Premium longevity healthcare - Interview with Health Nucleus Part 4
In this post you’ll learn about:
The personalised nature of a Health Nucleus visit
A vision for getting tens to hundreds of thousands of patients through this proactive healthcare provider
Why Dr. Duchicela likes the Longevity Blog :-)
One of my favourite aspect of a Health Nucleus visit is the number of experts reviewing my medical data, to guide my health outcomes. Here I am getting my blood drawn in January 2020.
Dr Duchicela: Dr Duchicela:
[laughs] There’s a lot of people let’s just say, with the caveat being that everything is very private and HIPAA compliant, but in terms of clinicians, it’s a physician like myself trained in family medicine and preventative medicine who would be looking over your report results, you’ll have at least one radiologist and a lot of times two radiologists because we do double checks where they check each other, which I think is good practice. You’ll have a cardiologist looking at your heart scan, the cardiac MRI is read by a cardiologist and not the radiologist and then with the genetics you will have the clinical genetics team reviewing any significant findings that you had and if there is something that was flagged, a lot of times what they’ll do is delve into the clinical history a bit more and talk with myself or one of the physicians.
So by the time your return of results session comes around you’ll have a lot of different clinicians looking at your data and analysing your data and there’s wide communication between the teams as well. If there is a significant finding we will also have a genetic counselor as part of the return of results session as well. A lot of different clinicians just for one person which is pretty amazing, I think it’s pretty cool to be honest that you have so many different disciplines involved in your care, but you kind of need to just because we look at some many different modalities.
Speaking of genetics data - I recalled fondly this Longevity Blog post exploring haplogroups and ancestral DNA.
Phlebotemy in action! It had been a few posts since I mentioned how gorgeous the staff at NextHealth are!
LB: Q: If you had to estimate the size of the clinical genetics team, how many folks would be looking at the data - it can be a range.
Dr Duchicela: We have two or three people at least looking into any significant variants or looking into something in the family history that was flagged, and they will do a deeper dive session into it. Two or three clinicians on that team that are dedicated to this.
LB: Q: And then in terms of other folks I’ll work with, there will probably be a phlebotomist, there might be some other nurse staff.
“we are developing is a follow up program where we have a nurse practitioner or a physician reach out every so often at different intervals and say ‘hey, how’s it going?’”
Dr Duchicela: A phlebotomist, a medical assistant, you’ll interact with all the different techs, there’s a different tech for the CT scan, a different tech for the MRI, a nurse for the balance tracking and body metrics collection, and what’s really exciting and what we’re hiring for right now and for the future we’re starting to develop a longitudinal program and we’re going to be hiring a nurse practitioner to actually check in with patients over time.
Right now I think one of the main criticisms of our testing is you come in for an evaluation, you get the testing done, you get the results back and then it’s almost like I’ll see you next year or I’ll see you in two years and there’s not a lot of touch points in between that. So what we’re going to be developing is a follow up program where we have a nurse practitioner or a physician reach out every so often at different intervals and say hey how’s it going, did you follow up with this particular test, we talked to you about this finding on your MRI did you ever go in and get that checked out with the specialist. I think it's just good care to do that and I think it hopefully reengages the patient too and gets them to keep thinking about their health.
It’s really easy after you get your results back you go hard for a month or two or three afterwards, cut out refined carbohydrates and start exercising every day and giving up smoking or cutting back on wine. But after three or four months that motivation kind of wears off which is just normal human nature. So what I would like to see happen more is that we have some sort of continuity program where we reach out throughout the year and say hey how are things going? Let’s check in. How can we support you?
LB: Count me in!
Q: There’s a lot more than just the clinicians and nurses you’ve mentioned behind the scenes at Human Longevity Inc, I know you have an R&D staff who are developing new analytics and new reports. I’ve actually met with some of them and discussed some of the new reports HLI is developing. What does that team look like? And what are some of the exciting things they are working on at the moment
Dr Duchicela: Yeah we have a lot of engineers, we have people who are specialists in imaging and in post processing imaging, machine learning scientists. In terms of what they’re working on, there’s two categories of goals with our products. We want to create products that are firstly accurate and second we want them to be accessible to the lay person, to the general consumer and we also want them to be accessible to physicians too who maybe aren’t trained in genetics or in precision medicine testing. We are continually trying to evolve our reports to make them easier to understand. It is a challenge, to be completely transparent, to take all of this information and to condense it and put it into an easily digestible report.
“We have an imperative to scale and to make this more affordable for people”
It’s hard to do and I think our initial iterations of this, we were essentially writing reports by PhD’s for PhD’s, which I felt we had to change, we needed to make it more accessible. That’s one aspect, how do we visualise the data differently, using the webportal to make it more apparent where people could enact change. The second aspect of that is what is the value of getting the testing through us versus an MRI somewhere else or genetic testing somewhere else and putting it all together on their own. I think it's really the analytics, taking these different modalities building these algorithms that are essentially like a crystal ball and doing it for the top five diseases and being able to dynamically say if you stop drinking alcohol or cut back on smoking your disease risk for alzheimers will go down by X percent. Kind of knowing that and having those numbers and validating them and also getting them FDA approved, that is kind of what we’re looking at in terms of the pipeline.
Side Note: All-up, I estimated that more than 15 unique staff review results or directly support the technology used to asses a patient’s data for a given Health Nucleus visit. Now that’s personalised medicine!
“I believe we have a chance to make 100 years old the new 60… for you, your family, friends and colleagues.” - the transformative purpose of HLI is to make 100 the new 60, and make the technology broadly accessible. Read more on co-founder Peter Diamandis’ Blog
And in scaling this, how do we offer this testing at a lower price point? With the MRI in particular, we’re looking at a lot of things with the MRI and that makes the scan time longer, so how do we develop software that makes the scan time less to make it more accessible to people and still get really really good data from it. So all those things we’re working on trying to optimise. We have an imperative to scale and to make this more affordable for people and we want to provide better insights based on the integrated data and building the models for that. That’s the exciting part about it and that’s what we're going to be focusing on in the three to five year range.
LB: Great! Keegan, thank you for taking the time to talk to me about this, it’s been fascinating, exciting and very enjoyable. I am excited that you’re in a leadership position at the Health Nucleus and have the vision and passion for this topic that you do. That’s fantastic for everyone that gets to come through the Health Nucleus.
Dr Duchicela:
That’s kind of you to say. I feed off the enthusiasm of the patient’s who come through. Just like yourself, we get some really interesting people coming through, people who are passionate about optimising their health. They really want to know their data and they want to take not only the insights that we can provide but they also want to take their data and make their own insights into it as well and they kind of just run with it and I think it’s fascinating and fun to see and it’s encouraging to see that people are so engaged with their health, that’s what I feed off of, that kind of enthusiasm, especially the early adopters like yourself who know and see the value of this.
We know that this sort of testing is going to be here and be ubiquitous in the next ten years once the price point comes down and we have the opportunity to educate more people about it and the testing becomes better. It’s really exciting to see we have a community now that’s growing around the types of testing that we’re doing and precision medicine in general so I think it’s an exciting time to be a part of it and to see where it goes.
LB: You mentioned this is version one of the algorithms and the need for more data over time to improve them.
Q: How many people do we need to have come through the Health Nucleus to make it possible for your team to have the data they need to make that crystal ball possible?
We discussed polygenic risk scores in Part 2 - find it here.
Dr Duchicela: I think we’re almost there to be honest. They’re already in development of these models right now and we use not only our data sets but we do derive from external data sets like the UK Biobank and other things that feed into these models. But for our next versions of the reports for these polygenic risk scales, we actually do have enough numbers now to give relative risk for a lot of conditions, which will be very helpful for knowing more about your health.
[Our target enrolment is] 100,000 people to do this type of deep analysis on. I think we will definitely be able to create models with less than that, but also using external data sources as well. So, stay tuned. I think in the next few months, they want to come out with these new versions of polygenic risk scales with relative risk and then validating more of these global disease models for diabetes and alzheimers and certain cancers and the non-diseased as well. So yeah we’re almost there with getting these crystal ball algorithms. Which is really exciting!
LB: So 100,000 people, that’s our target! How many more do we need?
Dr Duchicela: [Our current target is] 100,000. We want to build 10 of these centers around the world and we want to drive a certain number per year through. To date, we have had 5,000 people come through and with that number and with such a deep data set that we have, we’re starting to make some really really good models.
LB: Great, well good on those 5,000 people for helping to make this possible. And I will be doing my part to help you get 95,000 more!
Q: Anything more you want to add?
Dr Duchicela: I love your passion for this and I like your blog!
Note: the Health Nucleus has recently appointed a new Medical Director - Dr. Pamila Brar. Dr. Duchicela has transitioned to a role as full-time physician at the Health Nucleus, working directly with patients to optimise their healthcare!
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FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
Full body MRI screening technology - Interview with Health Nucleus Part 3
In this post you’ll learn about:
The power of Health Nucleus MRI algorithms (e.g. early detection of brain aneurysms or quantifying visceral fat levels)
Same examples of how multiple Health Nucleus visits enable deeper personalised analytics
How the Health Nucleus is prevention focussed, rather than on optimisation (but that’s a good thing!)
Part 3 - MRI analytics & health optimisation
Be sure to read Part 1 and Part 2!
Longevity Blog (LB):
Q: What kind of data will you be pulling out of the MRI scans? Besides the heart analysis and some of the cancer detection, which we already discussed. What will be showing up in that data and what will you use it for?
The blood vessels of my brain as revealed by Health Nucleus MRI data. Aneurysm free and healthy :)
Dr Duchicela: I think primarily it’s used for detecting the big things that we don’t want to miss that we really want people to know about early on, so things like cancer or aneurysms. With the post processing that they do on it, they’re able to reconstruct vasculature and vessels to look for aneurysms, even without using contrast which i think is really neat.
And then we have these different imaging biomarkers, so for Alzheimers we do hippocampal volume assessment where we look at the volume of the hippocampus and the ventricles surrounding them, and essentially see how do you compare to a healthy peer group? Are you a little bit lower or a little bit higher in these volumes, which correlates with Alzheimer’s risk. That’s one aspect.
At left, my visceral fat levels are highlighted by Health Nucleus MRI algorithms. Visceral fat is known to increase with age, and increased levels are risk factor for many diseases.
With MRI we also get the body composition like visceral fat levels, liver fat levels, liver iron levels, and muscle composition. What we’re doing with the MRI data is essentially training algorithms to better detect the sorts of cancers that traditionally you can’t detect with a non-contrast MRI, one we are working on right now is pancreatic cancer. We’ve developed a screening tool to use in MRI for pancreatic cancer and we’re in the process of validating it which is really really exciting. But that will just add to the overall comprehensiveness of the scan and of the experience, so yeah there’s lots of different things we get from the MRi, it’s pretty amazing how much data you can get from it and how much you can start to train these algorithms.
LB: Diving deeper into MRI analytics - I have a full body scan from May 2018, I’m soon to have another scan from January 2020, and plan to continue to do these scans every 12 to 24 months depending on my travel schedule, so you’re going to get a bit of a time series going with the data.
You’ve talked about disease risk and obviously we’ll keep assessing those things but in terms of somebody who’s trying to optimise, like myself who’s a bit of a biohacker or maybe an athlete who’s thinking about their performance and their muscle composition…
Q: What kind of optimisation intelligence could we derive from MRI data over time?
“If you come back multiple times, year to year or every two years, we can trend many things and see how you’re doing. ”
MRI analytics of muscle mass. At left, my colour coded leg muscle groups in May 2018. At right, January 2020. I added 1.3L of muscle mass during that time. Note: the pictured images are from a slightly different ‘slice’ of the data.
Dr Duchicela: I would look at the imaging biomarkers, looking at the visceral fat measurements and subcutaneous measurements that we get and quantifying and trending that. The scanner software automatically marks out where your subcutaneous fat is, where your visceral fat is, we can trend your liver fat measurements, your liver iron measurements and then obviously your muscle composition too and where you’re distributing your muscle.
If you come back multiple times, year to year or every two years, we can trend many things and see how you’re doing. Some people, even if their metrics are “within a normal range”, they want to get them better, and so when you have such an accurate test like the MRI you’re able to make that quantification, you’re able to make those comparisons versus for example other machines out there that measure your visceral fat too and kind of trend it, but really MRI is pretty darn accurate for that and one of the most accurate assessments available, so if you really want to know the numbers and get that in addition to your cancer assessment and your aneurysm assessment, I think MRI is the way to go.
LB: That’s really spot on in terms of the answer I was looking for, one thing I’d like to prompt you on…
Q: Is there opportunity to analyse the strength or flow volumes of the heart from your MRI data?
Dr Duchicela: We can see that your ejection fraction or how much blood you’re pumping out of your heart changes over time, now the question is does that actually translate into performance increases? We don’t necessarily think so for healthy individuals, because there’s lots of other things, like how fast your heart rate is going etc. So I would say not yet, I see where you're going with the question in terms of, could it be used to measure and trend athletic performance, not only for elite athletes, but for lay people who want to really maximise their athletic performance. I don’t think we’re there yet and I don’t think that’s necessarily the overall goal of this test. I think there’s a different series of tests that probably could do better than just the MRI for athletic performance trending and monitoring.
LB: Q: Are there any unique Health Nucleus tools that could be applied to assessing athletic performance and/or optimisation?
Dr Duchicela: I think with genetics we’ll start to get more information on that. There's already genetic predispositions to things like muscle tissue fibers and that sort of thing. What I would want to do as a medical director is to try to delve more into that and gather information on athletic history and get these metrics like VO2max and mile time etc and then start to work with the genetics to see if there are any predictors where we could make some correlations. That I think would be really exciting to do at some point in the future.
“I’m really excited what we have in the pipeline with this sort of scoring ... incorporating that with the coronary calcium score and putting it together and getting a global integrated risk score”
LB: Yeah I agree with you that it would be very exciting, and again it’s not your current focus, but I was curious to ask a few questions on the topic of optimisation, so thanks for that.
One of my big outcomes from my last visit to the Health Nucleus was a ‘prescription’ for cardio exercise and to increase my muscle mass on direct guidance from one of your doctors. I took that exceptionally seriously and have been dedicated to cardio fitness routinely since that time. So I’m really curious what you think might be evident in terms of one’s biometrics and data coming from their visit to help one measure their improvement in fitness over time.
Q: You’ve talked about MRI, and a bit about genetics, what else in there might show up in this visit compared to last time if I’ve done a good job at that cardio and exercise routine?
“ the best areas to look for changes and improvements would be in your imaging biomarkers, your core lab tests for metabolic biomarkers, lipids, a1c and fasting sugar. ”
My blood lipid panel over time; some great changes in between my first Health Nucleus visit (May 2018) and my second (January 2020).
Dr Duchicela: Yeah we’ve already mentioned the imaging biomarkers like your body composition, your liver fat level, those will definitely change with lifestyle change for sure, and then I would look at your traditional blood markers. You’ve probably already been measuring those, but making sure your [Hemoglobin] A1c is good, as well as your fasting sugars and your cholesterol numbers. In terms of trending data, that’s the kind of metabolic panel we would do. We can’t trend genetics so much, so I would say the best areas to look for changes and improvements would be in your imaging biomarkers, your core lab tests for metabolic biomarkers, lipids, a1c and fasting sugar. That’s where you’d probably best be able to see improvement and change.
LB: Cool, thanks for diving into that. And in terms of the genomic data that we’re pulling out, Q: what information in there will be actionable for somebody who wants to optimise? There’s examples of the ways you might metabolise certain precursors to vitamins, such as not being a good converter of beta carotene to retinol in the blood or the MTHFR mutation for methylation.
“It’s probably too early to hang your hat on these variants that tell you to eat a certain food or to do something very specific in terms of lifestyle unless you have one of these obviously high risk genes”
Dr Duchicela: Yeah I think that’s kind of the challenge with the genetics, the focus of the company from what I’ve seen so far is more on the hidden health risks with these high risk cancer genes, high risk cardiovascular disease genes or neurodegenerative disease genes.
In terms of optimising genetics, from what I’ve discussed with the clinical geneticist here and the genetics team, It’s probably too early to hang your hat on these variants that tell you to eat a certain food or to do something very specific in terms of lifestyle unless you have one of these obviously high risk genes, these monogenic findings. But I think it’s an area of consumer interest, what we're hearing from a lot of people is they want more specific lifestyle modifications based solely off genomics. I think that our genetics team needs to be a little more convinced that there are really good actionable things there.
It’s also a matter of prioritisation of where we put our resources, do we want to be more of a lifestyle service versus more of a medical service that’s catering towards physicians and the medical community? I think we’ll always have tension on where the focus should be. Right now the testing is looking for high risk medical issues that we can intervene on, like is there a BRCA mutation or a gene that puts you at high risk of colon cancer?
I am curious to know and to see where the science takes us with more of these lifestyle influenced variants, but i would say for right now for our testing [optimisation] is not one of the big focuses - we really want to try to prevent disease first and build off of that and then delve more into and put more resources toward lifestyle genomics.
LB: I think that that focus area is apparent from the way your suite of testing and reporting is arranged. In my view, everybody needs to be taking advantage of these proactive aspects of medical technology before thinking about health optimisation. You’ve got to take care of the core risk and any acute issues first, in order to maintain your wellness. So I don’t think that focus is misplaced at all. It’s intriguing to hear that your team is interested and noting increased demand for this sort of individual attention. I certainly think that that’s a growing market as well.
“what is the patient’s goal?”
Dr Duchicela: Totally. There’s a lot of companies out there that will do some direct testing and tell you exactly what to eat or avoid this food based off of you having this variant. I think we want to be a little bit more careful with that just because you really have to look at things holistically. I don’t think we really want to say - stop eating cucumbers based off your genetics, we really want to take into account what the patient’s preferences.
Like i was mentioning before with the wine example, really what is the patient’s goal, is their goal to have a super restricted diet so they can live forever, or is it to enjoy time with their family, or to be able to do a certain activity better, so I hesitate to hang everything onto genetics and dictate lifestyle just based on your genetics. We really want to develop something that's more holistic.
LB: That’s where the physician comes into the picture - in having a relationship with them that’s ongoing and aligned with your personal goals and values. I think it’s excellent you’re even mentioning personal values and thinking about them as a physician.
One of the things I think is totally rad is that - I’m sitting here interacting with you, I’m going to be talking to a doctor and several team members on my visit next week - Q: I was curious if you could remind me of how many medical professionals will be interacting with me directly or with my data as an outcome of my Health Nucleus visit?
I’ve split this interview into FOUR parts, due to its length! Part 4 will drop next week!
Previous Posts: Part 1 - Part 2
Follow-up Posts: Part 4
Note: the Health Nucleus has recently appointed a new Medical Director - Dr. Pamila Brar. Dr. Duchicela has transitioned to a role as full-time physician at the Health Nucleus, working directly with patients to optimise their healthcare!
Follow me on Twitter for the latest #Longevity news!
-
RT @rebeccavziegler: The cryonics payoff matrix. Choose wisely my friends. https://t.co/l1rzsmOC2w
-
My rate of aging: 0.79 It’s the new street cred What you got? https://t.co/aHzWHAfCnD https://t.co/L3rZC4QFN2
-
It’s official - I’m co-producing and hosting a new #longevity docuseries, and will begin shooting in a few months… https://t.co/wLGqRrBfbp
-
“The #longevity segment opened my eyes to the groundbreaking advances in biotechnology, health, and wellness. The i… https://t.co/F8YB7PAeMW
-
I’m completely mindblown by what AI has done over the past 3-6 months, and it continues to accelerate… https://t.co/hh0JslucRg
-
Longevity legends take on many shapes and sizes https://t.co/X9vGa7gvOe
I post related #Longevity content to Instagram as well, follow me @nickengerer
FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
Screening for cardiovascular sisease with MRI and CAC - Interview with Health Nucleus Part 2
In this post you’ll learn ABOUT:
Health Nucleus tools for assessing cardiovascular disease risk
The role of the Coronary Artery Calcification (CAC) score in assessing risk, particularly for younger people (30s, 40s)
How CAC scores might influence statin use
The limitations of MRI data in assessing risk
How genetic risk factors might influence risk
Combining imaging data, genetic factors and blood tests to further clarify risk
Part 2 - Cardiovascular disease
Be sure to read Part 1!
Longevity Blog (LB):
We’ve talked a little bit about cancer. Another big killer whose risk is a function of how old you are and a number of genetic factors is cardiovascular disease and in particular atherosclerosis.
I understand my risk as a man in his thirties is low for an acute event now, but the disease risk grows with time as the result of a decade on decade buildup of plaque, inflammation and wear and tear on the arteries…
Q: So how does coming to the Health Nucleus help inform someone about how their risk might change as they get older? What could a young person do using this information to minimise their risk of atherosclerosis and cardiovascular disease?
Coronary Artery Calcium Scoring. Credit: Cleveland Clinic
Dr Duchicela: Yeah that’s a great question. So in terms of cardiac assessments, one of the most powerful ones that we do here is the coronary calcium score. This is looking at calcified plaque buildup in the arteries of your heart. Essentially, the more plaque you have the higher your risk is of a heart attack.
You’re right, for someone in their thirties, who’s young, who is otherwise healthy, the chances of you finding plaque are low. Based on the general standard of care in the community, we wouldn’t be getting a coronary calcium score on somebody who’s 35 years old or younger. But here, because we’re under a research protocol, we have a little bit more leeway to push the boundaries in terms of testing in groups that may not otherwise be traditionally tested.
“we’re finding that actually about 15 to 17% of individuals around the age of 40 to 45 or younger actually have significant plaque build up. ”
And so for the coronary calcium score for example we are able to do it on a 35 year old, or 36 year old and we’re finding that actually about 15 to 17% of individuals around the age of 40 to 45 or younger actually have significant plaque build up. So we are probably missing a good amount of people out in the community who have atherosclerosis and calcified plaque in arteries of their heart which will predispose them to heart disease.
So when you come here to Health Nucleus and you if you meet the age requirement of 35 years or older (that’s what do here for the coronary calcium score), you’ll see what your plaque level, your score is, and then we will compare you to other people your same age and gender. So you get a sense of how you stack up to a healthy peer group as well and based on that, we take that into account with your cholesterol numbers and so, let’s say you have high cholesterol numbers, your LDL is elevated and your doctor is trying to push you to be on a statin or a cholesterol medicine.
If you get a coronary calcium score and your score is 0, there’s no calcified plaque seen, then you actually have a pretty good case to make that you shouldn’t be on a statin just yet . A lot of men and women come through here and their doctors are pushing and pushing them to be on a statin because their cholesterol is on the higher side, and we scan them and we get their coronary calcium score and it’s zero or very low that actually is pretty powerful in that it makes it not as urgent to be on a statin and you can talk more about lifestyle modifications and the diet, the exercise and maybe hold off on that statin for awhile longer.
A lot of men and women come through here and their doctors are pushing and pushing them to be on a statin because their cholesterol is on the higher side, and we scan them and we get their coronary calcium score and it’s zero or very low
LB: That’s a really clear answer Keegan, thank you for that.
Q: Could you comment a little bit on what the Health Nucleus can do with the MRI technology in terms of cardiovascular risk?
My heart beating, as observed by the Health Nucleus full body MRI scan and post-processing technology.
Dr Duchicela: For heart attack risk you get most of the assessment from the CT scan and the coronary calcium score. From the MRI what we’re doing is more structure of the heart so this is like what the chambers look like, how large the chambers are, or if they are hypertrophied or thickened because of high blood pressure or if it’s not pumping as well as it should be, like the ejection fraction is low because of early congestive heart failure or some sort of other heart failure. That’s what we get from the MRI. The MRI is more structural. It can find congenital abnormalities of the heart sometimes too, where as the CT scan, the one that involves a little bit of radiation, that is more for heart attack risk.
LB: That’s a good differentiation. Thanks for taking the time to answer that. And so in terms of a young person coming in, you’ve mentioned this kind of threshold of 35 years or older to do the calcium score, I don’t meet that criteria quite yet, but I’ll certainly do it when I get to that point.
Q: What other Health Nucleus tools can sit alongside the diagnostic imaging tests (MRI, CAC score) which can help a young person evaluate their lifetime risk of atherosclerosis?
Dr Duchicela: In terms of genomics, there are some genetic markers that predispose you to very high levels of cholesterol, that would be picked up not only in the blood screen testing, but also in the genetic testing.
Let's say you're twenty years old and we’re not doing a coronary calcium score, what we would use instead to help predict your overall risk would be the blood test, the lipid panel, your other metabolic markers like your haemoglobin A1c, your fasting sugar. And then from the MRI we’d be looking at your body composition, visceral fat deposition, visceral fat level. With MRI we’re now actually able to quantify pretty accurately your visceral fat volume and compare you to other people your same age and gender.
So those things would build into this risk profile, and then the traditional things like how much you drink, how much you smoke, how much sleep you’re getting, if you have signs of sleep apnoea. Even thirty year olds have sleep apnoea now, so those sorts of things all help build a risk profile for young people if you don’t have let’s say a coronary calcium score.
LB: Right and in terms of the genetic analysis, besides being predisposed to familial hypercholesterolaemia or other acute high LDL cholesterol genetics, Q: Is there another set or group of markers that you might be looking at at an early stage that can show someone’s risk?
Polygenic risk scores from my own Health Nucleus genomic report.
Dr Duchicela: What we currently have is a polygenic risk scale that tells you your relative risk. What we do is we look at gene variants that are more present in groups or individuals that have for example coronary artery disease, or who have had heart attacks and then we see if you share those same gene variants, there are weights given to each of these gene variants, and then you come up on a scale of low, medium or high risk.
“I’m really excited what we have in the pipeline with this sort of scoring ... incorporating that with the coronary calcium score and putting it together and getting a global integrated risk score”
But we’re not able to give specific numbers just yet, other than relative risk or absolute risk just because our dataset wasn’t large enough to do that. But what we’re developing right now, you’d essentially get a polygenic risk score or polygenic risk assessment that takes into account these genes associated with familial hypercholesterolaemia, but also other ones that on their own don’t dramatically increase your risk, but in aggregate if you take 20 or 30 of them together they can tilt you one way or the other.
So that’s actually the really exciting part, using polygenic risk scales and scores and building those models out. And we’re just at version one of this I’m really excited what we have in the pipeline with this sort of scoring and also incorporating that with the coronary calcium score and putting it together and getting like a global integrated risk score. So that's where we’re headed, but right now I’d say these polygenic risk scales can tell you you’re a little bit more like people with heart attacks or you’re a little bit less like people with heart attacks but it doesn’t give you an actual number just yet.
LB: That’s really clear and you’ve mentioned version one a few times so it’s clear that one of the things we need to do is get more and more people to come through the Health Nucleus and share their genetic information and family history etc.
One of the things I get really excited about and really enjoy in my visits to the Health Nucleus is going into the MRI machine. I think that’s one of the coolest things you guys do, I love picking the scene, the light color, the music, the things to look at. It’s really awesome.
Q: What kind of data will you be pulling out of the MRI scans and what will you be using it for? Besides the heart analysis and some of the cancer detection, which we already discussed. What will be showing up in that data and what will you use it for?
I’ve split this interview into FOUR parts, due to its length! Part 3 will drop next week!
Previous Post: Part 1
Note: the Health Nucleus has recently appointed a new Medical Director - Dr. Pamila Brar. Dr. Duchicela has transitioned to a role as full-time physician at the Health Nucleus, working directly with patients to optimise their healthcare!
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FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
Early cancer detection and big data - Health Nucleus interview Part 1
Shaking hands with Dr. Duchicela (left) during my January 2020 visit to the Health Nucleus!
In this post you’ll learn:
Dr. Duchicela’s background
Big Data & healthcare
The definition of ‘Healthy’
Early detection of Cancer
Part 1 - Intro, cancer detection, what is healthy?
In a series of three posts, Longevity Blog interviews Dr. Keegan Duchicela, Medical Director at the Health Nucleus in San Diego, California. Dr. Duchicela received his medical degree from UCSF in 2007. Since the completion of his residency, he has served as the Lead Physician at the Google Wellness Center (Google’s on-campus medical facility), and over the past three years has held several roles at the Health Nucleus including Clinical Director, Medical Director and Physician.
This interview, from the 24 January 2020, walked through a series of pre-written questions with Dr. Duchicela, and is presented in the form of a transcribed audio conversation.
Longevity Blog:
Q: What motivated you to become the medical director at the Health Nucleus? That’s a pretty cool job!
Dr Duchicela:
A: It is pretty cool! My training is in family medicine, so from the get go I have felt there is great value in preventing and detecting disease before it happens and having actual relationships with the patients to really delve into things other than just normal lab values and imaging. I think you really need to get to know the patient, their family, their socioeconomic context, and their culture, as well as where they live to really get a general sense of their health risks, because there are so many other things besides just labs that determine how healthy you are.
Corporate wellness centers, like those run by Premise Health, are becoming more common at big tech companies, like Google. And they recruit top-notch medical practitioners like Dr. Keegan to run them. Source
I come from a different perspective, I didn’t go into medicine to learn about genetics or advanced imaging or even precision medicine, my focus was more on getting to know the person holistically to really enable them to take care of their body, their mind and their family. I looked at health in that context. But as I went through training and through the kinds of places I’ve worked over my career; I worked for a few years at Google helping lead their onsite primary care clinics where I encountered a lot of interesting individuals, engineers who were doing some amazing things with Big Data, I started to really see the value in having a large data set on health metrics and what you can do with that sort of information and the impact you can achieve. I began thinking that the future of medicine for physicians is as good data scientists with excellent bedside manner.
If we could offer this testing at a very inexpensive price point to millions of people, how much better would our health improve overall? I think it could be pretty dramatic to be honest with you.
I really think that’s where we’re heading. And so as a physician I feel like it’s really important to grasp the implications of using Big Data and what it really means and how we can use these analytical tools to predict where we’re going with our health.
after I left Google, I was looking for a company that was doing innovative things
So after I left Google, I was looking for a company that was doing innovative things in this space and really Human Longevity was the only place that I found that’s using imaging, genetics, peripheral blood biomarkers, plus family history and past medical history and putting it all together and getting a comprehensive view of health. So that’s what attracted me to the position. It’s been a wild ride and very interesting to see how the company has evolved and progressed and I think we have a pretty bright future. It’s exciting to be the medical director and that’s kind of how I ended up here.
Looking at this from a primary care perspective, if we could offer this testing at a very inexpensive price point to millions of people, how much better would our health improve overall? I think it could be pretty dramatic to be honest with you.
Longevity Blog (LB): I love that vision and one of the things that attracted me to HLI (Human Longevity Inc.) was one of your founders Peter Diamandis. He’s one of my… ‘heroes’, I’ll call him, a mentor, somebody I look up to. He shapes my thinking a lot and that idea of inexpensive testing for millions and reaching and impacting people positively is a mission that I believe in. The Longevity Blog is me playing my small part in helping to accomplish that.
There’s a really interesting kind of dichotomy that we find between the healthcare industry and the Health Nucleus - and that’s thinking proactively about health care. If I were to go into my doctor’s office, my traditional GP here in Australia and didn’t have any acute symptoms of any sort and told them I was there to optimise my health, they would probably tell me to get outta there because they are there to take care of somebody who’s sick.
Q: So, I was curious what you think the Health Nucleus definition of “healthy” is and how might it be different from a traditional one?
From the Health Nucleus website
Dr Duchicela:
A: I think right now we are in version one of this, in that we are trying to create a suite of testing modalities. We are trying to detect the things that prematurely end people’s lives very early on. The broad categories of these would be things like cancer, metabolic diseases like aneurysm or heart disease, and neurodegenerative disease like alzheimer's. And right now our testing packages or testing suites are set up where we’re looking for those big categories of disease.
When we have enough data and we have enough people go through, and we are able to create advanced risk prediction tool kits and algorithms, that’s when the real promise of a company like this can come to fruition. We do get pretty rigorous metrics from things like genomics and also from the imaging biomarkers like liver fat and visceral fat, but what we really want to do and what we’re currently working on and what really excites me is taking your genomics - let’s say dementia or Alzheimer’s - taking your ApoE status and taking your hippocampal volume metrics from your imaging and also taking into account these other genomic variants that may not contribute to risk in such a large way as for example ApoE does, but on their own could tilt the needle one way or the other and putting this all together with your alcohol consumption, your BMI, your visceral fat levels and everything else and using machine learning and AI to come up with a ten year risk prediction for Alzheimer’s disease.
An example of the brain imagery data collected by MRI at the Health Nucleus, to compute metrics like hippocampal volume. Pictured: my own brain!
That’s where I think the true promise of this testing lies, but those algorithms need to be developed and it really does take a large data set to develop those algorithms. So right now I’d say in terms of our testing modalities we have a really good screening test for these five big categories of disease, but we really want to evolve into becoming the crystal ball for alzheimers, the crystal ball for metabolic disease, the crystal ball for prostate cancer or breast cancer by putting these algorithms or data modalities together and really deriving some good inferences from them, but we need a large data set first. I think that’s the biggest challenge with this.
LB: Right and so that kind of definition of healthy is actually shifting perspective out ahead of time almost, not just are you healthy now, but will you be healthy in the future and what can we do to minimise your risk and hopefully be able to be more predictive with more data and better algorithms that you’re continuing to develop.
Dr Duchicela:
it’s tricky to give a one size fits all definition of health. You really have to take in the context of the individual and see what their values and priorities are and what they want out of their life
A: Yeah and everyone really has their own definition of healthy, because different people have different values. For example I had a patient the other day who is a wine entrepreneur. This is his business, this is how he supports himself and his family, and to tell him, “Hey listen, if you really want to optimise your health and be quote-unquote completely healthy, you may want to avoid the amount of alcohol you’re drinking, because alcohol is a carcinogen.” For him, that would actually negatively impact his lifestyle. He wouldn’t necessarily be living a happy life if he gave up his profession. So, I think it’s tricky to give a one size fits all definition of health. You really have to take in the context of the individual and see what their values and priorities are and what they want out of their life.
And if you ask people about this, it’s not one size fits all. I think that’s the art of this, figuring out what drives them, what motivates them to come in to get assessed; Is it a family member who was recently diagnosed? Is it because they have a grandchild now and they want to be able to be healthy and active for when they get older?
And, at least as a physician that’s what I’m trying to focus on, how do we judge success? I don’t think it’s necessarily just not dying at an early age. It’s essentially living a fulfilling life and accomplishing the goals that you want to accomplish, whether that be having your own wine business and doing that as a profession or living to 100 and being cancer free the entire time. So, I think what we like to do here at the Health Nucleus is focus on the goals of the patient and really try to tailor our recommendations and counseling towards their goals.
LB: That’s great and I love that individual nature of it and the reflection of values and goals that the individual has. You’re right that the definition of healthy has to sit in that spectrum. That’s an encouraging answer and one I definitely agree with.
You just mentioned at the end of your talk there, cancer. Cancer is actually something that has personally impacted me, even directly in my own wife who has had to have two big peritonectomy surgeries for appendix cancer, thankfully she’s in remission now.
I think about the widespread availability of Health Nucleus technologies and MRI scanning etc. and think about if we had had routine access to something like that, how might that outcome have been different.
Q: Now, I don’t want you to go into theoretical outcomes for my specific case, but I’m really interested in helping to share with folks how the Health Nucleus can detect the actual presence of cancer, not just cancer risk but the actual presence of cancer at an early stage.
Dr Duchicela:
A: That’s a great question. When looking at our testing modalities, we have the imaging which is almost like a point-in-time disease test. We’re looking for disease right now, or early early disease, that’s the hope. With the genetic testing, it’s more your disease risk five years, ten years down the road. So the imaging is really powerful in that we can tell you within a few hours after a scan, if there is something concerning, a soft-tissue mass or an aneurysm even.
our goal is to develop a test that doesn’t use radiation, that we can give safely to many many people, that covers most cancers and then have a suite of tests to fill in the gaps essentially.
With our imaging, that’s really the goal, we cover some cancers pretty well, but we also have some gaps in our cancer coverage, just to be completely transparent. We don’t pick up colon cancer or certain other GI cancers very well, the MRI results are limited because we don’t have people do a bowel prep ahead of time, so we would still recommend a colonoscopy or a Cologuard test for that.
Certain pulmonary cancers you can’t get too well just yet with MRI but we’re working on that. No screening test is perfect, and you can’t catch every cancer with one single test, but our goal is to develop a test that doesn’t use radiation, that we can give safely to many many people, that covers most cancers and then have a suite of tests to fill in the gaps essentially.
My own Health Nucleus MRI scan (pictured), from 2018.
Or maybe they can go through their traditional medical provider to do the colon cancer screening if we don’t have a good option for it here. So in terms of developing a test for cancer, it’s tricky because we don’t want to say that if you have a completely clear scan you’re cancer free, there are gaps and limitations with the current technology. But over time as we are able to get more patients through, we’re able to do better processing on the images, so hopefully we will start to fill in those gaps with better early detection of cancer.
LB:
Q: You’ve made very clear caveats on the limitations there, but where does your technology excel and succeed? There would definitely be some anecdotal examples of detecting certain types of cancer at an early stage. You certainly have some excellent technology in that space, could you elaborate a bit further on that?
Dr Duchicela:
I think where it excels is that we’re able to get really good images without having to use contrast and that’s really important if we’re trying to scale this and bring it to many people at a low price point, we want to make it safe too. We do have pretty good post processing.
Let’s take prostate cancer for example, most men will die with prostate cancer, rather than from prostate cancer. So the trick is, how do we know which prostate cancer is going to be an issue and is going to prematurely end your life and which is so slow growing that they will most likely pass away from other things instead of the prostate cancer. With the post processing that the computer scientists and radiologists, people much smarter than myself, have developed, they’re able to light up and differentiate with the software these higher grade lesions in the prostate that have a higher chance of being a concern and being more aggressive and truly cancerous.
Image Credit: UC London. Prostate cancer screening by MRI is becoming more widely accepted. That’s very good news for early detection and treatment. Source
So that kind of differentiation on the back end is really powerful. We don’t want to be detecting things that won’t really harm someone in the long run. If you’re familiar with prostate cancer screening in general, it’s pretty controversial just because if we find something, we are almost obligated to biopsy it and there can be complications with biopsy. So we really want to make sure that we are finding things that are meaningful, and I think with the post processing that we do with our scans we can make that differentiation and better guide them to say alright this a lesion that is at a much higher risk, so we would suggest you get a biopsy, as opposed to alright this is lower risk lesion based on our scans and it may be more reasonable to watch and wait, get a serial PSA, that sort of thing.
LB: That makes a lot of sense, and you’re right in terms of wanting to minimise false detection or follow up treatment or biopsy to the really significant or possibly progressive forms of the cancer. That’s really fascinating.
We’ve talked a little bit about cancer, another big killer and one that is kind of a function of how old you are and how long you’ve been alive and a number of genetic risk factors is actually cardiovascular disease and in particular atherosclerosis.
I understand my risk as a man in his thirties is low for an acute event now, but that it’s really decade on decade buildup of plaque and inflammation and wear and tear on the arteries that increases the risk…
Q: So how does coming to the Health Nucleus help inform someone about their risk as they get older and what they can do as a young person to minimise the risk of atherosclerosis and cardiovascular disease?
I’ve split this interview into four parts, due to its length! Part 2 is coming soon :)
Note: the Health Nucleus has recently appointed a new Medical Director - Dr. Pamila Brar. Dr. Duchicela has transitioned to a role as full-time physician at the Health Nucleus, working directly with patients to optimise their healthcare!
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Full body MRI data: health screening of the brain, heart and abdomen
What is a 3D full body MRI and what did I learn from completing one at the Health Nucleus in San Diego?
Full body MRI scan technology
Full body MRI data is an incredible advancement for health screening.
As we covered in our inaugrual post, our Founder (Nick), chose the Human Longevity Inc ‘Health Nucleus’ in 2018 as the starting point for his personal comprehensive health screening journey.
The San Diego based centre, focuses on employing cutting edge capabilities for detecting disease at an early stage. Full body MRI scanning is core to their offering.
This post offers a quick overview at what this technology is capable of.
What is a full body MRI? (With Video)
Magnetic resonance imaging (MRI) has the ability to image the inside of your body in great detail, through the use of strong magnetic fields and radio waves. It does this without the use of harmful electromagnetic radiation (like X-rays or CT scans).
At the Health Nucleus, the full body MRI scan emphasises the brain, cardiac health and cancer screening within the chest, abdomen and pelvis. It also produces valuable information about body composition.
Here is a great short video from HLI that you can view below that explains this a bit further:
Why purchase a Full body MRI?
The future of healthcare is proactive & preventative, and that future is underpinned by comprehensive health screening technologies like the full body MRI!
The current state of ‘reactive healthcare’ (only treat you once you are sick), has already pioneered nearly all of the medical treatments required to treat the most common life-threatening diseases.
This however requires that they are detected early at the ‘treatable stage’. This is where full body MRI scanning comes in handy.
A full body MRI like the one offered by the Health Nucleus, scans the brain, heart and abdomen in high resolution. Through their specialised suite of sophisticated post-processing algorithms, they are able to detect tumours that are only millimetres in diameter.
This technology can also discover brain aneurisms before they ruptures, as well as abnormalities of the heart or circulatory system.
You may be surprised to know that the Health Nucleus has found clinically significant findings in 40% of their clients! These aren’t all revealed by the full body MRI, but many of the more serious and dangerous findings are (e.g. pancreatic cancer).
What is a full body MRI experience like?
A fully body MRIO requires being inside of an MRI machine for up to 70 minutes (with a short break in between). This can be quite intimidating for some people.
Here is a short video describing Nick’s full body MRI experience:
What did a FULL body MRI reveal about me?
““I spent nearly 75 minutes in the MRI machine, watching amazing images from outer space on a ceiling-mounted monitor, while listening to relaxing transcendental music””
Example full body MRI data - The Brain
Brain analytics, highlighting the different regions of Nick’s brain.
As is the case for many folks undertaking proactive health screenings, Nick’s full body MRI did not reveal any pathological findings.
What was gathered however, was a wealth of valuable baseline data. As an example, the brain scanning established normal values for the volumes of each of the major regions of the brain.
One area of particular interest is the hippocampus, whose volume is known to decrease with age, along with a decline in short-term memory and overall ‘plasticity’ (ability to adapt to new learning).
As Nick ages, we’ll be able to monitor his hippocampus for any changes in its volume. As well as other regions under increased pressure with aging, such as the hypothalamus.
Example of full body MRI data - The Heart
Nick’s heart beating away!
Cardiac MRI is a specific type of scanning approach, which can watch the heart beat and trace the flow of blood.
For example, the ‘ejection fraction’ can be quantified, and tracked over time. Any abnormalities in heartbeat are also immediately apparent.
Cardiac MRI reveals the structure of the heart, and in particularly can detect any hypertrophy (abnormal growth of a heart chamber) or thickening of the heart wall because of high blood pressure.
Example of fully body MRI data - Visceral fat
MRI data is also exceptional at revealing body composition.
One of the more important predictors of the risk of disease and/or mortality (risk of dying) are an individual’s visceral fat levels.
Another important metric is the total volume of fat in your liver (e.g. fatty liver disease).
The full-body MRI can directly quantify these volumes, compare you to a reference population and give you clear advice on how much fat you need to lose to lower your disease risk.
FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.