Today, I review, link to, and excerpt from The Curbsiders’ “#520: Healthspan Medicine, A Practical Approach”, April 6, 2026 | By Paul Wurtz.
All that follows is from the above resource.
#520: Healthspan Medicine, A Practical Approach
Transcript available via YouTube
CGMs, Sleep, Exercise, and Metabolic Health in Primary Care
How do we help patients improve health span without letting wearables, biomarkers, and wellness trends take over the conversation? Learn how to think about CGMs in patients without diabetes, how to interpret early cardiometabolic risk beyond the A1c, how to prescribe exercise in a practical way, and how to counsel patients about sleep, wearables, and even peptides. We’re joined by Dr. Sandeep Palakadedi (Dr. “Deep”), founder and CEO of Velocity Health and author of The Ultimate Asset.
Beyond Glucose: ApoB, Lp(a), and Early Cardiometabolic Risk
Body Composition, VO2 Max, and Functional Longevity
Sleep, HRV, and Wearables
Prescribing Exercise in Real Life
How to Talk to Patients About Peptides
Take-Home Points
Disclosures
Dr. Palakodeti reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Healthspan Medicine Pearls
CGMs can be helpful in patients without diabetes, but only if clinicians and patients understand what counts as signal versus noise. Brief postprandial spikes can be physiologic; persistent elevation is more concerning.
A flat glucose trace is not the same thing as low cardiovascular risk. If a dietary pattern lowers glucose excursions but raises ApoB, that may represent a dangerous tradeoff.
ApoB is often more useful than LDL-C when the standard lipid panel may be underestimating atherogenic risk, especially in patients with insulin resistance, elevated triglycerides, central adiposity, or metabolic syndrome.
Lp(a) helps quantify inherited cardiovascular risk and may justify more aggressive treatment of modifiable risk factors even when the standard lipid panel looks reassuring.
Muscle is a major glucose sink. Resistance training improves insulin sensitivity and should be part of nearly every metabolic health plan.
VO2 max and muscle mass are not vanity metrics. They help clinicians and patients work backwards from the functional goals of older age.
Sleep is not a luxury variable. Chronic sleep deprivation can worsen blood pressure, triglycerides, glucose regulation, and overall metabolic health.
Wearables can be useful teaching tools, but they can also drive “data neurosis,” “orthosomnia,” and unnecessary obsession with physiologic perfection.
The most effective interventions in preventive medicine are still the “core four”: sleep, nutrition, fitness, and emotional resilience.
When patients ask about peptides or other longevity interventions, a structured framework can help keep the discussion thoughtful, safe, and grounded.
Healthspan Medicine in Primary Care
Why This Matters
Many patients are drifting toward cardiometabolic disease long before they meet formal diagnostic thresholds for diabetes or cardiovascular disease. They may have a slightly rising A1c, creeping blood pressure, elevated triglycerides, worsening sleep, increasing waist circumference, low exercise capacity, or a troubling family history. The challenge in primary care is recognizing these early signals before disease fully declares itself (expert opinion).
Dr. Palakadedi emphasizes that the conversation should not focus only on lagging indicators. Instead, clinicians should help patients understand the underlying drivers of health span: sleep, nutrition, fitness, body composition, stress, and long-term cardiovascular risk. The goal is not merely to react to disease, but to intervene earlier while patients still have a long runway to change trajectory (expert opinion).
Wearable Devices
Should Patients Without Diabetes Use a CGM?
Continuous glucose monitors are increasingly available to patients whether clinicians recommend them or not. Dr. Palakodeti does not suggest pushing CGMs on everyone, but he does think they can be useful tools in selected patients. Examples include patients with a strong family history of diabetes, metabolic syndrome, borderline or discordant glycemic data, impaired fasting glucose, or patients whose A1c does not seem to match the rest of the clinical story. They may also be useful for the highly motivated “interested hobbyist” who wants to understand how food, exercise, stress, and sleep affect their glucose (expert opinion).
For many patients without diabetes, the CGM is best framed as a short-term experiment rather than a permanent device. A 60 to 90-day period may be enough to learn how their body responds and then use that information to guide sustainable lifestyle changes (expert opinion). Interested providers can consider using them on themselves to better understand them for the sake of informing their patients.
What Is Normal Versus Abnormal?
One of the most important counseling points is helping patients understand what they are likely to see before they start looking at CGM data. Not every spike is pathologic. Brief rises into the 160 to 180 range may occur after meals, during high-intensity exercise, or during periods of stress (Agiostratidou 2017).
.The more useful question is not just how high a patient spikes, but how long they remain elevated. A transient rise that returns promptly toward baseline is less concerning than sustained elevation over the next 2 to 3 hours (Freckmann 2024). This creates a high-yield teaching opportunity. Exercise-induced spikes, for example, may reflect normal physiology during intense exertion. Similarly, poor sleep and stress may cause hyperglycemia through chronic hypercortisolemia and sympathetic activation. In this way, CGMs can help patients understand that glucose regulation is about far more than just carbohydrates (expert opinion, Freckmann 2024).
Watch Out for Data Neurosis
CGMs and wearables can quickly become counterproductive when patients begin perseverating on every number. Dr. Palakadedi describes this as a kind of “data neurosis,” where patients over-rely on their devices to tell them whether they are healthy, recovered, or at risk. This is especially common in high-performing individuals and athletes, who may see frequent spikes during high-intensity training and then incorrectly interpret those spikes as evidence of disease.
If the device is starting to drive anxiety rather than insight, it may be appropriate to pause. In some cases, taking a week off from the wearable can be as informative as continuing it. The goal is to use the technology to educate patients, not to trap them in constant self-surveillance (expert opinion).
Beyond Glucose: ApoB, Lp(a), and Early Cardiometabolic Risk
Why a Flat CGM Trace Can Be Misleading
A practical clinical problem arises when a patient sees postprandial CGM spikes and responds by adopting an extreme diet such as a saturated-fat-heavy carnivore diet in order to flatten the line. That strategy may reduce visible glucose excursions, but it can create a different form of risk if ApoB rises substantially. In that scenario, the patient may feel as though they are reducing diabetes risk while actually increasing atherogenic burden.
This is a recurring theme in preventive medicine: patients make tradeoffs based on the metric they can see. The clinician’s role is to redirect attention toward the outcomes that matter most over time.
ApoB and LDL Discordance
ApoB is one of the most useful markers when the standard lipid panel may be underestimating risk. Patients with insulin resistance, high triglycerides, central adiposity, and metabolic syndrome often have discordance between LDL-C and ApoB. In those settings, ApoB may track risk more closely than LDL-C alone (expert opinion).
A practical pearl from the discussion is that an ApoB of 115 mg/dL is meaningfully elevated. Many clinicians think of values under roughly 80 to 90 mg/dL as more reassuring, though targets should ultimately depend on baseline risk and prevention context. This becomes especially relevant when a patient’s LDL-C looks only modestly elevated but ApoB suggests a larger burden of circulating atherogenic particles (expert opinion).
Lp(a) and Inherited Risk
Lipoprotein(a) is another key biomarker in preventive cardiology. It helps quantify inherited cardiovascular risk and may explain why a patient with apparently reasonable traditional labs still seems to be on a higher-risk trajectory. Elevated Lp(a) is often used not as a direct treatment target, but as a reason to manage LDL-C, blood pressure, weight, and lifestyle more aggressively (Koschinsky 2024).
Looking at the Bigger Picture
Spikes on a CGM do not map perfectly onto future diabetes or cardiovascular risk. Rather than over-focusing on one data stream, clinicians should keep attention on the big drivers of disease:
insulin resistance and metabolic dysfunction
ApoB and other atherogenic markers
body composition
cardiorespiratory fitness
sleep quality
visceral adiposity
blood pressure and overall cardiovascular risk
In select patients, imaging such as coronary artery calcium scoring or coronary CTA may also help refine risk conversations, but these are usually adjuncts rather than first-line tools in this type of health span discussion (Swarup 2024, Attalah 2026, expert opinion).
Functional Longevity: Investing in Yourself
Why Body Composition Matters
Body composition tells a more meaningful story than weight alone. Dr. Palakadedi discusses using DEXA scans to assess subcutaneous fat, visceral fat, and appendicular lean mass index (ALMI). While many patients also use home scales or gym-based body composition devices, those tools may show substantial discordance compared with DEXA. Still, the exact number is often less important than the direction of change. The critical question is whether body fat is decreasing, muscle mass is increasing, and the patient is moving in the right direction over time (expert opinion).
For clinics or patients without access to DEXA, repeat measurements on the same scale, waist-based measures, or waist-to-height ratio may still offer useful trend data.
VO2 Max as a Long-Term Functional Metric
VO2 max is one of the most powerful markers discussed in the episode. It reflects cardiorespiratory capacity and, more broadly, the physiologic reserve that supports function later in life. Rather than treating it as a niche athlete metric, Dr. Palakadedi frames VO2 max as a way to work backwards from a patient’s desired future.
If a patient wants to dance at a granddaughter’s wedding, walk several flights of stairs, travel independently, or remain functionally robust into older age, then they need enough cardiorespiratory reserve to make that possible. Since VO2 max tends to decline with age, patients who are already near the lower threshold in midlife may not have enough reserve to remain functional later unless they actively train it now (expert opinion).
Formal VO2 max testing can be unpleasant and is not necessary for everyone. In practice, wearable estimates, field tests, and trend data may be good enough to guide the conversation, especially if the question is simply whether fitness is moving up or down over time (expert opinion).
Strength and Muscle
Grip strength is easy to measure and often discussed in longevity medicine, but Dr. Palakadedi cautions against overemphasizing it. A patient may have very strong grip strength and still have poor overall muscle mass and low functional reserve. In his practice, the more important question is total skeletal muscle reserve, not isolated forearm strength.
His preferred framework is to think about appendicular lean mass and function over time. He aims for patients to build enough muscle reserve that they can remain independent, avoid frailty, and recover better from illness or injury. This is the “saving for retirement” analogy applied to physical reserve: patients are building reserves now because they will inevitably draw on them later.
Prescribing Exercise in Real Life
Resistance Training
Resistance training is a cornerstone of metabolic health (Tucker 2022). Muscle acts as a glucose sink, improves insulin sensitivity, and supports long-term function (Richter 2025). Patients do not need to become bodybuilders or spend their lives “pushing iron.” Bodyweight work, resistance bands, machines, free weights, and structured progressive overload can all work. What matters is consistent resistance against muscle with progression over time. A practical pearl is to start with posture, balance, and movement quality first, particularly in older or deconditioned patients. A program that causes injury is not a good program (expert opinion).
Zone 2 and Cardiorespiratory Fitness
To improve cardiorespiratory fitness, patients generally need to spend real time doing aerobic work. The discussion emphasizes roughly 150 minutes per week of moderate-intensity or “zone 2” training, broadly meaning exercise at an intensity where one can still talk, but not comfortably sing. This time does not necessarily need to be divided evenly across the week. Many patients can succeed as “weekend warriors” if that is what their schedule allows (Piercy 2018, expert opinion).
High-intensity intervals may also have a role, but many patients benefit most from first building a reliable aerobic base. The more important question is often not what the ideal plan is, but how the patient will actually fit the work into their real life (expert opinion).
Practical Nutrition Pearls
Dr. Deep also gives several practical strategies for patients trying to improve metabolic health without becoming overly restrictive:
Prioritize protein and fiber
Aim for roughly 30 grams of protein per meal
Avoid “naked carbs,” meaning carbohydrates eaten entirely by themselves
Pair carbohydrates with protein or fat when appropriate
Take a brief walk after meals, even 5 to 10 minutes can reduce intensity and duration of glucose spikes
For many patients, these small changes help smooth postprandial glucose patterns without forcing them into unsustainable diets or extreme food rules.
Sleep and Stress Management
Sleep as a Foundational Intervention
Sleep is one of the “core four” and may be the most neglected (expert opinion). Patients with poor sleep often show drift in multiple metabolic markers long before anyone diagnoses a disease. Blood pressure rises, triglycerides worsen, glucose handling deteriorates, and subjective energy declines. For many patients, focusing on sleep may unlock the capacity to improve the rest of their health behaviors (Cedernaes 2015).
Sleep Architecture and Restorative Sleep
Dr. Deep highlights that total time asleep is not the whole story. Some patients sleep 7 to 8 hours but get very little deep or REM sleep. Low restorative sleep may reflect a chronic stress state with persistent sympathetic activation and elevated cortisol (Greenlund 2022). Wearables can sometimes help uncover this pattern, though the numbers should always be interpreted cautiously (expert opinion).
HRV and Sympathetic Overdrive
Heart rate variability is discussed as a directional marker rather than an absolute score to compare between individuals. A declining HRV paired with a rising resting heart rate may suggest sympathetic overdrive, illness, inadequate recovery, or worsening stress burden. But HRV has a strong individual baseline, and patients should not compare their numbers directly with those of friends or athletes online (Tegegne 2017).
Month-to-month trends are generally more useful than single-day readings. Most importantly, clinicians should not let HRV override how a patient actually feels. If someone feels well, a “bad” wearable score should not necessarily dictate the day (expert opinion).
Avoid Orthosomnia
Dr. Palakadedi uses the term “orthosomnia” to describe a pathological obsession with achieving perfect sleep scores. This concept applies more broadly to the entire wearable ecosystem. When patients become fixated on optimizing a score instead of improving their real health, the tool has started to distort the goal.
How to Talk to Patients About Peptides
Start with Curiosity, Not Dismissal
Patients increasingly ask about NAD infusions, BPC-157, and other peptides or longevity compounds. Dr. Palakadedi emphasizes that these conversations should be handled with care and without making patients feel foolish for asking. Patients are usually asking from a place of wanting to feel better, recover better, or age well.
The EASI Framework
His practice uses an EASI framework:
Evidence
Alignment
Safety
Impact
Each domain is scored from 0 to 3. High scores suggest a more reasonable intervention to consider. Very low scores argue against use. Intermediate scores call for shared decision-making and a careful discussion about uncertainty (expert opinion).
Using BPC-157 as an example, the evidence base is limited. There are no robust human randomized controlled trials, though there are animal data and substantial anecdotal use. The theoretical mechanism is promotion of angiogenesis and improved delivery of healing factors to relatively avascular tissues such as tendons or cartilage. That may make it appealing for musculoskeletal complaints, but the lack of strong human data means this is far from a slam dunk (Mayfield 2026, expert opinion).
The Benefit-Harm-Burden Matrix
The practice also uses a Benefit-Harm-Burden framework:
Benefit: What is the concrete goal? What meaningful improvement would count as success?
Harm: What are the side effects, stop rules, and contraindications?
Burden: What does the treatment actually require in terms of injections, cost, sourcing, time, and follow-up?
For BPC-157, one important caution raised in the discussion is that its angiogenic properties may make active malignancy a reason to avoid it (Józwiak 2025). Another key issue is sourcing: many peptides are not FDA approved, and product quality is variable. In that setting, the clinician’s role may be less about endorsing the treatment and more about helping the patient think clearly and reduce harm.
The Core Four
Throughout the episode, Dr. Palakadedi returns to the same foundational framework:
Sleep
Nutrition
Fitness
Emotional resilience
No supplement stack, peptide protocol, infusion menu, or wearable dashboard can replace those fundamentals. The core four remain the most powerful interventions in health span medicine.
Equip primary care clinicians with a practical framework for interpreting CGMs, sleep data, fitness metrics, and preventive biomarkers in patients seeking to improve health span.
Learning objectives
Identify which patients without diabetes may benefit from short-term CGM use and recognize what constitutes meaningful signal versus physiologic variation.
Recognize early cardiometabolic risk even when A1c is only borderline abnormal or appears inconsistent with the clinical picture.
Explain how ApoB and Lp(a) can refine risk assessment when traditional lipids do not tell the full story.
Prescribe practical lifestyle interventions centered on protein intake, post-meal movement, resistance training, and aerobic conditioning.
Counsel patients on sleep, HRV, and wearable data without reinforcing orthosomnia or data neurosis.
Apply a structured framework to patient questions about peptides and other longevity interventions.
Citation
Wurtz PJ, Palakodeti S, Williams PN, Watto MF. “Healthspan Medicine: A Practical Approach” The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast April 06, 2026.
