most potent longevity drug”
• Weekly:
• Weight training 3 days
• Zone 2 training 3 hours—Zone 2 training to stimulate mitochondrial function
• VO2 max training 1 day
• Get as fit as possible to prepare for natural decline with age
5. Marginal Decade
• You want to intentionally train for the activities you care most about continuing into your later years
• Build up the strength and stamina while young to combat the predictable decline as you age
• Want to ski at 80? You better be in top 1% condition at 50
6. Diet
• Avoid fads. Attia recommends Keto (hard) or Mediterranean diet (easier). More monounsaturated fats & less carbs.
• Avoid Standard American Diet: • Highly refined carbohydrates • Processed oils • Added sugar
• Eat more: • Real food • Avocados • Olive oil • Protein • Nuts
7. Diet Questions—Are you undernourished or overnourished? Are you undermuscled or adequately muscled? Are you metabolically healthy or not?
• Most have poor metabolic health, are over nourished, and are undermuscled.
• You want to reduce energy intake while adding lean mass.
8. Heart Disease
• Everyone 18+ has some degree of heart disease. Accumulating every day.
• Get your ApoB and Lp(a) tested. Those matter more than cholesterol.
• Goal: ApoB 20-30 (baby level)
• Impossible to get there with diet and exercise alone. 80% of his patients take statins.
9. Sleep 
•  Poor sleep impacts everything. It gives even seemingly healthy people "old-man blood": hormone and inflammatory levels of someone decades older.
10. Cancer
• Cancer is closely linked to metabolic dysfunction. Get healthy to avoid it.
• This chronic inflammation creates an environment that induces cells to become cancerous.
• Otherwise aggressive early screening is our best defense. Late detection is a death sentence.
11. Neurodegenerative Disease
• Most difficult of the horsemen. Medicine 2.0 can't do anything for us.
• What's good for the heart is good for the brain. Exercise & sleep are our best weapons.
• Exercise maintains glucose homeostasis and healthy vasculature.
• Sleep heals the brain.
12. Metabolic Dysfunction
• Basically an issue in your body's fuel processing. On a spectrum.
• Heart disease, cancer, and dementia are all built on metabolic disease. Each one is amplified by metabolic dysregulation.
• Exercise, diet, and sleep are our weapons here.
13. Emotional Health
• Emotional health issues are one of the biggest roadblocks to longevity in his patients.
• If you are not happy, why would you want to live a long time?
• Take care of your emotional well-being just like you would heart disease.
• It's ok to admit you need help.

References

1. Outlive: The Science and Art of Longevity by Peter Attia and 
2. Thread by @ColinKeeleuy on longevity
3. Exercise and Its Benefits (Travel to Health)
4. Exercise for Bone Health (Travel to Health)
5. Travel to Health website (link)

Nitrates/Nitrites in Foods and Their Effects

Hydroponics—Farming without soil, which uses less water

Nitrates in Plants

Several factors influence the accumulation of nitrates in plants, which include:

• Lack of sunlight or water, variety, maturity
• High levels of fertilizers
• Excessive use of nitrogen fertilizers should be avoided so as to reduce nitrate buildup in soil and vegetables.^[5] 
• Nitrate levels in the soil, and 
• Quality of irrigation water

Nitrate is nontoxic below maximum residue levels (MRLs), but if it reaches above this level, it "could" (see more details later) be dangerous due to its reduction in nitrites, which can react with amines and amides to produce “N-nitroso” compounds responsible for gastric cancer.^[5,6] High levels of nitrates in children stomach are also responsible for methemoglobinemia (blue baby syndrome).^[7,8]

The Healthy Route to Nitrite Processing

Certain vegetables contain nitrates, which break down into nitrites when eaten. Nitrites are necessary and life-enhancing, providing the nitric oxide we need to keep our blood vessels dilated, and minimize risk of high blood pressure. 

Studies have shown that nitrites packaged in vegetables can improve oxygen efficiency and delivery by dilating blood vessels, resulting in:^[1]

• lowered blood pressure
• improved breathing for those with Chronic Obstructive Pulmonary Disease (COPD)
• decreased age-related cognitive decline
• increased blood flow in those with Peripheral Artery Disease.

The Unhealthy Route to Nitrite Processing

If nitrites are so beneficial, how can they be so harmful when consumed in meat? The answer is not in the nitrites themselves, but in how they can be converted, under certain circumstances, into nitrosamines—recognized as one of the most potent carcinogens in the world.^[1]

Research is now clarifying that nitrosamines are formed when nitrites are consumed in the absence of plants (vs. meat), because phytonutrients found in plants can block nitrosamine formation. Because meat contains none of these plant phytonutrients, when nitrites are added to meat as preservatives and colorings, nitrosamines form in processed meat.

Summary

Because phytonutrients found in plants can block nitrosamine formation, it's safer to consume plants with nitrates/nitrites than meats with added nitrates/nitrites.  However, in order to maximize the health benefits from eating vegetables, measures should be also taken to reduce the nitrate and nitrite exposures.^[9] For example, 

• Vegetables must be stored and processed properly to prevent bacterial contamination and hence reduction of nitrate to nitrite.^[10]
• Consume vegetables with high phytonutrients contents vs. low phytonutrients contents.
• Avoid processed meat because nitrites and nitrates are added to processed meat to help them maintain that nice pink color:^[2-4]
• The problem is, in the presence of heat—especially high heat—nitrites can combine with amines in processed meat to form nitrosamines, and these are carcinogenic.

References

1. Effects of agriculture production systems on nitrate and nitrite accumulation on baby-leaf salads
2. EWG Releases Dirty Dozen Guide to Food Additives (Dr. Mercola)
3. Total N-nitroso compounds and their precursors in hot dogs and in the gastrointestinal tract and feces of rats and mice: possible etiologic agents for colon cancer.
4. No risk from nitrates in vegetables, says EFSA
5. Santamaria P. Nitrate in vegetables: toxicity, content, intake and EC regulation (review) J. Sci. Food Agric. 2006;86:10–17.
6. Savino F, Maccario S, Guidi C, Castagno E, Farinasso D, Cresi F, et al. Methemoglobinemia caused by the ingestion of courgette soup given in order to resolve constipation in two formula-fed infants. Ann. Nutr. Metab. 2006;50:368–371.
7. Greer FR, Shannon M. Infant methemoglobinemia: the role of dietary nitrate in food and water. American Academy of Pediatrics Committee on Nutrition, American Academy of Pediatrics Committee on Environmental Health, 2005. Pediatrics. 2005;116:784–786.
8. Chan TYK. Vegetable-borne nitrate and nitrite and the risk of methaemoglobinaemia. Toxicol. Lett. 2011;200:107–108.
9. Correia M, Barroso A, Barroso MF, Soares D, Oliveira MBPP, Delerue-Matos C. Contribution of different vegetable types to exogenous nitrate and nitrite exposure. Food Chem. 2010;120:960–966.
10. Leszczyńska T, Filipiak-Florkiewicz A, Cieślik E, Sikora E, Pisulewski PM. Effects of some processing methods on nitrate and nitrite changes in cruciferous vegetables. J. Food Compos. Anal. 2009;22:315–321.