T.A. Sciences® is dedicated exclusively to creating research-based, clinically tested wellness products that help address telomere shortening through the science of Telomerase Activation.
It’s always a pleasure to tap into Dr. Raffaele’s brain, and in this podcast he doesn’t disappoint. In fact, his practical contextualization of where we are with anti-aging medicine might just be one of the smartest you’ve heard yet. What is truly remarkable about Dr. Raffaele is not just his grasp of the field both scientifically and clinically, but his ability to apply a nuanced approach that is tailored to each individual patient. After all, as he eloquently points out, we must first figure out which of the many components of aging needs improvement or correction, then target our approach accordingly. The simplicity of that statement belies his firm grasp of the complex landscape of anti-aging assessments and interventions, as you’ll see.
One of the important topics that surfaced in our conversation is the role of telomere length. Dr. Raffaele has been measuring telomeres in study cohorts and in his patient population for well over a decade. Has looked at well over 2,000 telomere length measurements, many of them longitudinally. Not only that, but he has also integrated telomeres alongside other biomarkers of aging, including DNA methylation clocks, and tried-and-true metabolic markers such as lipids. So, if you thought newer approaches to biological age assessment were making telomeres and other assessments redundant, think again. We’re entering a time where we must wrestle with how to incorporate and act on all these important measures. ~DrKF
Epigenetic aging clocks have been having their time in the sun, but that doesn’t mean that we should dismiss telomere length and other biomarkers of aging. In fact, the number of scientific publications on telomeres to date still dwarfs those on epigenetics and other biomarkers. Not only that, all chronic diseases of aging have short telomeres as a risk factor.
In this podcast, Dr. Raffaele brilliantly contextualizes our journey towards better understanding the biology of aging. His ability to combine decades of science, together with his extensive practical clinical experience (his patients are a remarkable study cohort in their own right), leads us to start to understand just how all these different biomarkers and interventions can fit together within the anti-aging field. And, towards an increasing refined ability to apply “the right intervention in the right circumstance” to counteract inappropriately-advanced aging.
In this episode of New Frontiers, learn about:
- How to think about telomere length in context of other aging biomarkers, and even how telomere length helps inform their interpretation
- Interpreting telomere length results – when to act
- Telomere looping, and how it makes considering telomeres relevant even in your 20s or younger
- The heritable nature of telomere length
- Considering CMV for its effects on telomere length, immunosenescence, as well as risk for more severe COVID
- Understanding that not all tissues, and not even all cells within that tissue sample, will bear the same biological age signature
- How to interpret aging tests that might seemingly contradict, but in fact provide important information to nuance an intervention
- How those at the forefront of epigenetic clock development are starting to draw conclusions parallel to long-term telomere researchers
- How to select the right anti-aging intervention for each individual depending on underlying aging dysfunction
- Additional interventions in anti-aging toolkit such as rapamycin, TA-65, NAD, and hormone optimization
- Rapamycin – when to use it and when not to use it, and dosing considerations
- Connections between mitochondria, telomeres, and sirtuins, in the cont ext of DNA damage, and the ability of NAD to stabilize telomeres
- Jinfinity: a new option for measuring intracellular NAD levels (previously lacking as a direct measure)
- PhysioAge Health Analytics – a physician’s tool to track and interpret large amounts of patient aging data, and measure if interventions are working
Dr. Joseph Raffaele received his BA in philosophy from Princeton, his MD from Drexel. He trained at the New York Hospital Cornell University Medical Center, and was formerly a clinical assistant professor of medicine at Dartmouth Medical School while in practice at Hitchcock Clinic. He’s a member of the Endocrine Society, is board-certified in internal medicine, and is a diplomat at the American Board of Anti-Aging Medicine.
In 1997, he co-founded PhysioAge Medical Group, where he exclusively practiced age-management medicine with a focus on personalized hormone optimization, and physiologic age assessment. And we’re going to be focusing on this today, in 2007, he co-founded PhysioAge Systems, a web-based biomarker data collection and reporting system now used by age management practices around the world to assess, monitor, and communicate to patients the effectiveness of their treatments.
Since 2009, he’s been involved in clinical telomere biology research, and he’s published four studies of the effect of oral telomerase activators on normal aging adults. He’s lectured nationally and internationally on the clinical application of telomere biology. In 2015, he founded the Raffaele Medical Group and blogs regularly about telomere biology, hormone optimization, and biomarkers of aging on raffaelemedical.com, and physioage.com.
Dr. Raffaele: https://raffaelemedical.com/
https://physioage.com/ (Health Analytics)
Haycock study – telomere length and risk of cardiovascular disease
Dr. Raffaele’s publications regarding telomerase activation as a positive health maintenance intervention for impact on age-related biomarkers: 2011 and 2013
The relationship between epigenetic age and the hallmarks of aging in human cells Kabacik, Horvath and colleagues (May 2022)
Epigenetic changes during aging and their reprogramming potential (using Yamanaka factors) David Sinclair (2019)
Telomerase reactivation reverses tissue degeneration in aged telomerase-deficient mice DePinho (2011)
Axis of ageing: telomeres, p53 and mitochondria Sahin & DePinho (2012)
Dr. Raffaele on New Frontiers:
Immuno-Senescence: What Clinicians Need to Know
The Best Biomarker of Aging: What Clinicians Need to Know
Testing and Treating Telomeres: What Clinicians Need to Know with Dr. Joseph Raffaele
Dr. Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine and, of course, today is no exception. I’m very excited to be with Dr. Joe Raffaele. We’ve been podcasting together for years now. Let me give you his background. You’ll love our conversation. Actually, my conversations with Joe are always some of our top podcasts.
He received his BA from Princeton, his MD from Drexel. He trained at New York Hospital of Cornell University Medical Center. He was also a Clinical Assistant Professor of Medicine at Dartmouth. He’s a member of The Endocrine Society. He’s board certified in internal medicine and is a diplomat at The American Board of Anti-Aging Medicine. In fact, he’ll be at A4M in Vegas this year, along with me in December. In case you’re there, please do find us and say hello.
In 1997, he co-founded PhysioAge Medical Group, where he exclusively practiced age management medicine with a focus on personalized hormone optimization and physiologic age assessment. You know, you’re just a pioneer in this field, Joe. I mean, you’ve been doing this for a long time and you have a lot to teach us. Since 2009, he’s been involved in clinical telomere biology research and he’s published four studies, the effect of oral telomerase activators on normal aging adults.
He’s lectured nationally and internationally on the clinical application of telomere biology, and in 2015, he founded Raffaele Medical Group and blogs regularly about telomere biology, hormone optimization, biomarkers of aging. You can find him at raffaelemedical.com and physioage.com, and all of that information will be over on our show notes. Dr. Raffaele, again, welcome to New Frontiers.
Dr. Joseph Raffaele: Thank you very much, Kara. Great to be on here. As you said, we always have a great conversation and I’m happy to share it with your listeners.
Dr. Kara Fitzgerald: Yeah, and I just appreciate your commitment to the science. You’re always thinking, digging, expanding, and you’ve been doing this longevity medicine for a long time. It’s really popular now. Many, many people are turning their attention towards this. I’m thinking like Altos Laboratory and Bezos. There’s just a lot of attention. Oh, and like Saudi Arabia, they’re going to be funding their longevity research with a billion dollars annually. I mean, it’s astonishing, and you-
Dr. Joseph Raffaele: Wow.
Dr. Kara Fitzgerald: … I know, and you’ve just been in this space for a long time and you’ve got so, so much to teach us. You and I have been talking about telomere length. You’ve been looking at telomeres in your patients along with many other biomarkers for many years. It’s a good utility.
However, the upstart epigenetic clocks, like we used in our study, and I know that you’ve been using them looking at DNA methylation patterns, associated biological aging, have really kind of taken over the landscape. Telomeres are… Perhaps their sun has dimmed a little bit. However, I think we do not want to kick telomeres out of this conversation. They have a place, and I want you to talk about it, where they stand in their role in biology of aging.
Dr. Joseph Raffaele: Yes, so first I should say you’ve got to stop telling people how long I’ve been doing this.
Dr. Kara Fitzgerald: Well, not that you would know by looking at you.
Dr. Joseph Raffaele: Coming up-
Dr. Kara Fitzgerald: You obviously practice what you preach.
Dr. Joseph Raffaele: … coming up on 63, I’m starting to get a little worried about that, but thank you. Yeah, so the virtue or sort of, I guess, of being in the field for as long as I have is I get to see how things come and go to a certain extent and how things can be reborn, and you’re absolutely right. When I first started looking at aging, it was at the sort of challenge of Robert Butler, who was the head of the NIA at the time, The National Institutes of Aging. He said, “You call yourself an anti-aging physician, Joe. How do you know whether or not you’re really doing a good job with your patients?” I’m talking about how well they feel and all the great stuff that they’re telling me about and how their friends are saying they look great, et cetera. He said, “What’s your metric? How are you measuring aging?”
If you treat high blood pressure, you measure blood pressure, and so that set me on the journey to look at biomarkers of aging. Back then, there were many fewer, almost no molecular markers of aging. We were looking at things like skin elasticity, arterial stiffness, pulmonary function, cognitive function. There was really large databases of information about how those change characteristically over time.
Then, in the early 2000s, telomere biology started to come on the rise. The Nobel Prize was given out to Elizabeth Blackburn for her discovery of the role of telomeres in aging and telomerase. That was a pretty hot topic back then. It was thought about as being one of the big biomarkers of aging, that molecular clock that ticks, but the correlation with chronological age wasn’t quite… I mean, we thought it was relatively impressive then. Maybe R squared of 0.4 depending on the study that you’re looking at, which is still quite good. You consider a biomarker to be aging, even if it’s an R squared of 0.1 and perfect correlation is that one.
Then, these epigenetic clocks came along and they were, you know, Steve Horvath’s original one was correlating at 0.9 and higher, and few of them were at… like one’s at 0.98. They were saying, “Telomeres schmelomeres.” I don’t think I’ve ever said that work before, but these new clocks are so much better, so why should we think about telomeres? I get that, and so many studies were published because of the ability to look at epigenetics sort of retrospectively on data banks of samples, which you can do with telomeres, but with I think sort of the gold standard telomere measurement that I consider, Flow FISH. It’s a little bit tough. You can’t really do that as easily.
With this new biomarker coming out that was so hot, everybody started directing their attention to it, but I think what has happened with that is that we’ve kind of lost sight about the really pivotable role that telomeres still play in the biology of aging and how it actually really is still, I think, a linchpin in the aging process. You can’t ignore it.
Dr. Kara Fitzgerald: Yeah. I want to say that when you and I talked early on, and I was in the middle of my study and we were looking at the original Horvath clock because none of the second and third generation clocks were available at that time, but I was all about DNA methylation epigenetic clocks. I, at that time, naively thought that they would supplant telomere measurement. Absolutely I was convinced, and I look back with a degree of embarrassment because telomeres are rich and there’s a massive database so much greater than what we’ve got on epigenetic clocks. I want you to just speak to some of that. How are they useful? How do we want to use telomeres along with epigenetic clocks in our clinical practice?
Dr. Joseph Raffaele: Yeah, so I think that I use as many tools as possible. I say that to start it out, but just in terms of telomeres, you’re right. I don’t remember the exact citation, but there was a sort of chart of time and number of publications looking at telomeres, epigenetic clocks, composite physical biomarkers, and I think one other type of way of measuring aging over time. The Y axis was the number of publications and the X axis was time. And telomeres were far greater than any of these other ones in terms of numbers of citations, tens of thousands of them. Whereas, epigenetic clocks was lower, but much more sort of current on the X axis.
So there is a whole lot more information out there. I mean, every chronic disease of aging has many, many papers showing correlations with telomere length, mean telomere length and the average telomere length (mean or median telomere length). For instance, cardiovascular disease has a nice study by Haycock that looks at the length of telomeres. In a sort of graded fashion, there’s an increase in cardiovascular risk with the shorter telomere length that you have. Same thing actually for cancer and for diabetes, for COPD, so many things. All the chronic diseases of aging have short telomeres as a risk factor for them, and you get disease earlier and more severely if you have short telomeres.
The reason for that is because telomeres are sort of what I call your sort of biological 401(k). It’s how much reserve you have built into your stem cells, into your white blood cells, and into the tissues, the cells of the tissues that are highly proliferative like skin and gut, et cetera, that to just sort of deal with the slings and arrows that you’re exposed to over the course of your lifetime or what we call now the exposome. Either it’s stress, physical, psychological, infectious, viral, bacterial, cancer, you name it. Anything that causes cells to be stressed, to die, and then have to be replaced is going to involve telomere biology.
If you have really short telomeres, you have less reserve, just as if you have a really small 401(k), your ability to have a nice, long retirement living in good fashion, the analogous thing would be a good, long health span, is going to be shortened because you don’t have that reserve there. You’re going to come up short sooner if you don’t have the longer telomeres.
Dr. Kara Fitzgerald: Well, let me ask you this. Okay, not to bring up the length of time you’ve been practicing anti-aging medicine or age management medicine, you’ve been looking at telomeres for a very long time, so you’ve seen thousands of patients. Through the course of an individual’s given treatment you’ve looked at telomere length, and you’ve been able to favorably change it. I know that you have, and maybe talk a little bit about how you do that, but how does it correlate clinically in your years of experience?
Dr. Joseph Raffaele: Yeah, so I started measuring telomere lengths in a cohort study here that we published two papers off of in 2007. We started the cohort study, published the papers in 2011 and ’13. We looked at a group of people. We measured multiple biomarkers from the organ level to the tissue level to the molecular level, and telomeres being one of them and immune system function being another prominent one. Over the course of the last, say, 15 years or so, I’ve been, well, 12 years, I guess, been looking at telomere length in a good majority of my patients.
It’s a not inexpensive test, so I don’t necessarily run it in all my patients, and some of my patients are on the younger side as well. I’ve looked at probably well over 2,000 telomere length measurements, and many of them in longitudinally over a decade in some patients, even longer in patients like myself. You get an idea about what information telomere length gives you, and I would say that at this point, a really good analogy would be telomere lengths to cholesterol.
In 2011, I blogged a little piece about telomeres being the next cholesterol, and I sort of opined at that point that because of all the data that was out there correlating chronic disease and particularly cardiovascular disease with cholesterol, shortened telomeres being almost as big a risk factor if not slightly bigger than just total cholesterol for cardiovascular disease risk. I opined that we would be doing it as regularly in patients as we do cholesterol now, and it’s now, whatever, 11 years later and we’re still not doing it as regularly. I think one of the reasons is that I think median telomere length is sort of like total cholesterol. While it is at the extremes definitely indicative of increased risk of high cholesterol and increased with very, very short telomeres, and decreased risk with longer telomeres under really, really low cholesterol.
It’s not as granular a test as we would like it to be. For instance, in lipid biology, now we look at LDL, not just total cholesterol because somebody’s total cholesterol would be very high if their HDL is very high then their cardiovascular risk is not that bad or actually is relatively low. Now, we look at things like LDL. Then, we look after that to get more granular at LDL particle size, too look at the small, dense LDL. Then, we looked at thing like lipoprotein (a), which is sort of one of the major biggest risk factors for cardiovascular disease, probably the biggest one in lipids.
While we have that technology in research to look at things like the critically short telomere or break it down between the different kinds of blood cells that we’re looking at telomeres in, not just the generic white blood cells, that’s available and I think it gives us much more information. Clinically, that’s not available yet. A couple of places do 20th percentile telomere length, which is a little bit better, but correlates pretty closely with median telomere length.
I think that the reason I get it in everybody is because if you have really, really short telomeres, that’s something you want to know. If you have really long telomeres, that’s great. I mean, it doesn’t mean you should go out there and smoke and drink and not exercise, but it means that you have sort of probably a degree of cushion for losing telomere length that you don’t have otherwise. I’ve seen this in my practice. I’ve seen 50, 60-year-olds come in with telomere lengths of a 20-year-old because they won the telomere lottery. Telomeres, by the way, are highly heritable, about 70% heritable, even a little bit higher than that.
Dr. Kara Fitzgerald: Huh. Interesting.
Dr. Joseph Raffaele: Yeah. I mean, very, very heritable, and likewise I’ve seen young people, I had a 39-year-old with the telomere length of a 70-year-old. She didn’t know that. She had a little bit of premature graying and a strong family history of cardiovascular disease, but putting that, you know, giving people that information is, I think, helpful and also allows us to interpret some of the other biomarkers that we do as well. I think that’s kind of where I would put it at this point. I think you’re right. The latest kid on the block, the epigenetic clocks, have… and now, the metabolome and the proteome is becoming more available and is probably going to start maybe supplant even potentially some of these clocks, or at least give them a little bit of a run for their money.
I think the key take home that I have from looking at all these biomarkers of aging in patients over the years is that all of them give very good and important information. None of them is the end all and be all. There isn’t. I don’t think there’s… You’ve heard me say this before and I’m going to repeat it, and I think your other guest, Dr. Levine, would also agree. There’s no single perfect biomarker to aging because aging occurs at different rates between individuals, within individuals in different tissues, different organ systems.
I’ll have a patient come in, and this more than norm. We look at nine major biomarkers for aging, from lungs to arteries to cognitive function, brain, to skin, to body composition, and then on down to telomeres and epigenetic clocks. We talked about GlycanAge before for immune system, inflammatory potential. Patients can be 10, 15, even 20 or 30 years below their chronological age on one of them and the opposite on another one of them, and patients are like… This could happen with multiple different ones. It’s rare that you come in with somebody that’s 50 years old and all of them are within five years of their chronological age.
Patients will say, “Well, what does that mean? Does that mean that these are just junk and they’re not right? They’re giving me bad information? Which one of these is right?” Of course, they want to choose the ones that are younger as the right ones for them. No, the answer is really that, yes, your lungs were not endowed with as much reserve capacity as your arteries were. That’s just you genetically and what’s been happening to you over the course of your life. That could be the case for somebody who runs and smokes, okay. Their lungs are not doing as well from the smoking, but they’re keeping their arteries a little bit healthier from the running.
I mean, it is really a combination of all of these things that you see, which then allows you to target your interventions toward the organ system that is most in need of care. Now, it turns out that a lot of these things have beneficial effects in multiple different organs, just as bad habits have deleterious effects in multiple different organs. Seeing that whole range of different biomarkers of aging being high and low, that’s the norm, and I can say that with some confidence having looked at… I now have hundreds of patients with the full panoply of biomarkers done on them, and you really see that that is the norm.
Dr. Kara Fitzgerald: That’s just a really great, very well-stated explanation of your clinical experience. Of course, we’re looking at clocks these days. We’re looking at multiple clocks when we order them from TruDiagnostic. I know that everyone wants to focus on the one that’s the youngest and sort of rest there, but to your point, we need to look at all of this information and drill down and work on our given areas of imbalance. I appreciate you saying that you don’t see all of the biomarkers as uniformly very young or uniformly very old. It’s always a mix. I think that’s underlying, exclamation point really important.
By the way, you know that third generation DNA methylation clock is the Pace of Aging, and that’s a compilation of biomarkers, or maybe not most, but a lot of them, and actually, maybe most. I’d have to do a side-by-side checklist of what you’re already looking at in your practice.
Dr. Joseph Raffaele: It’s pretty close, yeah, from the Dunedin cohort. Yeah, so that’s the thing that I would say, and I think Morgan Levine also talks about the PhenoAge and then add to that blood pressure and pulmonary function and the other things they looked at in the Dunedin cohort hemoglobin A1C, that clock’s about as good in terms of predicting health outcomes and mortality as these other ones that correlate with chronological age much more highly because correlating perfectly with chronological age is useless. I mean, why don’t you just use chronological age? It’s the different between chronological age above or below the age acceleration when it’s above and deacceleration when it’s below that’s important.
That’s what that new clock, the Pace of Aging clock is, that third generation clock, is picking up, and it’s a really interesting tool. I mean, I think it needs, as all these clocks do, more validation with actual markers from practices like mine or other cohorts so that you know what to do with it. I found it really fascinating in this paper that just came out by the clock mavens themselves, Steve Horvath and the first author was Sylwia Kabacik, that’s how you spell it. It was a paper looking at human tissues in-vitro and looking at the hallmarks of aging very closely and looking at the epigenetic clocks using the skin and blood clock.
I won’t go through all the details, but what he said in the end was that this clock correlated very nicely with nutrient sensing, one of the hallmarks of aging or deregulated nutrient sensing, depending on which nomenclature you want to use, mitochondrial function, stem cell exhaustion, and altered cell communication or intercellular communication. It did not seem to correlate at all in these tissue experiments, and they were very controlled, very, very elegantly done studies with genomic instability, telomere attrition or cellular senescence, three of the big, major players. They admit at the very beginning of the paper that telomere attrition and cellular senescence are absolutely major factors in the aging process.
Dr. Kara Fitzgerald: Yeah.
Dr. Joseph Raffaele: What he said at the end was, “Look, we have this initial excitement about these clocks has been a little bit tinged about by this question of, what does it mean when you have the clock giving you this information? What does it mean when you change this?” Now, yes, there is correlation with multiple different outcomes and there’s been validation sets that have been done, and I don’t think it’s just like gray hair that’s sort of there tracks along with time, but doesn’t really mean anything. Absolutely not.
That’s absolutely not the case, but this change in epigenetic landscape in DNA methylation that takes place, what he says in this study that it is not, whereas, as you might think it’s actually change in actual CPGs along the deep methylation of CPGs along the DNA. What he thinks he’s picking up more from these elegant clone studies is that it’s a change in the cellular composition of that tissue. Now, think about that. That’s a big statement from the epigenetic clock guy, right?
Dr. Kara Fitzgerald: Yeah.
Dr. Joseph Raffaele: It’s not actually that the DNA methylation pattern is changing, or at least we haven’t been able to measure that at the single-cell level, but it’s that the tissue might have some stem cells in it that have younger epigenetic age versus some exhausted T cells if you’re looking at peripheral, the white blood cells, not at actual tissue. Looking at the composition of the tissue that you’re looking at, that’s actually very close to what’s happening with telomere biology where looking at the… You’re looking at white blood cells, so you can maybe break it down into granulocytes and lymphocytes now if you use Flow FISH.
All lymphocytes are not the same. B cells have longer telomere lengths than effector memory cells that have been around working on fighting off viruses, et cetera. Naïve T cells have longer ones, so the composition of the lymphocytes in your circulation is really what you need to look at. To look at actual change in telomere length, you need to look at just the naïve T cells, just the senescent suppressor cells.
I was really shocked and amazed by the parallel between what Horvath was saying about epigenetic clocks and the tissue composition and what’s been known and better appreciated about telomere length. Maybe this is going to start coming around again if the technology becomes available for looking at single-cell telomere length. It’s available, I mean, it’s called STELA (single telomere length analysis). It’s available, but just in a research setting, and if we can get those available, then we’ll be able to see and have another clinical tool sort of akin to LP(a) and its improvement in prediction over total cholesterol.
Dr. Kara Fitzgerald: No, that’s pretty interesting. I mean, I just… Yeah, and clearly the price will need to drop down to-
Dr. Joseph Raffaele: For sure, yeah.
Dr. Kara Fitzgerald: … be commensurate with lipids. That would be amazing and covered by insurance, but yeah, yeah, yeah. I’m all for that. I have a couple of thoughts on what you’ve just said. The first one is, and folks, yes, the links to these papers will be in our show notes, so you can go and grab that Horvath March 2022 paper. The first… Is that the paper you just referenced? Excuse me, May..
Dr. Joseph Raffaele: Is it… Yeah. Well, it was… June is the actual, but online was May, right.
Dr. Kara Fitzgerald: Okay, okay. The first thing is continue with our broad clinical investigations that we do on every patient. Don’t lean into one biomarker associated with biological age as your primary investigation, so blood pressure matters, lipids matter, you know, the beautiful lipid panels we’re able to access these days, CRP, et cetera. You know, grip strength, just all-
Dr. Joseph Raffaele: Sure.
Dr. Kara Fitzgerald: … of our tried and true biomarkers continue to be very important, and I think what you’ve just said hits that home. The other piece that I want to ask you is this paper seems to suggest that these changes to the DNA methylome are response to cellular environment changes versus drivers of the cellular aging. I mean, is that what you glean from the paper? Is that accurate?
Dr. Joseph Raffaele: Well, I’d say… Well, so it’s an interesting paper because it’s a very dense and obviously it was a huge amount of work to do. When you say environment, what they did was it was all in-vitro and they subjected the cells to either control medium or then irradiation to look at genomic instability, then to factors that cause cells to go into senescence through stress. It was a RAS oncogene stress, and then they also let another one of the cell populations go through just replicative senescence where they just doubled and doubled and doubled.
You have the three different ways in which you can cause cellular senescence and cellular aging. What they found was that… That’s sort of the environment that you’re talking about. It wasn’t an actual cellular environments, the kind of stresses that cause cells to age from either senescence standpoint, telomere attrition standpoint. What they found, which was really, really fascinating, was that the epigenetic clock ticked along moving the-
Dr. Kara Fitzgerald: Reflecting the changes.
Dr. Joseph Raffaele: … right, right, exactly, unless, particularly in a replicative aging one. Yes. There was the epigenetic clock was ticking along, but in the ones that were just in-vitro that had been subjected to just a week, or I forget how many days it was, of irradiation, which caused a lot of “aging” of the telomeres and drove senescence, it didn’t actually age the epigenetic clock, so-
Dr. Kara Fitzgerald: That’s so fascinating
Dr. Joseph Raffaele: … that’s actually happening, which is really the fascinating thing. I think the take home from me from all of this and from what I’ve been reading is that aging is getting more complicated. I mean, we knew it was complicated-
Dr. Kara Fitzgerald: Yeah, yeah, yeah. Well-
Dr. Joseph Raffaele: … but now we know enough to know that it’s even more complicated than we thought it was.
Dr. Kara Fitzgerald: Yeah. Yeah, yeah, yeah. It’s definitely complicated, squared, logarithmic, but listen. They only looked at skin and blood clock though. Is that right? I mean, why didn’t they look at the other clocks?
Dr. Joseph Raffaele: Yeah, I think they said that they settled on it, I think, because it was that it outperformed the other epigenetic clocks in its reliability in an in-vitro experiment-
Dr. Kara Fitzgerald: That’s interesting, oh, okay, okay, so they didn’t get to because… You know, all the clocks are looking at different CPGs.
Dr. Joseph Raffaele: That’s-
Dr. Kara Fitzgerald: I mean, there’s some overlap.
Dr. Joseph Raffaele: … that’s absolutely right. Sure. Absolutely true.
Dr. Kara Fitzgerald: Okay. All right, so that’s interesting. All right, so then my other question, and I want to talk about root cause aging or upstream cause of aging and kind circle back to telomeres, but I also want to bring up David Sinclair’s work using Yamanaka factors, which directly address epigenetic changes. That’s how you create inducible pluripotent stem cells. You layer the transcription factor, Yamanaka factors, onto them. In their lab, they created aging, they created an aging model in mice, and then they reversed it using Yamanaka factors. They did this in mice themselves, and they also did this in an optic neuropathy that they created. They basically made aging in the eyes and in mice and through epigenetic manipulation, and then reversed that using Yamanaka factors.
That would suggest in a way, to me, that these changes to DNA methylation and other epigenetic processes are really kind of root cause, and then all the cellular stuff is downstream, and that would include telomeres. What I’m hearing you say is that maybe not, or maybe it’s a combination and the epigenetic changes are response to changes to the cellular environment, which makes sense. It really makes sense. I want to hear what your thoughts are on what I’ve just put out to you, and then I also want to see, where is telomere dysfunction in terms of root cause of aging or upstream cause of aging?
Dr. Joseph Raffaele: Yeah, so I haven’t read… I’ve heard of those papers. I haven’t read them in detail, so I don’t know the details of them. I’ve always been concerned about using Yamanaka factors and people thinking of them as sort of age reversal. I mean, I think of them more as de-differentiation factors rather than actual age reversal because you’re taking a cell from a differentiated state and moving it back into a pluripotent state.
Dr. Kara Fitzgerald: You can control that, though, so that’s what they did. They didn’t use… I think they used three of the four and they didn’t bring it all the way back to pluripotent stem cell status. They clearly stopped. Okay, go ahead.
Dr. Joseph Raffaele: I think that there are many different ways to “skin the aging cat” is what I would say from that because I’m thinking about, for instance, they did sort of a similar thing from a telomere standpoint in Ron Depinho’s studies when he was at Harvard in 2011. They took a mouse that was a knockout mouse for… I believe it was TERT, an aspect of telomerase, and then allowed it to age more rapidly. Then, because of the way in which they set it up, giving him a molecule, and it happened to be Tamoxifen, to turn it back on caused actual reversal of aging. I mean, the gray hair, the shrunken testicles, the smaller brain, the smaller spleen, the fur, the skin, the subcutaneous fat all went back to a younger mouse. That is age reversal, no question about it.
Dr. Kara Fitzgerald: Yeah.
Dr. Joseph Raffaele: I would love to have had that same experiment repeated looking at the epigenetic clocks of various tissues and of white blood cells in these animals to see what took place. Did he have accelerated epigenetic aging with the lack of telomerase that brought the aging phenotype? Then, when you turned on telomerase again, did you get a reversal of that epigenetic aging? I mean, what Horvath’s paper says or suggests is that that wouldn’t necessarily take place based on these in-vitro studies, but it’s more complicated than that because we’re now… I’m learning, other people knew for a while, but I’m learning that all of these things interact in very complicated ways.
From his lab, Sahin has looked at the relationship between mitochondria, telomeres, and sirtuins and the NAD metabolome and it turns out that they’re intimately linked. If you get damage to DNA, which turns on the DNA damage response, either through replicative senescence, short telomeres, or through just stress like irradiation on the telomeres, even in a post-mytotic cell, then you turn on the DNA damage response. You turn on p53, which then turns down the master mitochondrial biogenesis regulators, PCG-1 alpha and beta, and that, then, causes an increases in reactive oxygen species. You get cells that can’t divide and don’t have good energetics.
That in turn causes problems with sirtuins. The sirtuins then as the NAD levels go down and the sirtuins, which are important for maintaining telomere health, can actually get repressed by PGC-1 alpha and beta. You get sort of a vicious cycle where that gets worse and worse. Interestingly, if you give NAD in that model, and once they’ve gotten short telomeres, then you can slow down that process, stabilize telomeres, and then prevent the fibrosis of the liver that takes place in that model system that occurs if you don’t have that.
There’s a number of different ways that you can turn things back depending on which one’s gone awry. I think they’re all interrelated, and so I’m not surprised about the results that you were talking about. I just think there’s different ways that you can go about it, but that’s what else makes it complicated because you have to apply the right intervention in the right circumstance. Which problem is it? Is it short telomeres? Is it mitochondrial dysfunction? Or is it the fact that NAD is being chewed up by macrophages’ upregulation of CD38? It’s a number of different things that take place, and so as a clinician, that’s when I sit back and I say when people are like, “Oh, let’s take rapamycin,” or, “Let’s take NAD,” or, “Let’s take a telomerase activator,” just because it’s been good in some animal models and maybe it shows some correlation in observational studies in humans.
In the individual that’s about to consider doing that, is that the right intervention? Well, you don’t know unless you measure these things and take a look and see. That’s where I think clinical longevity medicine, which I guess is the latest term that we use for what I do-
Dr. Kara Fitzgerald: Right, right.
Dr. Joseph Raffaele: … gets… you know, is put to work at looking at these markers and trying to figure out, what is the right way to go about it? For instance, I’m very grateful that you did this when you were too busy with your book, I think, and we had that meeting with Sapere Bio-
Dr. Kara Fitzgerald: Right.
Dr. Joseph Raffaele: … and they had a new test to look at another way of looking at senescent cell burden. We started an IRB registry here to look at patients in our practice getting this test, which looks at p16, which is a cell cycle inhibitor that is thought to be one of the major markers for senescence, although there is no single major marker for determining whether a cell is senescent or not. Certainly this is one of the top markers.
We look at that and then we look at a couple of other things that balance, these balancing factors, whether or not the cells have a lot of proliferation taking place, looking at CD28, whether or not they’re exhausted. Looking at another marker called LAG-3, and looking at whether there’s a lot of autophagy inhibition, which is sort of a marker for whether there’s high mTOR activity. We’ve gone through about 50 patients at this point and looking at the results and the algorithm based on sort of the model that we have of what’s going on with these markers and how they are informed by clinical studies is that about 10 or 15% of the patients really should try to avoid rapamycin because they don’t have a lot of senescent cells and their… Senescent is… You know, senescent cells aren’t all bad. They’re the major tumor suppressor mechanism.
Those people could be at increased risk for cancer and cardiovascular disease. I’ll talk about why cardiovascular disease if you want me to, but certainly cancer because they don’t get enough senescence going on. They have probably some mutations in the promoter to p16 that doesn’t allow them to turn on appropriately the cell cycle inhibitor when the cell is pretty damaged. Likewise, there’s people who are like, “Get that person on rapamycin.” They’ve got a lot of autophagy and inhibition, got a huge burden of senescent cells, but if you’re just out there thinking, “Well, I read in the latest or heard in the latest podcast that rapamycin is the next best thing since sliced bread to keep me alive longer,” that may not be the case for you.
Dr. Kara Fitzgerald: Right. Right. God, that’s really interesting, so… All right, so you probably don’t have anything that you can report on this observation clinically? You know-
Dr. Joseph Raffaele: You mean in terms of-
Dr. Kara Fitzgerald: … you think you’re using it or not using given the-
Dr. Joseph Raffaele: Right. No, we only
Dr. Kara Fitzgerald: … phenotype?
Dr. Joseph Raffaele: … we’ve only just been… We just took a while to get the IRB up and going. We have 50 people and we’ve gotten baselines. Not everybody, I mean, I’d say I have about eight, nine people now who started rapamycin, and I have just a couple that are cooking with their follow-up tests, so I don’t have results to report on it yet.
Dr. Kara Fitzgerald: How are you dosing the rapamycin?
Dr. Joseph Raffaele: We’re doing four to six milligrams depending on size once a week-
Dr. Kara Fitzgerald: Once? Okay.
Dr. Joseph Raffaele: … for eight weeks-
Dr. Kara Fitzgerald: Okay, so-
Dr. Joseph Raffaele: … which is sort of in the ballpark of what a number of other studies have done.
Dr. Kara Fitzgerald: Yes.
Dr. Joseph Raffaele: You know, six is the number. Some go to eight, some four. I know other people have used one milligram daily, but I think the thought is that the pulse and with the half-life of rapamycin, you want to go to drug-free after a week until you start your next dose.
Dr. Kara Fitzgerald: All right, so that was just… I’m just really appreciating your work here. Couple of questions. One, you worked on developing kind of an AI system for tracking all of the various biomarkers. Isn’t that correct? Are you using that?
Dr. Joseph Raffaele: Well, yeah. I mean, you’re referring to PhysioAge Health Analytics, which is like my little baby.
Dr. Kara Fitzgerald: Yeah. What’s going on with that? Are you inputting all of this massive-
Dr. Joseph Raffaele: Yes.
Dr. Kara Fitzgerald: Okay.
Dr. Joseph Raffaele: That’s the thing, so harkening back to this whole idea I started with Bob Butler is that you really can’t practice personalized evidence-based at that time anti-aging medicine unless you’re measuring what you’re doing and you’re measuring the effects of what you’re doing. The data that came out of the cohort trials that we did sort of was really interesting in terms of these biomarkers and how they correlated with age. Along with a Stanford PhD in genome technology Jochen Kumm and one of my colleagues at the time, an MBA, Jerry Fortunato, we started this company to help doctors in my field measure on a personal and granular level the aging process in their patients so they could tell whether or not their intervention’s been working.
That in a nutshell is the mission of PhysioAge Health Analytics, but for the individual, what the idea is, is to be able to get as close… I’m sorry, not the individual. We talked about the individual. Really, the idea, the other sort of benefit of it is that this is all being collected into a single database. We have 60 sites using it around the world at various places, and so uploading all of that data into one system allows each of the practices to see how well they’re doing in they’re doing in their population, and then also to show each individual how well they’re doing.
Then, we have this massive database that’s growing. I mean, massive is..It’s a unique database in that… what’s the word? The complexity of the tests that we’re doing, the GlycanAge, the DNA methylation, the telomeres, et cetera, is not done on a lot of individuals in, I think, any databases that I know of right now.
Dr. Kara Fitzgerald: Right.
Dr. Joseph Raffaele: I would not say that we’re yet doing any AI on it. We have… We’re collecting data. We have algorithms in there that help the doctors sort of think about things like, “If X, Y, and Z are true about your patient, then you might want to think about this,” but we’re not making true AI biostaticians, bioinformatics types work on it, but I am collaborating with GlycanAge in an early study to look at the effect of what we’re doing on the GlycanAge.
We’ve sent some data into TruDiagnostics, that I know you’ve worked with, to see what’s happening with body composition from our database to add to some other databases to see how epigenetics can predict body composition. Trying to contribute to the greater knowledge, but while at the same time helping patients and practices understand what they’re doing with their patients and how well they’re performing.
Dr. Kara Fitzgerald: In the show notes we’ll put in contact information so if clinicians want to participate with PhysioAge, they can access it. They can access you and use it. Is that possible?
Dr. Joseph Raffaele: Yeah, yeah. That’d be great. I mean, we’re always looking to increase the number of doctors, and… Now, I like to think of PhysioAge while it’s not a full-blown medical record, and at some point it may be, it may have to be, but I created it because it’s what I needed to practice the kind of medicine I want to practice. For me, it’s the true meaningful use because I can look at… I’m using it every day with my patients. I can at just a glance look at all these markers and see how interventions have affected each of them individually and in groups of them so that I know. Then, I can also look at my whole practice and say, “Oh, you know, I’m doing a pretty good job with getting hemoglobin A1Cs down.”
The average person in my practice has a GlycanAge that’s 15 years younger if they’re a female and 25 years younger if they’re a male. What can I do to improve that? Who are the ones that aren’t doing as well? Why are they not doing as well? If there’s some new technology that I’ve read about, I can at a glance, well, not a glance, but a quick keystroke or two look for people who fit the criteria that might benefit from that new approach, either lifestyle, a diet, pharmaceutical, supplement. That’s what I think the EHR should be doing for doctors-
Dr. Kara Fitzgerald: Yes-
Dr. Joseph Raffaele: … and patients, not-
Dr. Kara Fitzgerald: … of course, it’s not.
Dr. Joseph Raffaele: … what it’s currently doing.
Dr. Kara Fitzgerald: Right, right.
Dr. Joseph Raffaele: Right.
Dr. Kara Fitzgerald: Man, that is so, so, so interesting. God, I want to… I’d love to do a webinar with you on it and just really walk through.
Dr. Joseph Raffaele: Yeah, that’d be great. That’s be fun.
Dr. Kara Fitzgerald: Wouldn’t that be so cool?
Dr. Joseph Raffaele: Mm-hmm.
Dr. Kara Fitzgerald: Everybody wants to know… You know, there’s a lot of clinicians listening to this podcast, but of course, there are a lot of just savvy consumers who want to get ahead of the curve. You’re really individualizing based on the myriad tools that you’re using to work up individuals, but there are core products that you’re going to time and again. Now, I’m going to just kind of put you on the spot. What are the interventions that you’re finding most people respond to regardless of their phenotype?
Dr. Joseph Raffaele: Yeah, so you’re… What’s the term? You’re asking me what my stack is? Or-
Dr. Kara Fitzgerald: Yeah.
Dr. Joseph Raffaele: … what do I prescribe for patients? Well, you know, look, it is, as I mentioned, it depends on where you are in the aging process. That really can be very different from your chronological age and different for your chronological age in one system versus another, and so I want that information. I mean, look, I do a lot of hormone optimization, and what I’m fascinated by is how these new technologies for measuring aging are really validating that hormone optimization is anti-aging. I mean, it’s really crazy how these epigenetic clocks are showing that menopause accelerates aging by these epigenetic clocks – that premature menopause does, surgical menopause does – and then people on HRT, it decelerates it.
Likewise with probably the newest one, which is the GlycanAge. I mean, you see people with low estradiol levels, be they male or female. Their GlycanAge is going to be higher even if they’re doing good things with body composition, et cetera. I look at that because that… I’m still… I will never stop being fascinated by how important, how much effect hormones have on individuals, how they feel, how they function, and how they age. That being said, there’s many other things to do along with it. I mean-
Dr. Kara Fitzgerald: Well, how often are you using TA-65? I’m a fan of it and I haven’t actually measured my… Well, I’ve looked at the DNA methylation telomere clock, but I haven’t measured them directly.
Dr. Joseph Raffaele: Shame on you, Kara.
Dr. Kara Fitzgerald: I know.
Dr. Joseph Raffaele: You got to come here. We’ll send you-
Dr. Kara Fitzgerald: I know.
Dr. Joseph Raffaele: … a kit.
Dr. Kara Fitzgerald: I know, I know.
Dr. Joseph Raffaele: We’ll send you a kit.
Dr. Kara Fitzgerald: I know. I know I need to come there. I know. I was supposed to go there at IHS, and then-
Dr. Joseph Raffaele: Right.
Dr. Kara Fitzgerald: … something-
Dr. Joseph Raffaele: Yeah, something happened.
Dr. Kara Fitzgerald: … happened. I know I need to go there.
Dr. Joseph Raffaele: I would probably have every one of my patients on TA-65 if it weren’t for the cost. I try to do it… I say to patients, I give them sort of a continuum. After we measured the telomeres, then also we looked at the senescent cell burden from a lymphocyte subset standpoint that if you have a lot of CD28 negative suppressor T cells, then you probably have a lot of senescent cells. You have a lot of viral burden and your immune system’s not going to be functioning as well. It’s going to put you at increased risk of severe COVID, and so I will say you really want to get on that, and if you have to drop something else to get on that, you should get on it.
Other patients are sort of, depending on their age, if they’re 60, 70, 80, their telomeres aren’t going to be as long as they used to be. It’s good to get on it under those circumstances. Then, as I said, there are young patients who have telomeres of a 70-year-old, and once you measure that, it’s important that they try to do the most they can to keep them from getting shorter. I have many patients who have stable telomere length over a decade. Hasn’t gone down. I have a number that have gone up, some that have gone down, and perhaps I think probably less rapidly than they would have otherwise.
I certainly do that, and there’s some other interesting studies that show that it’s not just the critically short telomere or even the mean telomere length that is the most important thing. There’s this phenomenon called telomere looping over long distances where to have a telomere long enough way before you’re going to cause a cell cycle arrest or senescence because of short telomeres that when it gets a little bit short, it can now no longer loop back up to 15 megabase pairs from the telomere to turn on or turn off a gene. You could argue that there’s perhaps an optimal telomere length for each person and that letting it get shorter might not… Keeping it from getting shorter even in your 20s or perhaps even younger might be beneficial.
Now, I don’t recommend that just yet, but I could see theoretically how that might be a way to go because of the importance of it’s not just a ticking clock. It does things like regulates your epigenome, gets regulated by your epigenome, also is a marker, is a sort of barometer of oxidative stress. Telomeres, I think you asked earlier, how upstream are they? I would say they’re pretty much at the top of the upstream, and that’s why they’re in the top three of the hallmarks of aging along with genomic instability and epigenetics. Those are sort of the top three.
Dr. Kara Fitzgerald: The top players. Yeah, I’m bullish on TA-65. I think it’s doing… You know, the focus is on its influence of telomerase, but I think if hopefully they’re doing, and you would know, if they’re looking at epigenetic changes and not just the clock. There’s a heck of a lot more going on than just the various CPGs selected to demonstrate biological age that we can look at, and we will eventually publish on some of those other findings-
Dr. Joseph Raffaele: Oh-
Dr. Kara Fitzgerald: … in our research.
Dr. Joseph Raffaele: … interesting. You looking at that now? That’s great.
Dr. Kara Fitzgerald: Yeah, yeah. We profoundly changed promoter region methylation in our study population big time as compared to controls and towards a healthier pattern, so gene body methylation tends to drop in the aging journey and promoter region tends to become hypermethylated. Genes are turned off, but then these crazy gene bodies like oncogenes and so forth tend to get turned on. We were able to shift that, so I need to do a drill down into exploring the various genes we shifted it on, but yeah, it’s a paper that I would love to write. Before we do that, we’re actually publishing on a case series of women who finished our program-
Dr. Joseph Raffaele: Oh, great.
Dr. Kara Fitzgerald: … so that’s first. Yeah, it’s pretty exciting, and the Pace of Aging has been… Our interventions have shown response in the Pace of Aging Clock, which is pretty cool.
Yeah, so TA-65, I think it’s an important compound and something that I’ve been taking in the morning for probably since we started talking. I don’t know, maybe before then. We’re wrapping up. I feel like we could talk for another hour. I want to ask you just about NAD and whether that’s kind of a workhorse supplement in your practice for many individuals. Are you being more select in who you prescribe it to? Then, beyond that, I just want to ask you any final comments. I know we were going to chat about COVID and CMV and the relationship to telomere length, but whatever you want, so NAD and then final thoughts for our podcast today.
Dr. Joseph Raffaele: Well, great. Yeah, so NAD is something that… you know, one of the hot substances, obviously, out there and particularly because of David Sinclair’s popularization of it in his book. Then, there’s a lot of very valid science. As I mentioned, some interesting studies about supplementing with NAD overriding this problem with the short telomeres and stabilizing them by helping the sirtuins again because sirtuins are NAD-dependent enzymes. For me, again, back to my whole sort of mantra, which is if you can’t measure it, don’t mess with it. I didn’t really know who was NAD (deficient). I mean, obviously, on average, an older person’s going to be more NAD deficient than another, but I kind of shied away from it.
There is a company now called Jinfiniti that measures intracellular NAD levels and I’m starting to get results back on patients and see those that are low and supplementing with NAD and trying to get their levels up, but we’re still in the early stages of that.
Dr. Kara Fitzgerald: Okay.
Dr. Joseph Raffaele: I think that it’s really an interesting area, particularly with some of this research showing how interrelated all of these metabolic and epigenetic pathways are and how telomeres are also at the heart of them, that I think what we’re really going to be looking at is turning the dials on all these different sort of substances to try to get the right combination in the right person. That’s where I think at some point the kinds of AI that you were talking about, we’re going to be doing it on our database to try to figure out, what’s the correct way of making these people-
Dr. Kara Fitzgerald: What about-
Dr. Joseph Raffaele: … do these?
Dr. Kara Fitzgerald: … so… Yeah, so a surrogate marker of NAD would be looking at various Krebs cycle intermediates, maybe lactate pyruvate, et cetera. I mean, are you doing that? Would you use that as a suggestion that NAD might be beneficial in the person?
Dr. Joseph Raffaele: I mean, I think you could do that. I’m not doing metabolomics like that just yet just because there’s only one of me, unfortunately, and I do think that that could be another way of looking at it. I’m waiting to see how well this Jinfiniti test performs and whether there’s clinical correlations with it because if it does perform well, which I think so far it looks like it is, then-
Dr. Kara Fitzgerald: Good.
Dr. Joseph Raffaele: … we can dose based on that and we can see if a person that goes from a low level to an optimal level, we’re foreseeing changes in other areas of their biomarkers. That would be really, really, really interesting to do.
In terms of the other stuff, the CMV and COVID, I think that I do get CMV titers in everybody because I think it is very important to see what effect it’s having, whether or not you’re going to be at risk for more severe COVID. People who have high CMV titers or are CMV positive, even if they’re young, and we’re seeing more and more young people getting sort of relatively significant disease, it’s not just a linear increase from young age to old age.
There’s definitely younger people, but that’s probably because their immune systems are not the same as their chronological ages and that they actually have older immune systems that have senesced because of CMV and because of the effect that CMV can have on shortening telomere length. Then, the other thing, there was an interesting paper that came out about looking at telomere lengths to see BioViva modeling it. If you’re in the bottom 10th percentile, then you run out of telomere reserve to mount an effective response from your naïve T cells and your effector memory cells and that is something… If telomere length testing was 50 bucks, I would say everybody should do that to try to know where they are in their risk-.
What my takeaway message is that this field that I chose to go into, as you say long ago, was probably the best decision I ever made in my life because I love what I do. It’s fascinating seeing how all of the science is starting to make sense. All the ways that we look at aging are sort of coming together with still lots of conundrums out there to figure out, but I think we’re going in the right direction. We’re keeping the body as healthy as possible. That’s why I call PhysioAge “Physio Age Health Analytics.” How healthy are you in comparison to what’s the optimal health that you could have? If you’re deviating away from that, what could we do to bring you back to that?
Dr. Kara Fitzgerald: Well, Dr. Raffaele, as usual, it’s just been a great time talking to you. I mean, you’re just so brilliant and you’ve got your head wrapped around this in such an elegant way, and you’ve got your clinical experience to always bring it home. I think as much as I love these amazing biogerontologists who are teaching and really doing the deep investigation into the biomarkers of aging, it’s the people who are sitting with the individuals and actually enacting these interventions and paying careful attention such as yourself.
I mean, you’re really kind of… you’re a leader here is really distinguishes what’s going to work and what isn’t going to work and what we should be doing. You’re playing an incredibly important role in this whole work that we’re doing right now, and I agree with you. We are at a pivotal time. It’s very, very exciting. It is really new. We’re cutting the edge in a lot of ways, but we’re also dancing on a bigger, more solid edge, I think, than we ever have, and it’s just an exciting time to be practicing this medicine. Again, thank you so much.
Dr. Joseph Raffaele: You’re welcome. That was very well put and you’re making me blush, but thank you very much. It’s always great to be on your show. I’m glad that you have this platform to get this information out there and you always ask great questions and have great guests, so thank you.
Dr. Kara Fitzgerald: Well, I really want to do, and people just comment on this, “Wouldn’t you love to do a webinar with Dr. Raffaele and just look at PhysioAge and what it’s about?” Aside from me needing to actually get to your clinic, Joe, as a patient, it would be so fun to look at this with everyone. All right, well, conversation to be continued, I’m sure.
Dr. Joseph Raffaele: Thank you very much.