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Demystifying the conversations we're already here at RRE and with our portfolio companies. In each episode, your hosts, Will Porteous and Raju Rishi will dive deeply into topics that are shaping the future, from satellite technology to digital health, to venture investing, and much more.
Raju: Hello, listeners and viewers, welcome to another episode of our RRE POV. I’m Raju Rishi, and I’m joined by my partner Will Porteous.
Will: Hey everybody. Great to be back.
Raju: Dude, you’re looking good. You’re looking very good.
Will: [laugh]. It’s nice to see you for a change.
Raju: I know, I know. Just as an aside, if you’re used to listening to us on Apple Podcasts or Spotify, you can now also watch our podcasts on YouTube. So, how do you feel about video podcasting, Will?
Will: I think it’s a great leap forward. And, like past great leaps forward, it may be a little messy at first, but I think we’re going to do well with this. It’s a good medium. The world is visual.
Raju: I know, but your messy is, like, near perfection.
Will: Ah [laugh] hardly.
Raju: [laugh]. Today’s episode is going to be focused on a topic that typically becomes more and more important the older you get, which is longevity, which I’ve been dabbling in for a long time, and I think, you know, Will, you and I did a podcast on this a while ago.
Will: Yeah, well, you are older than I am, so it makes sense that you’re pioneering the longevity side of the conversation.
Raju: Yeah, somebody’s got to do it. It becomes more important the older you get. There’s no question about that. At its simplest, longevity means a long duration of life, longer than the typical lifespan for your species. I just want to get your thoughts, Will. Like, what are your thoughts on longevity? And what’s kind of like… a good lifespan? Would you want to live forever? I mean, that’s just one of the questions.
Will: Yeah. You know, it’s funny. I’ve been thinking a lot about this lately and maybe this is going to be a little morbid for a second, but I’m in my early-50s, and I’ve started to sort of really pay attention to how long people live. And that sounds sort of trite. I was paying attention to it before, but you know, the number of people who only live into their 80s is sort of striking. And for me, that’s 30 years from now. 30 years is a very measurable chunk of my life now that I’m in my 50s.
Yeah, I think I’m going to live longer than my 80s. I bet I will. Like, statistically, I think we are likely to live longer. You know, mortality in the US has actually been declining slightly. But I think there’s ample evidence that overall, we will see an extension of lifespans. Would I want to live forever? It’s a great question. I think the saddest part about living forever would be outliving all the people that you care about. So, probably not.
Raju: Yeah, I mean, but you got to make the assumption that everybody lives forever, right? I mean, could live forever at some point. I don’t think it’s going to be a select few. Although you might. You know, like, I’ve seen your running patterns. You might be the one, but like, it doesn’t always happen.
Will: My running patterns aren’t going to guarantee anything in terms of longevity. It’s just, it’s a daunting thought. But yes, I would like to live longer, and I would, but I would like to live healthier for those longer years. And I think your point about wellness and quality of life is the essential one.
Raju: That’s the key. And I agree, when you ask me that question, I would say, like, 80 or 90 minimum. But like, that’s kind of expected now. You know, would I like to live to 150? Maybe, but I certainly have to be quality of life, and I would have to rethink my goals, I think.
And there are a bunch of downsides. I mean financial sustainability per individual. I mean, think about Social Security and pensions. They were designe—one of the reasons Social Security is in trouble is it was designed to operate for people dying in 50s or 60s, and now we’re living a long time. Living costs are pretty substantial, so…
You know. And I was just thinking about this other day, what about the legal systems? What does a life sentence in prison mean—
Will: Huh [laugh].
Raju: —if you live forever. Think about that. That’s crazy. And what about death do you part, right? Do you have time-limited marriages? I mean, think about it. Like, you and I are good for, like, 30.
Will: We’re either renewing a 30 or, you know, it’s a restart.
Raju: Yeah, it’s like a mutual renewal.
Will: It’s a great point. When you think about a lot of long marriages that kind of hang in there, but maybe they should, maybe they shouldn’t.
Raju: Yeah, and you know, when you do a SaaS contract, it’s like, okay, you know, we will re-up upon mutual agreement. Or, you know, you just think about some contracts that are out there. You wonder, like—look, I’m very happily married, and I would never sort of encounter I would not approach my wife about this, but I know that in some cases, it might be better if you just like, hey, let’s take this 20 years at a time. And if you both don’t like it, you know, you kind of got this—[laugh].
Will: So, you’re willing to sign a 20-year marriage as a service deal with, you know, with an open-ended renewal? [laugh].
Raju: Yeah [laugh]. I don’t know, for some people, it should be shorter than that, I think. I don’t know. I don’t know.
Will: Maybe so.
Raju: Also, like, think about the workforce, right? What happens if you’re trying to be CEO of a company, but that person is not going to ever die?
Will: Oh, right.
Raju: And so, like—and how do you get into the workforce? Because nobody’s got job openings.
Will: Well, and the whole subject of, kind of, career span really gets exploded. It’s very convenient and easy to say, well, after a certain age, you’re going to have a second career of some kind that it’s going to be like some form of semi-retirement, but your point earlier about the financial implications of living much longer is thing one. But thing two is, maybe I don’t want to retire. Maybe I like what I do. Maybe I want to keep working.
And is the system rigged in such a way to force capable people out earlier? In some professions, it is, and in some professions, maybe that’s a good thing. Maybe the decline in reflexes and that sort of thing means that pilots and basketball players and others should leave the work, leave the—at least, whatever tier they’re operating in the workforce.
Raju: Yeah. I mean, but in theory, you know, infinite life at perfect health means, you know, maybe you get a once-in-a-lifetime athlete, but they play forever, and eventually, if you got a basketball team, you got the five best from a thousand years playing, and there’s not a lot of opportunity. It’s kind of a weird thing. So, that doesn’t mean we’re not going to be searching for it.
Will: So, it’s a worthwhile goal, and you have spent a lot of time thinking about this and researching and paying attention to the evolving science around longevity and wellness.
Raju: And I think we talked a little bit about this topic once before, when we were talking about wearables. But my thinking has evolved a little, and I thought it was just good timing for us to chat about it again. So, I’m going to frame this exercise here of discussion, but typically there’s four factors, or five factors that impact longevity. One is genetics. This is a big range: 10 to 50% of lifespan is attributed to your genetics. So, you’re kind of given a set of cards to begin with and now the question is how do you address that?
That’s lifestyle and environment, and you know certainly diet, physical activity, sleep stress, social connection, living conditions, environmental conditions are critical. And I will tell you, like, living conditions and environmental conditions are critical, and when you look at healthcare, and you take two individuals who have, you know, similar types of lifestyles, but their living conditions are different, lifespan is materially different if you don’t have electricity or running water. I know some—you know my previous partner at Sigma Partners, he was simply, he said, like, the biggest impact I can have in terms of charity is to make sure everybody in the United States gets running water. And if we can guarantee that we’re going to have a massive, you know, sort of positive impact on healthcare in the United States. So, you know what I wanted to talk about today, Will, is just—I got this prop back here.
Will: Oh, wait. Is this the fountain of youth? What do you have?
Raju: Yes this is—no, this is an hourglass. Probably should just do this so we don’t go too long. No, no—[laugh]
Will: [laugh].
Raju: Yeah, if I don’t turn this over every, you know, 30 minutes—
Will: Well, Raju, you know what I need to say at this point. Like sands through the hourglass—
Raju: Oh, my God. There you go.
Will: —so are days of our lives. This is—
Raju: Yes.
Will: It’s about longevity, the days of our lives.
Raju: Even back then. Even back then, they were longevity-ing. In terms of, like, startups and healthcare intersection, there is innovation happening in five sectors. And you know, kind of, we’ve been at this for a long time at RRE. We played a lot of these levels.
And what I’d like to sort of talk about, and set a game plan with you, and get your thoughts as well is, your thoughts on each of the sectors. And I’ll do a little bit of explanation because I think there’s some—I have different evolved thinking on this which is, you know, slowly seeping into the healthcare marketplace that I think people should be aware of, and I’d like to spend some cycles on it. But there’s really five sectors where startups are investing and creating value. One is health data, and we know all about that and I’ll kind of go through the framework on that. Second is really important, which is insights and plans.
The third is precision and personalized medicine. The fourth is verticalized solutions, and maybe we’ll touch a little bit today on frontier tech. We won’t go too deep, I think, Will, because, you know, we only got limited time. And if we’ve got another session on we’ll do stuff on frontier tech, which I think is super interesting and is a little bit controversial, and that’s just reprogramming your genetics.
So, health data. We talked about this in the prior episode, but it’s good to recap it. This is like getting your weight and your body fat and your blood work and your urine analysis and your microbiome and your genetics and your sleep data and your MRI data, fitness data, all of that kind of stuff. I think when we talked last, your biggest usage was your watch, you have a Garmin watch?
Will: Yeah, that’s right. And I know you’re a master of your data in this department. And I think a lot of people want to be masters of their data. I have my Garmin watch, I track my sleep religiously, I know a lot about my heart rate—
Raju: What do you do to track your sleep? What do you do to track sleep?
Will: So, my watch tracks my sleep. So, I know duration, I know average resting heart rate during sleep, I know Heart Rate Variability during sleep.
Raju: And do you do anything? You take your blood work, you just get the regular stuff, or you get something more sophisticated?
Will: I guess I get the regular blood panel once or twice a year, which is a pretty robust panel, but I have to say it’s the data portability that’s a problem for me. I have all these charts from all the times that I’ve gone to get a physical, and I wouldn’t say that I’m—I think I’m, sort of, locked into where my data lives inside of the hospital system that I’ve been a part of for a long time. I need to figure out how to get it out of there.
Raju: Dude, dude, dude, we’ve got a company for you called Redox [laugh].
Will: Oh, awesome. Awesome. Great idea.
Raju: [laugh]. Yeah we do, actually, just for listeners. We have a company called Redox which does interoperability of healthcare data. It doesn’t do it for individuals yet. So like, you can’t go to Redox and sign up and say, “I want to collect a bunch of stuff,” but it is helping to expose the data that sits in the hospital systems.
I don’t know. I think by law, you’re required to be able to get that, Will, and I would encourage you to, sort of, go get it.
Will: Yeah.
Raju: I go to a provider who uses Quest, and Quest provides a really fantastic application which basically plots every single one of those blood work biomarkers and urine biomarkers and shows me the trajectory over time. So, I can see that, I can see which ones are green, which ones are red, and I can see how they’ve been evolving. So, you know, I don’t get overly concerned about certain biomarkers if they’re relatively—they’re not in the best condition, they’re not red, but they’re getting close, but they haven’t changed in a long time. So, you know, it’s not like they’re going out of whack, but you should get that. And if you don’t, maybe talk to your provider about, you know, being able to go to Quest or LabCorp, or, you know, Function Health or something like that, which is going to give you that chronology. Because that chronology is super, super important.
Will: Yeah.
Raju: How about microbiome? Have you ever done a microbiome test?
Will: I have not.
Raju: Okay, time to do it, my friend. Genova Diagnostics has one. I would recommend you do it. You have to poop in a box, I’m sorry to say, but like, hey, it’s a one time thing.
Will: It’s a small price to pay for knowing some important things.
Raju: It gave me some interesting data. It told me—and I didn’t realize this—I mean, generally, you know, it was in good shape, and for whatever that looks like in life, I don’t want to be the examiner, by the way. I don’t want to take the data and provide the analysis on it. But nonetheless, it was good. It told me I was slightly allergic to cashews and cucumbers.
And I don’t really have gastro problems, but I actually eliminated those from my diet. And I don’t believe it’s psychological, but I felt better.
Will: Amazing.
Raju: And I used to eat them a lot, yeah. So, do that. Have you had your genetics done?
Will: I actually just had it done, and I haven’t got the panel back, yet. So, yeah.
Raju: Yeah. There’s, like, a 10% likelihood you’re my son.
Will: [laugh]. I should be so lucky. Can it be higher than 10% please?
Raju: Okay it’s 25% [laugh].
Will: Okay, okay. [unintelligible 00:14:10] feel better.
Raju: You do your sleep. Have you done a full body MRI?
Will: I haven’t done a full body MRI. And so, I want your opinion on this. When I talked to my provider about it, she’s like, “Well, people are doing them, and you see a lot of blobs. And you end up having to go investigate the blobs.” And she said, look, I’ve got a lot of patients who have had to do a lot of invasive stuff to confirm that the blobs weren’t anything they needed to worry about. So.
Raju: Yeah, I got to be honest with you, this blob thing is a real thing, right? Providers hate it. They hate this Prenuvo and this Ezra, which I think Function Health recently bought. And the reason they hate it is because there is a lot of blobs. But the thing about these tests that I think are valuable is the rate of progression or change over time.
Will: Sure.
Raju: Imagine you get a ba—and it’s the same thing I said about blood work. You get your baseline. Maybe you know your cholesterol is a little high, and it’s always a little high. It’s not changing at all, so your body’s not building additional cholesterol; that’s just kind of who you are. Same thing with blobs, right? If there’s a blob in your skull or someplace, you know, near your lungs or whatever, and you do this, you know, Prenuvo thing and you do it the following year and it hasn’t grown, it’s probably nothing.
There are certain blobs that really do matter, and so you probably should do one and ignore the ones that have a high likelihood. But you know, the problem with the healthcare system is you are designed, as a healthcare provider, to minimize the amount of time that you’re dealing with patients and only addressing the emergencies. And we don’t really focus as much on wellness because you can get into a rat hole, right? It could be nothing and you spend a lot of money in testing and stuff like that, and gotten biopsies, and it’s really nothing to worry about. And there’s a reason why the healthcare system is designed to just address issues that sort of have materialized. But I think they’re still good. How about CGMs or metabolic detectors?
Will: I haven’t because those basic markers are always in a really good place on me. Like, A1C and that sort of thing, I’ve never had a blood test that showed anything alarming, so I haven’t experimented with CGMs or anything like that.
Raju: I’ve used most of these, just as reference. Like, I got its Withings scale. It’s pretty good, I got to tell you, like, weight is very good, but then it also tells you body fat, and tells you basically, like, electrical flow through the body and how that sits. And it’s so variable in those dimensions that—because I could basically, like, from a weight perspective, I, you know, I see a trend. You know, sometimes, if you retain some water or whatever, you know, your weight is going to go up, but it’s not really commensurate with your body building up fat.
Body fat analysis is kind of all over the place. I haven’t found one that works well at home, but the trend line definitely works. So, as long as you let it fluctuate, and—because I take my weight every day and body fat analysis every day—the trend line tends to work. Blood work, urine analysis, microbiome, genetics, sleep I do all the time, and MRIs infrequently, but fitness, I do a bunch.
Will: So, let me ask the billion-dollar question. What are you doing to integrate all of this data into a holistic picture? And how do you think about the cadence in which you gather data?
Raju: This is the key question. The insights and the life plan, or the daily, weekly, monthly plan, or yearly plan for an individual, it’s very fragmented today. Every one of the providers that I talked about, they’ll all give you a plan, but none of them are capturing—holistically—that data, and I think they’re all kind of coming up short. The area I wanted to really spend time on here is actually, like, flipped a bit from the last podcast.
Will: Yeah?
Raju: Yeah because it was all about getting all of those biomarkers and developing a game plan that said, okay, these supplements will help this, you know, sort of out-of-whack biomarker, or, you know, your testosterone level is too low, so you should try some peptide therapy, and you know, testosterone hormone replacement therapy or something like that. We’ve been doing a lot of work at this company that you know I’m affiliated with, called Elementary. The old logic says, take all of the data and prescribe some changes. And the new model that I think people are thinking about is quantum biology-based—so just so you have a reference point around what this—is that health is not a destination. It’s about preservation of energetic margin against the pull of entropy. And as a material scientist and a solid state physicist, I grok this [laugh].
Will: Yeah, that’s a beautiful phrase: “Preservation of energetic margin against the pull of entropy.”
Raju: Yeah. This is the key. And what I mean by that is, we have batteries inside of us, and if you—that fuels you, right? And like, people have always told me—and I’m not trying to be cocky here, but I’ve got a lot of energy. I’ve got a lot of capacity.
Will: You do have a lot of energy. Part of the reason I love having you as a partner. You bring so much energy to everything you do. I don’t know where it all comes from.
Raju: Yeah, I kind of don’t know. That I think is a genetic thing. You’re kind of born with it. I don’t know. But there is something there. And I have a big battery, okay? But it’s not about the size of the battery—well, size of the battery definitely matters. Size matters. [laugh] Sorry.
Will: [crosstalk 00:20:05].
Raju: Okay. I don’t know, I don’t know, I don’t know. But it’s also, like, the recharging is super important. And so, biological systems we know about the sympathetic and parasympathetic, like flight or fight and the rest state. So, biological systems are either in a survival state where you’re liquidating battery capacity or a regenerative state where you’re compounding capacity.
Will: Yeah.
Raju: That’s really, really important to know. And it turns out, if your body is spending a lot of time in the survival state, you can take the same input—supplements, you know, like, lifestyle changes, whatever—and it can either heal or harm you depending upon that state. That’s what is super interesting because when you’re in a chronic state of liquidating because your body is fighting something, what you really want to do is get yourself into a state where you can start regenerating, and then the supplements and the treatments work.
Will: I want to pause you for a second because I’m sure a lot of our listeners who are paying attention to issues of health and longevity have been hearing about chronic stress, kind of modern work life, and chronic stress, the fact that we’re rarely in a de-stressed state enough to recover, it sounds like that’s what you’re talking about.
Raju: Absolutely. So, regeneration of your body only occurs when your bioenergetic capacity exceeds the defensive demand. If you’re chronically in a state of stress, you’re basically depleting your battery just as fast or even faster than it can fill it. And so, you got to get to a point where that regeneration is possible. And the key to all of that is a term called resilience.
The easiest way to understand that, and it’s the simplest, but not really complete, is HRV. When you look at that index, which is the variability of your heart rate, that is effectively your heart’s ability to go from high to low, sort of like, output. Heart rate variability is a fantastic metric. It’s like, you know a harmonic wave. You know you’ve seen a sine wave. The larger the size of that sine wave, the healthier you will be as an individual.
You want the lows to be lows, and I’m not talking about, like, emotional lows. I’m talking about just de-stressed. And you want your capacity to be able to burst up to those highs to be as powerful as possible. You know you want sufficient amplitude between the high flux, which is the performance part of things, and low flux, which is a deep recovery. That’s a lot of the new thinking that’s focused around healthcare.
I think the miss here by a lot of folks that aren’t thinking in this dimension is they feel like supplements that will treat, sort of, conditions of your, like, something out of whack biomarker are going to be accepted by the body no matter what state it’s in.
Will: Ah, this is interesting. So, and probably when people are most acutely stressed in that survival mode, in that mode where they’re liquidating capacity, maybe that’s the mode in which they’re least able to benefit from supplements?
Raju: Yes. Exactly. And so, a lot of it is just wasted and it can be counterproductive. So, you’ve got to solve that amplitude and delta issue first because regeneration only resumes when there’s a surplus. And so, when you look at that, you know, sort of that sine wave, or that, you know, harmonic graph, you look at the ceiling and the floor.
And it turns out age, actually, you know, basically shrinks the ceiling. And state, which is whether you’re in the parasympathetic or sympathetic, determines the floor. So, if you don’t meditate, you don’t get into a situation where you’re de-stressing your body, your amplitude decreases because the floor just moves up. And you got to get the—the floor is actually something that you can control. The ceiling, sometimes you can’t because of age, unless we talk about some of the newer technologies, which we will get to.
Will: How do you think about exercise in that context? Is exercise a stressor that is shrinking the amplitude or is exercise expanding the amplitude?
Raju: It expands the amplitude. It’s basically, what is your peak, right? You know, age will ultimately determine—without the use of, sort of, genetic modifiers and, you know, things that are coming around—what happens is you have this maximum peak of energy level and energy utilization, and as you age, it will drop. Your maximum peak will drop. But if you don’t exercise, it drops even further.
So, as long as you can—because you’re pushing your body to the limits and you’re expanding, you know, the ability for—it’s like your lung capacity. I was a trumpet player. I played the trumpet for a long, long time.
Will: I bet you have big lung capacity.
Raju: Massive lung capacity, but it’s probably way, way worse now because I don’t play every day anymore, but I used to be able to swim, and I took the PADI test to do the scuba diving, and you got to do the two lengths, you know, underneath the pool. I could do that, no problem, right? And people were like, struggling for it because you had a big lung capacity. That’s essentially like you—because I was exercising my lungs, I had that capacity. I could use the full capacity of my lungs.
The same thing’s true with just exercise in general. It increases the amplitude, the peak capacity. It’s like a runner. They don’t run as fast as they need to, but when they want to burst, they can power in, and your muscles have that capacity. So, you want to, you know, work on that ceiling by exercising.
Age is naturally going to diminish it. If you age, you know, like, without, you know, using some sort of, like new fangled tools to sort of de-age, if you want to say, reverse aging, it’s going to naturally decrease the ceiling. But it will shrink more if you don’t exercise. Let’s say you’re exercising perfectly. You’re going to have that capacity.
But if you’re not letting your body recover properly, then the floor is basically going up and you’re basically spending more and more time in this usage as opposed to, sort of, recovery mode.
Will: You’ve completed a thought there because exercise without sufficient recovery is only going to prolong the survival state.
Raju: Correct. And that’s the key here. And I don’t want to get into—we’ll probably have a podcast with Jeff Xu, who’s the CEO of Elementary on, who’s been thinking about this way longer than me. I’m just sort of recounting some of the pieces of the things that I’ve learned with working with him for the past several years. And when that product comes out, it basically creates ten micro-journeys that will help you maximize that amplitude.
Will: Well, I can’t wait for that. We have to have Jeff on soon. I’m sure our listeners are interested.
Raju: We’re going to have Jeff on.
Will: Great.
Raju: It’s super cool. Just talking about the structure. So, the insights and the plans, I’m a little skeptical about them. I’m a little skeptical about it because I do believe if you’re in a situation where your ceiling and floor have been maximized, the supplements will work, right? Because you take the supplement and your body leverages it.
You know, when you’re in the state of rest, it leverages, like, caffeine you want to leverage during that performance, you know, interval. You know, creatine, you want to leverage at different times. So, there are supplements that are valuable to you in each of those states, but if you take them at the wrong interval, like, if your body’s constantly fighting something. There’s a lot of inflammation, you know? And I’ve talked about the four different states of the human—like, systems of the body before, so I won’t really get into that, but I’ll mention them.
Like, there’s the energy production layer, there’s the, you know, methylation layer, which is how your genes express themselves, there’s the inflammation layer, there’s oxidative stress layer, and there’s things that can affect that. Those systems kind of interoperate, but the more important element of those is where you are relative to your, you know, parasympathetic or sympathetic state. If people are working on things in this area, I’d love for you to reach out because I’m super interested in folks that are thinking broader than simply, you know, here’s a blood work issue, and so this is what you should take as a result of it. Because I think healthcare is a journey, and you can provide a lot of these supplements and they can affect different parts of your system, some in a positive way, and some in a negative way. And if you don’t have that feedback loop in your application to really understand whether it’s impacting the user properly, you’re probably just guiding it in the wrong direction.
So, I think a model has to be recursive in healthcare. It has to be recursive. And unfortunately, most healthcare applications are not recursive. They just tell you what to do, and then, you know, if you do it, they’ll tell you the next thing to do. And they’re not sitting there saying, like, “Stop doing that.” They never say, stop doing that because the course of action is, like, that’s the right thing to do. Everybody would say, eat more vegetables, you know? Or take this.
Will: We’ve adopted two very rare feedback loops and—true feedback loops—on the data side. Like, we’ve grown up with a culture that asks for an annual physical and doesn’t do more than that in terms of comparing data. Now, you’re different. You’re in a class by yourself in terms of your consumption of this data, but most people, the healthcare system that they live in has no meaningful feedback loop before they get into crisis.
Raju: That’s true. It’s true. All right, I’m going to touch on a few other topics here, Will, which are outside of this feedback loop. I think this is the area where we need to spend the most time to improve healthcare across the world. It’s taking the data and providing the right insights, but using the proper framework because if you use the wrong framework, you’re going to create plans that don’t necessarily help people.
However, there are other topics which are important, and I don’t think they should be stopped, and I think people should work on them. I think that they need to be applied in the framework that I just talked about earlier, though. One is precision and personalized medicine. Okay, so I do believe this is problematic. Today, the drug choice is just prescribed based upon your blood work. They don’t take into account, you know, kind of, drug-to-drug interactions. They don’t really—because they don’t know what everybody’s taking in terms of supplements and diet.
They’re not weight tailored or body-fat tailored. They’re not sitting there saying, like, “Hey, let me give you this drug, but because your body fat is this, body fat index is this, maybe we should adjust the dosage.” Part of it is because it’s difficult to do. But I think we’re going to get into dosing personalization, and we are going to get into these drugs that are sort of a combined pill so you can take them. I think another problem that’s got to be solved is, like, if I take, you know, vitamins and I take a statin and I take a, you know, omega-3, when should I be taking these? Should I take them on a full stomach at the beginning of the day or are there two pills that counteract each other? I think there’s a massive opportunity in there. And then I think dosing personalization is important.
Will: Roll that thought forward for our audience for a second. How do we get from our current go to the pharmacy and buy a standard dosage of something or a standard size of a supplement, how do we get from there to dosing personalization? What does it take?
Raju: I think it takes two things. I think we need to do some clinical studies based upon the individual not being one human, but the individual being if I take the clinical trial and I divide it into 100 people, and I look at weight, and I look at a bunch of other biomarkers and see the efficacy of the drug, I can say, hey, listen the optimum unit for this drug is per pound of individual, not by the individual, and the blood work. So, I think that’s required. I also think you need a continuous loop feedback mechanism. And that may mean you need to take your tests more often, just to see how you know your body’s being impacted by that.
But I think, you know, you can simplify the biomarkers and, say, weight, you know, body fat, or certain metric, eventually, if you have good feedback loops, it can be completely personalized just to you. And so, that’s what I think it’s going to take. I think you need this recursive mechanism, and I think you need clinical trials that are testing the drug in that way. Which they’re not. They’re just, you know, doing it per human today.
That’s an area I think—I think we have another area that people are spending a ton of time on are longevity clinics. I think this is a great area, honestly. I think, you know, they’re blending data aggregation diagnostics and care navigation to provide wellness services. But I think these clinics are more wellness oriented than they are longevity. You know, they’re saying, hey you know, here’s a peptide therapy, here’s a, you know, weight management protocol.
I think some of them will extend life, but I think most of what is being done today is to improve quality of life. And I think it’s early days to be able to determine whether there’s any efficacy to elongate life. If people taking this do live five years longer, then, yes, but I don’t think they’ve been around long enough to say that.
Will: Right. Yeah, right.
Raju: So anyway, that’s sort of my thing. But that’s still good, like, I believe, if you’re going to live 80 years, you know, and that’s it, and you can’t stretch that, then live the best 80 years of your life, right, you know? If you were going to live to 85 then those best 85. I would hate to live to 80 and just at the age of 60, be like, you know, non-functional. Another area that people are working on is microbiome-guided interventions, and that’s tracking GI symptoms. I know you have some experience with this.
Will: I do.
Raju: Do you feel like they work? Do you feel like the testing and the tracking of the GI symptoms and the improvement of inflammation markers that the world has that down or do you think it’s just sort of early days in that navigation?
Will: No, I think we’re very early in our navigation of this. I think that we need a GI reference panel that we come back to over and over again. It’s probably a very individual panel, but until, sort of, the profession, really, embraces the complexity of GI health, I’m not sure we’re going to get there. You know, an awful lot of our medical system is basically engineered to look for cancer throughout the GI tract, from top to bottom. And unfortunately, there’s a history of GI cancers in my family, so I get screened for a lot of different things.
And if you look at the enormous effort that goes into that, it’s energy that is over-directed, I think, in that world. Here in New York, obviously, we have access to great healthcare. We have so many sophisticated ways to look for cancer, but we’re not deploying a lot of resources to really understand microbiome health with any degree of sophistication that I’m seeing. And if it’s happening, it’s happening outside of mainstream medicine.
Raju: I agree with you a hundred percent. It’s kind of interesting. Look, I don’t want to be a naysayer around the healthcare system that we’ve developed, but you know, we do put a lot of energy and money into specific areas. Like, we have cardiac wards at hospitals. Guess what? If you just built this multi-billion dollar hospital system with all the latest, you know, operative equipment to deal with putting stents into people, somebody has a heart attack, you’re probably going to recommend a stent.
Will: [laugh]. Oh yeah.
Raju: And that’s rough, right, because, you know, everyone doesn’t need one. And so, you know, there was this, [unintelligible 00:36:40] Finland or something like that, they did a study where they said they measured, like, heart attack patients and how long they lived. So, I’m going to take some liberty here because I don’t really know the exact quote, but what they showed was that the people who had heart attacks lived longer on average if they had a heart attack when there was a cardiac surgeon convention, so they weren’t available. It’s crazy.
Will: Right, yeah.
Raju: There’s a lot of theories that say, you know, like, you should dose people with high dose aspirin when you have a heart attack, and that’s better than, you know, putting a stent in. I’m not a doctor, so please, please, anybody who’s listening don’t, like, you know, listen to exactly what I’m saying, but you know, you should verify, like, that this is the right course of action for you. And so unfortunately, like, there’s a lot of money that has been poured into cancer, there’s a lot of money that’s been poured into cardiac issues and diabetes, and they have built solutions that require beds and equipment, and they have to utilize them. So anyway, a bunch of verticalized solutions, they are growing like crazy. Like Nutrition, we have Yuka and Chronometer and [unintelligible 00:37:52].
Weight loss, one of our favorite portfolio companies, Noom, you know, is out there. We have mental health with Calm, Headspace, Spring Health. Addiction, with our portfolio company, Groups in [unintelligible 00:38:03]. Fitness, sleep. So, I think those are going to continue to proliferate. And I do not want to imply to anyone that they aren’t valuable. They are.
I think they will take you to some level. Like, watching your nutrition is not a bad thing, and understanding what you’re putting in your body is not a bad thing. It’s actually a really good thing. Over optimizing on it, not understanding the rest of the ecosystem of, like, not understanding your genetics, not understanding, you know, I could eat all the cucumbers in the world, I mean, Yuka will tell me it’s super healthy, but, like, I’m slightly allergic to it.
Will: Right.
Raju: That’s what I’m saying. You’ve got to get that loop in there. I think weight loss is becoming really interesting with GLP-1. And I’ll talk a little bit about this because, you know, I know Noom had—has—I think, the best weight management solution in the marketplace, and they have recently introduced GLP-1 into the equation. But Noom’s organic solution was based on psychology, you know?
Don’t go to the supermarket hungry. You know, your mom is telling you, you know, “What’s the matter? You don’t love me, so you don’t eat my food?” Like that is BS, right? Like, don’t listen to that, you know? Or, “There's hungry kids, you know, in whatever foreign country or whatever. Finish your plate.”
You know, those things have just kind of created, you know, disastrous results in Americans and, you know, all over the world, and they have a way to reprogram your thinking around food, tips and tricks and things like that, and get a social network in place so that you’re helping each other. And then GLP-1 came around, and people said, “Oh, look, I’d like to take a pill and just, you know, miraculously lose weight.” No one knows, you know, what the long-term implications of these GLP-1 are. And frankly, they’re expensive, so you know. They might be a great starting point, though.
So, I hate to discount innovation. I love innovation, but sometimes maybe the true innovation is that the GLP-1 makes it easier to get on a pathway. And the beautiful thing about Noom is they’ve got an application that says, “Well, you don’t need to take that for the rest of your life. You’ve gotten to where you want to be.” And maybe the psychology piece of their application takes over.
Will: I think you’re absolutely right, and I think that there is, in the Noom environment, this feedback loop of it is very rudimentary, but it is the drugs you’re taking, the food you’re eating, and your progress towards your goals. And I think to come back to something you said earlier, one of the most powerful ideas I think we’ve talked about today is the need for more recursive feedback, the need for better feedback loops. Actually, I think nutrition is a big, wide open opportunity in this regard. We have loggers and all manner of things that you can scan to log things. I think we’ve got to get to a much more fine-grained mode for trying to capture nutrition data, which is going to drive a huge amount of what we’re talking about. And again, it’s got to become part of an integrated data set.
Raju: Exactly. I have, like, more topics. I think maybe we reserve some of this for the next podcast, or video podcast. A lot of it, you know, we’ve got some frontier tech stuff that we could talk about cellular reprogramming, gene therapy, stem cells, that sort of stuff that’s like, you can people are experimenting with it. I think it is really important for us to understand and execute upon downstream but, you know, they’re not ready for prime time yet. It is areas that we are exploring and investigating.
Maybe we just take a podcast and look at the frontier tech side of healthcare downstream. But I’d also like to have you know Jeff Xu come on board and tell the world about Elementary. We’re getting close to launching in this country, and I think it’s going to be really an interesting vehicle by which some of the stuff that we’re talking about is reinforced.
Will: Well, digital health is a big area of focus for us as a firm and those both sound like great future conversations, so I think we should plan for that. Listeners, thank you for joining us today. It’s been a great episode. I know I’ve learned a lot. It’s always a privilege, Raju, to sit with you and hear your thoughts in this area. Always, always, thank you so much.