Things to Remember
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Two very different paths to 98: One patient stayed remarkably healthy her whole life with almost no medical issues (just lucky biology), while another survived multiple heart surgeries, procedures, and even COVID thanks to modern medicine. Both approaches can get you to a long life - sometimes it's good genes, sometimes it's good doctors.
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Medicine is shifting from "wait and treat" to "predict and prevent": Doctors are getting much better at spotting who's at risk for heart disease, Alzheimer's, or cancer decades before symptoms show up - using genetic tests, blood markers, and other tools that weren't available even 10 years ago.
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"Healthy living" is way more specific now: It's not just vague advice like "eat better and exercise." Scientists now understand exactly how things like strength training (not just cardio), eating during specific time windows, sleep quality, and even loneliness affect your cells and inflammation levels in measurable ways.
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Your cells tell your health story: New technology lets doctors analyze individual cells in your body to see how they're aging and what diseases might be developing - think of it like getting a much more detailed report card on your health at the cellular level.
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The goal is "health span," not just lifespan: Living to 98 matters less if you're sick and struggling for the last 20 years. Modern medicine is increasingly focused on keeping you functional and independent for as long as possible, not just adding years.
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What you can do now: Stay socially connected (loneliness literally affects your biology), add strength training to your routine, pay attention to sleep quality, and ask your doctor about preventive screenings that might catch problems early - especially if heart disease or other conditions run in your family.
This article explores why some people age healthily while others don't, and what modern medicine reveals about extending not just lifespan, but the quality years we actually live.
There's a question I keep returning to when I see someone in their nineties: Why them? Not in a morbid sense, but genuinely - what combination of luck, biology, and circumstance allows one person to sail through nine decades while another battles disease after disease?
Two Paths to 98: Comparing Natural Resilience vs. Medical Intervention
| Factor | Mrs. L.R. (Natural Health Span) | Mr. R.P. (Medicine-Extended Health Span) |
|---|---|---|
| Family History | Mother died at 59, father at 64, brothers at 43 and 75 | Not specified, but personal cardiovascular disease from age 62 |
| Major Health Events | Hypertrophic cardiomyopathy (heart muscle thickening) with leg swelling at 98 | Coronary bypass at 62, stent placement at 75, atrial fibrillation, COVID pneumonia at 96 |
| Medical Interventions | Minimal - diuretic for edema management | Extensive - bypass surgery, 2 stents, 2 ablation procedures, anticoagulation, cholesterol management |
| Current Functionality | Drives independently, lives alone, paints, completes complex puzzles, plays pattern-recognition games weekly | Functional with ongoing medical management |
| Longevity Factor | Stochastic (biological lottery) - no clear genetic or lifestyle explanation | Medical technology - repeated interventions preventing early death from cardiovascular disease |
| What This Represents | The mystery of natural resilience that science can't fully explain | Modern cardiology's ability to extend health span through precision interventions |
| Key Takeaway | Some people naturally avoid disease despite poor family history | Medicine can now keep people with severe chronic disease alive and functional for decades |
I think about this often because I follow two patients, both ninety-eight, whose lives tell completely different stories about aging in the twenty-first century.
The Woman Who Never Got Sick
Mrs. L.R. drives herself to appointments. At ninety-eight. She lives alone, paints award-winning oils, completes thousand-piece puzzles, and plays Rummikub - a tile-based game requiring sharp pattern recognition - weekly with a circle of eight women.
When I first saw her, it was for leg swelling. Straightforward enough. But what struck me immediately was the contrast between her vitality and her family history. Her mother died at fifty-nine. Her father at sixty-four. Her brothers at forty-three and seventy-five. Her husband - who shared her remarkable health span - lived to ninety-seven, but his family history mirrored hers: chronic disease and early deaths across the board.
The leg edema turned out to be from hypertrophic cardiomyopathy - a thickening of the heart muscle that makes it stiffen and struggle to relax. It's a condition I've studied extensively, having described the elderly variant in the New England Journal of Medicine years ago. The treatment was simple. A diuretic, some adjustments, and the swelling resolved.
But the bigger question lingered: Why was she so healthy?
Medical science doesn't have a clean answer. It's not genetic - look at her family tree. It's not lifestyle in the traditional sense, though she's socially engaged and mentally active. The most honest conclusion we can reach is that it's stochastic. A random stroke of biological fortune. She won a lottery she didn't know she'd entered.
I find that both humbling and frustrating. We've spent billions trying to decode longevity, and sometimes the answer is just... noise. Good noise, but noise nonetheless.
The Man Medicine Kept Alive
Mr. R.P. is also ninety-eight. But his health span looks nothing like Mrs. L.R.'s.
At sixty-two, he had coronary artery bypass surgery - a procedure where surgeons reroute blood flow around blocked arteries using grafts, essentially giving the heart new highways. By seventy-five, those grafts had developed atherosclerotic buildup - plaque formation that narrows vessels - and I placed two stents to keep them open. Later, he developed atrial fibrillation, an irregular heart rhythm that can cause stroke and fatigue. We tried medications. They failed. He underwent two ablation procedures - a technique where we selectively burn or freeze tiny areas of heart tissue to stop rogue electrical signals.
At ninety-six, he survived COVID pneumonia. He spent weeks in hospital, teetering on the edge of respiratory failure, but pulled through.
Mr. R.P. embodies modern cardiology's triumph. He has severe cardiovascular disease, the kind that would have killed him decades ago. But with repeated interventions - bypasses, stents, ablations, aggressive cholesterol management, anticoagulation - he's still here. Still functional.
He represents something equally important as Mrs. L.R.'s inexplicable resilience: the power of medicine to extend health span in those who need it most.
What's Changed (And What's Coming)
Here's where things get interesting. And I mean genuinely, materially interesting - not in a vague "the future is bright" way.
We're entering what I think of as the age of anticipatory medicine. Not predictive in the sense of reading tea leaves or family histories, but precise forecasting based on layers of biological data we couldn't access even ten years ago.
Consider this: we can now identify someone at high risk for heart disease - or Alzheimer's, or certain cancers - decades before symptoms appear. Not through guesswork, but through molecular signatures, genetic variants, protein clusters, and patterns in how their cells are aging.
That's not science fiction. That's happening now.
The Five Dimensions
I've come to think of this shift as occurring across five dimensions. They overlap, feed into each other, and collectively represent a fundamentally different approach to aging.
1. Lifestyle+
We've always known diet, exercise, and sleep matter. What's changed is the specificity and breadth of what we now understand.
It's not just "eat vegetables." It's time-restricted eating - limiting food intake to specific windows - which affects autophagy, the cellular process where cells break down and recycle damaged components. It's not just "go for walks." It's strength training, which preserves muscle mass and bone density in ways aerobic exercise doesn't. It's not just "avoid pollution." It's understanding that air quality, noise exposure, and access to green space shape inflammatory markers - proteins in the blood like C-reactive protein and interleukin-6 that indicate chronic inflammation - in measurable ways.
Social determinants matter too. Loneliness isn't just emotional; it's biological. Chronic isolation affects cortisol rhythms, immune function, and cardiovascular risk. We can measure it. We can intervene.
I've started thinking of this as "lifestyle+" because it's everything - the totality of how we move through the world - not just the big three of diet, exercise, sleep.
2. Cells
We have roughly thirty-seven trillion cells in our bodies. Until recently, we treated them as a collective - "the immune system," "heart muscle" - rather than understanding their individual molecular identities.
That's changed.
Single-cell sequencing allows us to read the genetic material of hundreds of thousands, sometimes millions, of individual cells. We can see how they differ, how they change over time, how they respond to stress or disease.
This opens doors that sound like science fiction but aren't. CAR-T therapy - chimeric antigen receptor T-cell therapy - takes a person's T cells, immune cells that recognize and destroy threats, engineers them outside the body to recognize cancer cells, and infuses them back. It's revolutionized treatment for certain blood cancers. Now we're working on ways to engineer those cells in vivo, inside the body, faster and cheaper.
Organoids - miniature organs grown from stem cells in the lab - can model a person's specific biology. We can test how their brain cells respond to Alzheimer's treatments before giving them the drug. We can grow beating hearts in dishes.
Actually, let me pause on that. I still find it unsettling, even though I've seen the images dozens of times. A small, rhythmically contracting cluster of cells in a petri dish. It's not a heart in any meaningful sense, but it beats. The implications are staggering.
3. Omics
"Omics" is shorthand for the layers of biological information we can now measure: genomics - our DNA sequence; transcriptomics - which genes are actively being read; proteomics - the proteins those genes produce; epigenomics - chemical modifications to DNA that affect gene expression; and the microbiome - the trillions of bacteria, viruses, and fungi living in and on us.
Each layer tells a different story. Your genome is static - the same DNA you were born with. But your transcriptome changes constantly, reflecting what your cells are doing right now. Your proteome reveals functional changes downstream of gene activity. Your epigenome shows how lifestyle and environment have chemically marked your DNA. Your microbiome shifts with diet, antibiotics, stress.
Together, these create a biological fingerprint unique to you.
Liquid biopsies - tests that detect tumor DNA fragments circulating in blood - can catch cancers before they're visible on scans. Certain protein signatures can indicate Alzheimer's pathology - specifically, tau and amyloid-beta accumulation - years before cognitive symptoms. Microbial metabolites - chemicals produced by gut bacteria - influence everything from mood to immune function to cardiovascular risk.
This is precision medicine's foundation. Not treating diseases categorically, but understanding your version of the disease at a molecular level.
4. Artificial Intelligence
AI in medicine isn't about replacing doctors. It's about integration.
Multimodal AI can synthesize data from electronic health records, lab results, imaging, genomics, wearables, and environmental exposures into risk models that are far more accurate than traditional calculators. It can identify patterns humans miss - subtle ECG changes predicting heart failure, retinal vessel patterns indicating Alzheimer's risk, voice biomarkers suggesting Parkinson's years before tremors appear.
But more importantly, AI can personalize interventions. Not generic advice, but specific recommendations based on your unique physiology, lifestyle, and risk profile. Interactive coaching that adapts in real time.
A 2024 study in Nature Medicine showed AI models predicting cardiovascular events outperformed traditional risk scores by nearly 20%. That's not incremental. That's transformative.
5. Sensors and Wearables
We can now monitor physiology continuously. Heart rate variability - the variation in time between heartbeats, which reflects autonomic nervous system balance. Blood glucose patterns. Sleep architecture - the cycling through different stages of sleep. Activity levels. Stress markers.
Continuous glucose monitors, initially designed for diabetes management, are being used by athletes and biohackers to understand how different foods affect their metabolism. Smartwatches detect atrial fibrillation with reasonable accuracy. Ring devices track body temperature, potentially catching infections early.
The data isn't perfect. There's noise. But the trajectory is clear: real-time biological feedback is becoming ubiquitous.
What This Actually Means
Here's what I want you to take away from this, because I think it's easy to read about "omics" and "AI" and "precision medicine" and think it's all abstractions.
It's not.
We're moving from reactive medicine - treating disease after it appears - to anticipatory medicine. Forecasting risk decades early. Intervening before damage accumulates. Personalizing treatment based on your specific biology, not population averages.
Mrs. L.R. got lucky. Her biology happened to resist the diseases that killed her family members. We don't fully understand why, and we can't yet replicate it.
But Mr. R.P.? His story is something we can replicate and improve upon. We kept him alive through repeated interventions, but imagine if we'd caught his cardiovascular risk at forty. If we'd aggressively managed his lipids, inflammation, blood pressure - not just with generic targets, but with precision based on his genomic risk and proteomic patterns.
He might never have needed that first bypass.
That's the promise here. Not immortality. Not stopping aging. But health span extension - living longer well, not just longer. Compressing morbidity into the final years rather than spending decades managing chronic disease.
The Stochastic Problem
There's a wrinkle I keep coming back to, though.
Mrs. L.R.'s health span appears random. Stochastic. And that's maddening, because we've built an entire medical system around causality - if X, then Y. But biology is noisy. Sometimes people just... thrive. For no discernible reason.
I don't know what to do with that. Part of me wants to dismiss it as a measurement problem - we just haven't found the signal yet. Part of me thinks maybe some things are genuinely random, and we have to accept that uncertainty.
Most days I lean toward the former. But I'm not sure.
Where We Go From Here
I've been practicing long enough to see medicine shift multiple times. The introduction of statins - drugs that lower cholesterol by inhibiting liver cholesterol production. Percutaneous coronary intervention - stents placed through catheters instead of open-heart surgery. Biologics for autoimmune disease. Each felt revolutionary at the time.
This feels different. Not because of any single breakthrough, but because of convergence. Multiple fields - genomics, proteomics, AI, cell therapy - maturing simultaneously and feeding into each other.
The next decade will look nothing like the last.
And that's thrilling. But also unsettling. Because with anticipatory medicine comes new questions: Who gets access? How do we avoid creating a two-tiered system where only the wealthy can afford precision interventions? What do we do with genetic risk information that predicts disease decades out? How do we balance early intervention with overtreatment?
I don't have answers yet. None of us do. But they're questions worth asking now, before the technology outpaces our ethical frameworks.
Mrs. L.R. still drives herself to appointments. Mr. R.P. still walks his dog every morning. Both are ninety-eight. Both are thriving, in their own ways.
One got lucky. One got medicine. In the future, I think more of us will get both.
At least, that's what I hope. But I'm still thinking it through.
