The quest to legitimize longevity medicine

On a bright chilly day last December, a crowd of doctors and scientists gathered at a research institute atop a hill in Novato, California. It was the first time this particular group of healthy longevity specialists had met in person, and they had a lot to share.

The group's goal is to help people add years to their lifespans, and to live those extra years in good health. But the meeting's participants had another goal as well: to be recognized as a credible medical field.

For too long, modern medicine has focused on treating disease rather than preventing it, they say. They believe that it's time to move from reactive healthcare to proactive healthcare. And to do so in a credible way-by setting gold standards" and medical guidelines for the field. These scientists and clinicians see themselves spearheading a revolution in medicine.

Eric Verdin directs the Buck Institute for Research on Aging, which hosted the meeting. We will look back in 20 years at this meeting as really the beginning of a whole new field of medicine," Verdin told attendees. Referring to the movement as a revolution" would be an understatement, he said. We can write new rules on how we treat patients."

Establishing a new discipline of medicine is no mean feat. Longevity doctors have started to make progress by establishing learning programs and embedding these courses in medical schools. They've started drafting guidelines for the field, and working out how they might go about becoming recognized by national medical boards.

But proponents recognize the challenges ahead. Clinicians disagree on how they should assess and treat aging. Most clinics are expensive and currently only cater to the wealthy. And their task is made more difficult by the sheer scale and variety of longevity clinics out there, which range from high-end spas offering beauty treatments to offshore clinics offering unproven stem cell therapies.

Without standards and guidelines, there is a real risk that some clinics could end up not only failing to serve their clients, but potentially harming them.

A visit to the clinic

Almost all longevity clinics offer their clients a suite of tests, usually over a four- to six-hour testing session. Blood tests are pretty standard-clinicians will look at everything from cholesterol and blood sugar to clues of inflammation. And beyond measuring your height and weight, these clinics will look at your body composition-how much fat you're storing and the density of your bones.

They might put you on a treadmill and measure your VO2 max-the amount of oxygen your body can use while you exercise. Many will assess your cognition, memory, and physical strength. You'll be asked questions about your diet, lifestyle, and well-being. Plenty of clinics will also offer a range of scans-and some will offer to look at your whole body in an MRI scanner.

Some clinics will continue to track your diet and movements after this initial appointment, using fitness trackers and wearable devices that monitor your sleep. You might speak to a nutritionist about your diet, a psychologist about your mental health, and a fitness coach about your exercise routine. Some will even analyze your genome and your microbiome.

The idea is to get a full picture of how well your body is functioning-and what could be done to improve things. Got a low VO2 max score? Maybe you need to start taking some HIIT classes. Your microbiome looks like it's missing some key microbes? Time to increase your fiber intake. The goal is to figure out which aspects of a person's health or lifestyle might prevent them from living a long, healthy life, and to address those aspects, even if much of the advice is common sense.

Such rigorous testing is not routine in modern medicine. This is partly because of costs, but also because excessive testing can cause patient anxiety, put people at risk of infections, and increase the chance of a misdiagnosis. But if doctors want to keep their patients in good health for longer, they need to start offering more tests, says Evelyne Bischof, director of the Sheba Longevity Center, which is embedded within a public hospital in Ramat Gan, Israel. Longevity medicine needs to become mainstream, and more people should have access to a full range of diagnostic tests that might pick up early signs of age-related diseases, she says.

Bischof co-led the development of the Healthy Longevity Medicine Society (HLMS), an international organization established in August 2022 to, among other things, build a clinically credible framework and platform for longevity medicine." The society now has more than 200 members, including medical doctors, healthcare professionals, and other people associated with longevity clinics, she says.

Bischof wants longevity medicine to be officially recognized as a medical discipline, like cardiology or neurology, for example. Clinics should meet certain criteria to qualify as longevity clinics, she says, and longevity doctors should be required to obtain qualifications before they can make use of the title. This would require signoff by national medical councils like the American Medical Association.

It will take years to get to this point, Bischof acknowledges. In the meantime, she thinks education is a good place to start. She and her colleagues have developed a course for doctors interested in longevity medicine. In theory, anyone with a computer can take the course, but it has been accredited by the Accreditation Council for Continuing Medical Education, which means that doctors who take the course earn credits that support their continued medical education in the US- something that is required by some medical employers. And it is already being implemented in four medical schools, Bischof says-although she adds she can't yet say which as the information is not yet being made public. Over 6,000 [have taken] that course already," she says. But it should be more-it should be 6 million."

This is a new field," says Andrea Maier of the National University of Singapore, who co-founded the private high-end" Chi Longevity clinic and is president of the HLMS. We have to organize ourselves; we have to set standards."

That task won't be straightforward. Longevity doctors agree on some key points-namely that they want to extend healthy lifespans-but they disagree on how to measure signs of aging in their patients, how to assess their general health, and how best to treat or advise them.

Questionable tests

Take, for example, aging clocks. These tools aim to estimate a person's biological age-a score that is meant to capture how close they are to death. More than a hundred of these clocks have been developed, and they work in slightly different ways. Many of them work by assessing chemical markers on your DNA-the pattern of which is known to change as we get older.

Lots of longevity clinics make use of these clocks. The problem is that they don't work all that well. When Verdin sent one of his own blood samples off to 10 different companies, he says he got 10 different results back-with estimates of his biological age ranging from 25 to 66.

The first such clock was developed by Steven Horvath, a researcher now at Altos Labs, a biotech company exploring ways to rejuvenate cells and, eventually, people. But even he warns of their fallibility. A few days before the longevity clinic meeting, he told an audience of scientists not to waste your money" on aging clocks.

Some argue that the clocks aren't useless. Using the same clock over time might give a doctor some idea of how their patient is progressing on a certain treatment plan. And a low score might provide the motivation a person needs to ramp up their exercise regimen. Maier uses multiple clocks when she runs clinical trials of experimental longevity treatments at her clinic. We have 60 clocks now in our lab, and you have to use different clocks for different populations in different studies," she says.

But others, including Sara Bonnes, medical director of the healthy longevity clinic at the Mayo Clinic in Rochester, Minnesota, is steering clear until there's more evidence. There is still controversy as to which is the best," she says.

And then there are the whole-body MRI scans. These essentially involve using a magnet-based scanner to look at your insides-all the way from the top of your head to about halfway down your shins.

MRIs are usually used to search for abnormalities that might explain a person's pain or other symptoms, or to check for signs of damage after a person has sustained an injury. But at longevity clinics, doctors are casting a wide net, and essentially searching the body for anything that looks unusual.

The problem is that almost all of us have a body that is unusual in some way. Nobody will be normal' or optimal in their body," says Maier, who doesn't offer the scans but wants to partner with clinics that do to learn more about their potential use. At the moment there is not clear evidence on how much harm you do and how much good you do."

While whole-body MRI scans might be appropriate for someone with a known risk of, say, cancer, they are not the right choice for everyone, says Anusha Khan, who directs Mosaic Theory MD, a private prevention and longevity clinic in Sterling, Virginia.

Khan refers to a clinical case a colleague shared with her. When the colleague's patient underwent a whole-body MRI, their doctors spotted something unusual in the person's biliary tree-a series of ducts connected to the liver and gallbladder. The person's doctors ended up performing a procedure known as ERCP-involving an endoscope and X-rays-to further investigate.

The lesion itself turned out to be harmless. But the medical procedure left the person with an infection-and they ended up dying with sepsis, says Khan. These are still clinical-grade interventions," she says. They shouldn't be taken lightly."

Wellness and the Wild West

The problem is, if longevity doctors want to standardize practices like the usage of MRIs for otherwise well patients, they will first have to define exactly what a longevity clinic is.

According to a working definition put together by Andrea Maier and her colleagues at HLMS, healthy longevity clinics apply healthy longevity medicine, which involves optimizing health and healthspan while antagonizing aging processes across the lifespan," says Maier. This definition would rule out centers that solely offer beauty treatments like botox, which only affect how young a person looks. But she acknowledges that it isn't yet totally clear where wellness ends and longevity medicine begins.

While most of the doctors presenting at the conference focused on health more generally, there were frequent mentions of physical prowess. Some speakers showed images of themselves mid-workout, muscles bulging. This is pretty gratuitous I admit," said David Karow, chief innovation officer at Human Longevity, a company that runs three longevity clinics in the US and China, as he showed the audience a picture of himself topless, mid-run during a triathlon. He then told the audience he was 51 when the photo was taken, but he was in the top 15 percentile of all male racers in this international triathlon above the age of 18."

And looks do seem to be important to some in the field. A longevity clinic director I shared a taxi with during the conference advised me on how I could benefit from a little botox, in the right places.

There's also the question of where should the cutoff be at the other end of the spectrum; for clinics that offer or recommend supplements, drugs or other treatments? There are no approved longevity medicines. And we don't have much evidence for the vast array of supplements being touted for healthy life extension, either.

And while most clinicians would argue that at least most of the treatments they recommend are generally regarded as safe, that is not the case for stem cell treatments, which numerous clinics are offering for longevity. Such clinics can be found in the US and in other countries, and might make claims about reversing the aging process, says Leigh Turner at the University of California, Irvine, who has been studying stem cell clinics for years. There are a lot of bold advertising claims, and there's not really meaningful data to back up those claims," he says. As of 2021, Turner found 89 such clinics offering treatments for aging" in the US.

There are a variety of stem cell-based treatments offered with vague promises of repairing and rejuvenating a person's body. One might, for example, involve removing some of a person's fat through liposuction, then attempting to extract stem cells from the tissue and injecting them into a person's bloodstream. These clinics are not regulated, and there's no way of knowing exactly what is being injected, or if it might cause an infection or clot, says Turner.

It doesn't help that consumer demand has really exploded" in the last five years, says Maier. Many clinics have lengthy waiting lists. Maier says she has people knocking on our doors" asking for all kinds of longevity treatments, including stem cell treatments.

It's a Wild Wild West at the moment," says Maier. She worries that if someone receiving such a treatment were to develop, say, a dangerous clot in their lungs, even the most unregulated countries would shut [longevity clinics] down." And if such treatments aren't delivered as part of a clinical trial, we will never learn whether or not they do anything, she says.

Maier says she has recently assessed the published evidence on stem cell treatments for longevity. For me, there is no evidence," she says. I would never do it." She doesn't want to pass judgment on those offering unproven and unregulated therapies," though. We have to define ourselves [as a field] first before blaming others for crossing a boundary," she says.

HLMS won't accept every membership application they receive. Individuals are turned down if there is any sign they are engaging in any kind of misconduct, says Bischof. The society also turns down biohackers. Those things we are very careful about," says Bischof, although she notes that she personally views the self-experimenters as friends."

Death is not optional

One area that longevity clinicians do seem to agree on is the finite nature of life. All of those contacted by MIT Technology Review are keen to distance themselves from immortalists, people who are on a quest to live forever.

Instead, most believe that the majority of people can live to around 100 in good health, providing they eat, sleep and exercise well, identify their personal health needs and address the earliest signs of age-related diseases long before they start to develop symptoms. When I walked into the meeting, one of the first things I noticed was the absence of the bowls of cookies that seem to be standard conference fare. In their place was a range of fresh-fruit smoothies. One doctor used the term previvorship" to describe overcoming a disease decades before it starts to cause significant problems.

It's not that I don't want to get older-I'm very happy to get old and die," says Maier. But I realized... that old age with lots of function is what I'd love to achieve for everybody."

The term immortality' should never be part of our discussion... it's a total pipe dream," says Verdin, who personally hopes to live to around 95. My worry is that it makes us like a cult."

Longevity doctors also tend to agree that, while longevity clinics are a pricey experience for the rich, they should eventually be accessible to everyone. The clinics charge between $5,000 and $50,000 a year," says Verdin. It's medicine for the rich, by the rich, which is something I deplore."

At the December meeting, attendees were offered the chance to win prizes. Stick your name in a fish bowl, and get a chance to win a biological age test, or a scan at a private clinic. The total worth of the ten to twelve" prizes on offer was 20,000, or around $21,600.

High price tags aren't just an equality issue. They can also exacerbate a placebo effect. People tend to feel better when they're given a sugar pill if they believe that candy might improve their symptoms. Paying for a treatment can exacerbate the effects, says Nir Barzilai, who studies aging at Albert Einstein College of Medicine in New York and is scientific director of the American Federation for Aging Research. You cannot afford to not be satisfied." And research suggests expensive placebos are more effective than cheap ones.

But prices should come down in time. Their vision is to start with high-paying clientele...but in the future look at how we can democratize this," says Verdin, who advises multiple longevity clinics. And at least three public longevity clinics have opened in the last few years, in Singapore, Israel and the US. These clinics are all affiliated with public hospitals, and the costs to patients are much lower than they are for those who visit private clinics, say the doctors who direct them. These clinics are also all running clinical trials of potential longevity treatments.

The healthy longevity clinic at the Mayo Clinic in Rochester is the first public longevity clinic in the US. Since the clinic opened in July last year, doctors have seen around 100 patients aged between 35 and 81, says Bonnes, the clinic's medical director.

Some want to maintain their health; others want help managing a disease. Still others have been referred by their doctor because they have already embarked on a longevity regimen, but are taking things too far, says Bonnes.

Certain supplements that they're taking may interact with other medications or things that they're on," she says. Taking 20 supplements may not be helpful." And some who are limiting their calorie intake can have eating disorders, she says. We don't necessarily know what's really going to help, but if we can at least avoid harm, that is a big step in the right direction."

Maier envisions healthy longevity medicine starting out in a similar hospital outpatient setting before eventually moving to GP care, just as we've seen asthma, for example, move from specialist to GP-led care over time. Let's define the protocol and then give it, in a decade, to the GP level," she says.

In the meantime, Barzilai and his colleagues are trying to make the field responsible," he says. There's a lot of longevity doctors out there, and a lot of them... I don't know what [they're doing]," he says. We have to educate longevity doctors-we tell them what we know, but more importantly, what they don't know."

The growing demand for longevity treatments should be met with credible, evidence-based medicine, says Maier. We have to come together with regulators and ethical committees," she says.

There is a consumer drive which cannot be stopped anymore," she says. This is a very fragile phase."