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INTRODUCTION  
PROOF OF CONCEPT
 
“We go through life. We shed our skins. We become ourselves. Ultimately, we are not seeking others to bow to, but to reinforce our individual natures, to help us suffer our own choices, to guide us on our own particular journeys.”
—PATTI SMITH, DETAILS, 1993
 
I am afraid of dying. It’s not the beginning or middle of life that is the problem; it’s the end. Those last 10 years have me scared. You see, getting older is a relatively new thing, and the fact is that we really aren’t that good at it. To be sure, medicine has done a great job over the past century helping us all live longer. Clean water, antibiotics, and modern surgery have postponed checkout time for most of us. The problem is that while life span has increased, our health span hasn’t kept pace. I am an orthopedic surgeon, and I will be the first to admit to you that contemporary healthcare has created a generation of invalids—people just surviving, not thriving, at the end of their lives. Our parents, who worked their whole lives for a retirement they thought would be filled with joy and purpose, are withering away as their frail bodies and minds disintegrate. Heart disease, hypertension, strokes, renal disease, diabetes, and fractures are more common than ever. Rates of Alzheimer’s disease, Parkinson’s, and depression are rising. Doctors continue to treat the symptoms while the causes go unmanaged. Aging has become unsustainable.
 
The sad part of all this is that we didn’t just screw over one generation. We took down two. I see this all the time in my office, devoted daughters and sons sacrificing their emotional and financial resources to try to deal with the unintentional but escalating demands of their parents’ failing health and vitality. Worse than that, they see what is happening to their parents and wonder what fate has in store for them. Add a dash of obesity and a touch of desperation, and you have a heady mix that makes people feel powerless and fatigued. Rudderless in a white water they can’t control. Two generations twisting in a medical, economic, and social whirlpool that is draining the vitality of our families and nation. Well I say, to hell with that.
 
I am a baby boomer. You know, the generation that blew up every demographic we passed through like a pig in a python. Well, we’re coming around the final clubhouse turn and heading for the Big Finale. Every day 10,000 people turn 60. Every single day. By 2050, the global population over 60 will double to more than two billion people. This trend has been called a silver tsunami, and the staggering medical needs that accompany this wave are expected to push our yearly national healthcare bill here in the United States to more than $4 trillion by 2030.
 
If we fail to make the changes needed to address the coming wave, it will not be for lack of funds. The global market for anti-aging products is increasing by 8 percent per year and will reach $191.7 billion by 2019. Insurance companies and Big Pharma have focused on drug pipelines responding to symptoms instead of causes and have been rewarded with handsome profits. The new millennium has seen a radical shift in our cultural attitude toward aging, and longevity research has exploded during the last 3 years. Still not convinced? Google certainly is. Its new life extension venture, Calico (a division of Alphabet), has put their money where their big data is. They inked a $1.5 billion 10-year joint deal with the Chicago-based pharmaceutical giant AbbVie to develop a new line of anti-aging drugs and therapies. Hungry startups abound in this new anti-aging galaxy. Unity Biotechnology, a maker of senolytic medications to reverse heart disease, osteoarthritis, and failing eyesight, has raised $116 million in Series B funding. The investors include Jeff Bezos and the investment arm of Amazon, Bezos Expeditions. Even the FDA, who had never previously acknowledged aging as a disease process, has finally shifted gears. This year the FDA approved its first-ever anti-aging drug study, a clinical trial of metformin.
 
It’s not just the AARP-crowd that is grappling with growing old. Who are the biggest consumers of plastic surgery in the United States? The Gen Xers. The generation known for extending adolescence is now hoping to extend their lives, too. They don’t just want to age healthier, they want to age prettier. Gen Xers are consuming anti-aging products and supplements at a record clip. Next up, the Millennials—a generation that craves authoritative, doctor-endorsed products is now seeking innovative solutions for healthy, experiential living. People of every age are looking for the pathways to better aging.
 
But what if the solutions were already here? What if we could translate all the exotic science and research breakthroughs of today into a practical plan that could invigorate and energize the way we all live right now? What if there were already ways to ease the negative effects of aging and keep diabetes, heart disease, cancer, Parkinson’s disease, and Alzheimer’s disease from ever starting? What if we could win the war on aging through prevention instead of intervention? I don’t know about you, but I am determined not to repeat the mistakes of the past and be herded to the north forty to run out the clock. I don’t just want to go through the motions. I want to thrive. And I think you do, too. You just need the tools. Where will you find the knowledge, instruction, advice, and motivation to get this difficult job done? Right here. Right now.
 
The Fountain is the story of a relationship—the most intense and complex relationship of all: the one between your body and your environment. Like all affairs, it’s defined by choices and sacrifice. Decisions carry consequences. Freedom demands responsibility. For most people, this relationship has always been unbalanced. Asymmetric. No matter what you do, it seems impossible to level the field. Our leaders have kept us in the dark, and those we have trusted most, our caregivers, are only now beginning to shed their white coats and partner with us. Not anymore. The Fountain is meant to be disruptive. It questions the established doctrines of traditional medicine that have brought us to this tipping point. This book is intended to give you the knowledge and tools to begin to recalibrate your approach to health. It will empower you to take control of your life and make better choices. It was written to help you thrive.
 
The book is organized into five distinct sections. I call them phases. Each section stands on its own, so cruise around as you like. You can pit for gas anytime. Anywhere. Phase One covers the science of aging. Science is, by definition, the art of observation. The opening chapter starts with the observation that the world is sprinkled with anti-aging hot spots, places where people have been able to live longer and more vigorous lives than anywhere else. Why start there? Because science requires context. Before you start drilling down to the microcellular level, you need to gain some perspective. People who live in these areas, called blue zones, which include Sardinia, Okinawa, Ikaria, Nicoya, and Loma Linda, have average life spans that exceed the rest of the world by at least 10 years. Not too shabby. More importantly, people who live in the blue zones have less chronic disease and more active lives. What do these widely disparate locales, some of them achingly isolated and rugged, possibly have in common that binds them together in a battle for vitality and longevity? There are clues. People in the blue zones eat a plant-based diet, rarely retire, exercise vigorously, and live with faith and purpose. What does this tell us? Humans are a resilient, ingenious species, and challenging environments select for the toughest of us. Check. You could take the blue pill and you’d probably be fine, but you would never know why. You’ll just go on believing what you choose to believe. Don’t do it. Take the red pill and keep reading, it will be worth it.
 
The first phase of the book also focuses on the fascinating science of aging. In this section, you will learn about what the brilliant Spanish biologist Carlos López-Otín and his colleagues call the hallmarks of aging. This team has created the first true unified model of metabolism, and it is all about energy and error. We’ll review each of these seven hallmarks, or signs, and their unique characteristics, and you’ll learn how to harness this incredible research to improve the quality of your health and life.
 
Can you cheat death? Not yet. But you can scam the hell out of life. The Fountain surveys the latest research on diet, exercise, mindfulness, supplements, and medications specifically targeted to help you wring the most out of life and to make the whole thing worth it.
 
The science section, and really, the rest of the book, is all about giving you the practical information and tactics you need to win these metabolic duels. Decrease error and preserve energy. You’ll learn how mitochondria work and why they are so critical to our vitality. If you’re going to live longer, you are going to need some more gas in the tank to get the job done. Nicotinamide adenosine dinucleotide (NAD+) molecules are your factory’s fuel rods and the most precious biochemical commodities in the metabolic universe. NAD+ is both the hammer and chisel of life. It is an important cofactor in many enzymatic processes and a critical player in generating the fuel to run those reactions. If you take one lesson home from this book, remember the importance of NAD+. I’ll also introduce some ways to keep your NAD+ levels high through exercise, diet, and supplements. Think stem cells and gene editing will hook you up with some sparkling new virgin DNA? Sorry, but you can’t get a genetic face-lift just yet. For now, you will have to be content with doing it the hard way. I will show you the risks and benefits of fasting and caloric restriction and why people can’t stick to it (hint: you already know why). Fasting works, but it is brutal on active people, and it simply isn’t a very practical approach to longevity. There are more attractive alternatives. You’ll also discover your first dietary tool to live healthier—time-restricted feeding (TRF). By limiting all your meals to within 12 hours or fewer, you can leverage the influence of your natural circadian rhythms and delay many of the hallmarks of aging.
 
The next phase in the book is diet, and things get serious here. The Fountain questions authority and undermines medical dogma with facts. We’ll bust all the biggest dietary myths. We’ve been told for 40 years that saturated fat causes high cholesterol, and high cholesterol causes heart disease. Nonsense. The diet-heart hypothesis is not supported by most research. Heart disease is driven by inflammation. You can get up to 35 percent of your daily calories from fat and mix the saturation level any way your little sclerotic-free heart wants to. Well, then sugar is going to kill you, right? Wrong, sort of. Overeating is going to kill you, not glucose. Your mitochondria need glucose to make ATP, the energy currency of the body. Sugar will just make your slow-motion suicide a little less painless. Look, you can get up to 55 percent of your calories from carbohydrates and you’ll do just fine. Keep the sugar at 5 percent. This won’t be that crazy hard if you avoid the place where most sugar is burrowed—deep within processed food. It’s lying in wait in your bag of Doritos for a chance to punch a ticket straight to your bliss point. Salt is another misunderstood thing. Where is most of Na+? Right next to the sugar in your party bag of chips. Once you get rid of the processed foods, the amount of dietary salt in your diet crashes down. If you continually load up your diet with salt, high levels might eventually hurt you by causing osteoporosis or cancer. What else can salt do? Adding salt to your food makes you hungry, not thirsty.
 
Don’t get me started on gluten-free. If you have celiac disease, I am so sorry because that sucks for you incredibly. It is a terrible autoimmune condition that reaches far beyond issues of gluten and wheat. As for gluten sensitivity, I am not buying it just yet. You’ll have to prove that one to me. Hey, I say go gluten-free if you think it makes you feel better, but beware of the very real risks of mercury and arsenic poisoning from a gluten-free diet. Rice is the original toxin sponge. Don’t believe me? Skip on over to Chapter 6 and find out the hidden dangers of going G-free. You can also amaze your friends and read about what gluten is. When you’re done, you can go grab some guilt-free pizza.
 
You could say that you don’t eat pizza because you’re on a high-protein diet. If you are, you need to shoot over to Chapter 7 to read up on why that might not be the brightest move ever. Protein itself is not bad, but an average guy needs only around 56 grams a day to take care of normal cellular maintenance, including muscle repair. The average gal needs even less; about 46 grams a day will keep her system humming. High protein intake is fine when you’re growing or if you’re a young athlete in the middle of a heavy training regimen. However, long-term high-protein diets do two very bad things. One, they can overload the filtration system in your kidneys. Two, they push up your levels of insulin-like growth factor-1 (IGF-1). Think that’s great? You shouldn’t, because IGF-1 is like catnip for cancer.
 
Don’t worry, I didn’t skip over any protected dietary classifications in my research for this book. In Chapter 8 I try to wrap my delicate stems around what being a vegan really means. Vegans reap some real benefits beyond identity and politics. Strength and physical performance are not incompatible with a life without meat. There are many great athletes who live off the green stuff alone. Remember that all choices carry consequences. The bottom line is that plant-based diets are cool, but we were designed as omnivores. If you are going to pull off the whole vegan lifestyle and stick with it, you better have your Amazon Dash button preloaded for regular vitamin B12 and iron supplements. Can you say vegetanemia?
 
The diet phase of The Fountain does wrap up with some good news: Coffee and tea are back, baby. Supplements are the aperitifs in this section, and I will help you to make some sense out of the absolute hot mess of literature on this controversial topic. The most important lesson of this chapter is that you should accept the fact that most of the world today is vitamin D deficient. Optimizing your vitamin D levels will help you maintain your bones and connective tissues. It also does a good job of mopping up excess circulating IGF-1 to lower the risk of cancer. In fact, when you get done whipping through this introduction, the first thing you should do is to roll on over to a pharmacy and buy yourself a bottle of vitamin D3 supplements. Your future self will thank you for it.
 
The next step in your journey is Phase Three: Exercise and Mind-Body. Of all the tools to combat the crappy way we age, exercise is the most powerful. There is no food, pill, or procedure that affects the body as powerfully as exercise. It truly is medicine. Working out alters the histone arrangements and epigenetic profile of your DNA within minutes. It improves your insulin sensitivity and energy reserves. It decelerates every hallmark of aging and promotes vitality. It is also sweaty and difficult. You need about 1 hour a day to get the job done. The type of exercise you choose is far less important than the simple act of doing it. I have my favorites, and you’ll learn why there really is no gain without a little pain. BTW, sweating is not an indication of caloric burn. It is simply a means to dissipate excess body heat. Hey, we can do some vinyasas together as you learn more about the benefits of yoga, tai chi, and other types of qigong. Wax on, wax off, people.
 
The final aspect of the exercise phase of The Fountain is all about getting your mental groove on. Let’s face it, getting older is not for the faint of heart. Mental focus and clarity will buy you some more time and help you stay sharp. Are Web-based mental training sites worth the money? No. I do believe in the concept of flow and think that people get more creative as they get older. The biggest mental advantage you could ever have to gain longevity is a strong sense of purpose. Never retire. Ever. Don’t move into an assisted living facility or retirement home. Ever. Your mind needs stimulation, and there is a natural affinity between the young and old that is too frequently ignored. If you want to live longer and keep the nugget working, you need to demand attention and interaction. Still, modern life is noisy. It’s important to get comfortable with silence and reconnect with your thoughts. Ten minutes of meditation a day is all you need to enhance creativity and performance no matter what your age.
 
I know what you’re thinking. This whole Fountain thing sounds awfully involved. Diet, exercise, supplements, meditation. Isn’t there some kind of pill that I can take that can do all this stuff for me, doc? Well … I wondered the same thing. We might not be there yet, but we aren’t that far from offering useful anti-aging drugs. I devote Phase Four to the medications that are being evaluated to help us live longer and better. As you reach midlife, your body starts to slow down its production of most of the hormones that define your personality and sexuality. The big four players here are testosterone, estrogen, growth hormone, and oxytocin. The real deal is that if you’re a middle-aged man and feeling crappy, it doesn’t hurt to get your free testosterone level checked. You’re probably okay, but when you are having trouble in the sack, the mind has a way of magnifying the problem. If you do have low T, there is nothing wrong with trialling low-dose supplements to nudge you back to the normal range. It doesn’t appear to elevate your risk of prostate cancer, although I would avoid supplementing if I had a history of prostate cancer. It might not turn your bedroom into a game of Twister, but it couldn’t hurt. If you do take a trip on the T train, please do it with a real live doctor watching your blood levels, not on your own through some sketchy dark web Italian pharmacy. Lei capisce? Hint: If you find that you have anger management issues, you might want to lay off the androgens and just stick to eggs and bacon.
 
Ladies, an increasing body of research suggests you should consider a few years of transdermal estrogen replacement therapy after you reach menopause if you’ve had a hysterectomy. No hysterectomy? Then let symptoms be your guide. Clearly, you can’t go the estrogen route if you’ve had breast cancer, particularly if it was an estrogen-positive tumor. Some of the difficult symptoms of menopause that women face are hot flashes and night sweats, which can wreck your sleep. Estrogen replacement can help, or you could also consider bioidenticals of selective serotonin reuptake inhibitors. Anyway, you’ll want to read this section before you talk to your doctor. It will help you get a handle on the realistic risks and benefits of this approach.
 
As for growth hormone supplementation, there is no doubt it does have a positive impact on lean body mass and muscle size in both men and women. But there is a huge downside. I recommend steering clear of growth hormone therapy as you get older because of the very real risk that its elevation of circulating IGF-1 will promote cancer development. It can also cause diabetes and heart problems. Oxytocin is a psychoactive hormone that seems to affect vitality. There is a lot of interest now in this hormone, and it may prove to be helpful in preventing frailty in the elderly. I’m listening.
 
Why do you need this book? Because it works. And perhaps you’ve reached the point where you’ve realized you need to make a change. I am a perfect example of how life can wear you down and lead you to a tipping point. Mine came at the hands of a surly, meaty-handed male nurse. Wait. I probably should explain. A few years ago, I thought I was doing pretty well. A busy practice on the beautiful island of Nantucket, two freshly minted children, and a beautiful wife. But there were some cracks in my foundation. I was having trouble keeping up my practice, my energy was low, my joints ached, and my wife was getting tired of my constant complaining. I felt terrible, but I blamed everybody else for my state. I never thought the problem could actually be me.
 
When I started having some weird neck and arm pain, I became alarmed. In true doctor fashion, I called my insurance agent to check on my disability coverage rather than seeing a physician. My agent lives in Philadelphia, and I hadn’t seen him in 20 years. He thought I needed more disability insurance (of course) and that I just needed an exam. He arranged for somebody to come out to the island to check me out. A few days later, a nurse from the insurance company made landfall and came by the office to do a physical exam. I unbuttoned my shirt and laid down on my crinkling table paper while this big, sweaty male nurse did an EKG on me. He casually asked me how tall I was. “Five-foot-10,” I told him. He raised an eyebrow. Then he asked how much I weighed. I said what I always say when the nice ladies check me in for my inter-island Cessna flights—185. He laughed and told me that may have been what I used to weigh. I persisted. “No, I’m 185, I’m what I’ve always been.” He tipped his smudged glasses down his nose and challenged me to use my scale or his. I chose the home-field advantage scale. 210. Two hundred and ten pounds. Shocked, I think I must have jiggled a little as I slowly sat down. I guess my wife wasn’t shrinking my pants in the dryer. The nurse, who was easily twice my jumbo size, drew some blood from my fluffy veins and packed up his gear. “You’ll be hearing from us,” he said as he left. Great.
 
My insurance guy called me a couple of days later. He wanted to know what the hell had happened to me. He asked me when I got old and fat. Nice. Then he tried to make me feel better and told me that he might be able to get me some insurance but that it was going to cost me. I had already stopped listening. What happened to you, Rock? When did you get old and fat?
 
Look, I’ve been an athlete all my life, and I’m a surgeon. Vain, self-centered, and more than a little egotistical. No argument there. Old and fat, however, was not acceptable. So, I started doing everything I had always been taught in medicine about living healthfully. I went on a low-fat, high-protein diet, started playing soccer once a week again, and cut out the snacks. I even ate apples. Apples! Six weeks later, still feeling cruddy, but a little leaner, I got on the scale for my triumphant exoneration. The scale spun like a roulette wheel. 208. I rubbed my eyes and jiggled a little while I double-checked the number. 208. My wife, who is ridiculously fit and insists on working out every day, told me I was doing it all wrong. I had to exercise every day, I had to eat less, and I needed to be less obsessive. Yeah, I got that. Sometimes I can be a little slow on the uptake, but I did realize that I needed to find a different way. I just wanted to know why. I started reading and researching everything I could get my hands on. The more I learned, the more I realized that she was right. I asked my wife for one of her workout DVDs. She gave me an “easy one.” I thought I was going to die, but I did it. I started doing daily high-intensity interval training. The workouts slowly got easier. I went to a balanced diet, cut down the calories, and started eating all my meals within a 10-hour period.
 
Things started happening fast. Good things. The weight started coming off. After 2 weeks, I lost 8 pounds. By 1 month, I had lost 15 and gave my wife permission to start throwing my pants in the dryer again. After 2 months, I had lost 25 pounds. At 3 months, my weight crept back up a little, but I realized that I could fool my internal thermostat by varying my diet and the type and length of my exercise. At 6 months, I was down to 180 pounds and felt a helluva lot better about everything.
 
That was 5 years ago, and I’m still 30 pounds lighter and feel 30 years younger than I did then. I’ve incorporated all the lessons I learned into The Fountain, and with this book in your hands, you, too, have the tools to look and feel much younger than you ever thought you could. You don’t have to be an athlete or medical person to do what I did. You just need some knowledge, motivation, and a little discipline to pull it off. It’s not crazy hard. It’s a tactical approach backed by intense scientific research. Eating better, eating less. Working out more, working out smarter. Taking targeted supplements. Using medications to fix the rest. Restoring the balance between mind, body, and environment. Does it require some work? Damned right it does, but the results will be worth it.
 
What if you’re only 30 or 40? I have news for you. Your DNA doesn’t care. You need to start applying the lessons in this book ASAP if you want to change your molecular fate. If you are serious about staying healthy, it doesn’t matter whether you are 20, 30, 40, 50, or 60. Your environment and lifestyle are already scrambling your genetic profile. If you are over 60, the clock is ticking. You better pay close attention and start your genetic renovation project immediately. Given enough time, most damage can be reversed. And time is the essence of this book.
 
That’s how The Fountain flows. Think of it as an owner’s guide to your body. A Google Maps to help you make better choices about how you live every day. When you are finished reading this book, it will all begin to make sense. There is no one single answer to the aging question. The solutions are complex. Yet, there is an elegance in their connectivity; a beauty in the science of it all. Metabolism is the network that connects diet, exercise, supplements, and medication. The sooner you learn the floor plan, the better. The Fountain won’t provide every answer you’re seeking, but it will give you a scaffold to frame the right questions. I might still be afraid of dying, but after researching and writing this book, I gained a clarity and vision about aging that I never had before. I used to fear getting older, but I am not afraid anymore. After you read this book, you won’t be either. We are going to crush this thing together.
 
What is an orthopedic surgeon like me doing talking about aging? One reason is that my work takes me right through ground zero of the very worst things that aging can do to people. Terrible things. I’ve spent my entire career rebuilding the worn-out cartilage, ripped tendons, and shattered bones that result from the way we have always aged. A surgical sin-eater. A collector. But it doesn’t have to be like this. Any one of the tools in this book can help turn this rusty freighter around and make aging a graceful and rewarding trek. Put them all together, and senior life starts looking a whole lot more junior. Don’t let the slippage of time simply mold you. Make health a habit. If you start applying the lessons you learn in The Fountain now, you won’t just have a better tomorrow, you’ll have a better today.
 
The other reason I am here telling you about aging is that I am a translator. I spend most of my day turning complex, scary situations into understandable, scalable explanations. The world can be a dark, dangerous place. Lighting it properly takes patience, nuance, and a keen interest in not just the why, but the how.
 
The Fountain is the product of years of canvassing the world for the latest meaningful opinions on longevity and thousands of hours spent reviewing and curating primary scientific research, and it will take you from the exotic corners of the globe to the churning nucleus of our cells, from sterile laboratories to sweaty gyms, from heights of outer space to depths of inner space. What are you waiting for? The secrets of a long life full of health, vitality, and meaning await.