The Longevity MD

The way my story started was I moved to London to start training here in the NHS, from Jordan, and I wanted to meet people in the healthcare startup scene. Just like yourself — you were just telling me you moved to London and wanted to meet as many people as possible. The way I did it was I literally went through a list of startups on AngelList that were working in healthcare. I searched every single startup in London working in healthcare and started to reach out: "I'm a doctor, this is my background — can I help with anything you're working on? Anyone working on something interesting, this is my skillset, do you think I can help in any way?"

So I met a few people, made a few connections, and met the person who later became my co-founder — he was working on a different project at the time. We became friends, and I started helping him with his health using metrics. He's a tech guy; he measures everything about himself. We started having that collaboration and he got a lot out of it, so we decided that maybe we should turn this into a product. And that's where it came from.

One of the things we worked on early on was that he measured his glucose level using a CGM. Our initial hypothesis was that we wanted to build a platform where we could coach people for longevity — we called it longevity coaching. And the question was: who are the people most in need of something like this? We identified them as people who are pre-diabetic — people just starting to develop diabetes, or just starting to notice some kind of metabolic problem. They're not so bad that they need a medical intervention yet, but they want to do something about it. That was the initial focus. So our app was focused on a CGM and optimising glucose using nutrition.

But then we noticed the growth wasn't that fast, and we were struggling to find product-market fit with that approach. I think our initial hypothesis was wrong. We tried to focus on people who need this the most, but that's not necessarily the people who want it the most. People in that category — diabetics, especially in the UK — expect these services to be free on the NHS. They don't pay for services like this. And they also might not be interested in optimising their health; that might be why they've reached the level of diabetes or pre-diabetes in the first place.

So as we were reevaluating where we were, we started analysing our users and doing extensive research. We found there was a segment — a user persona — that was using the app and using CGMs but didn't have diabetes. They were actually very healthy people who just liked the coaching aspect, to optimise their health. These were usually people who work at tech companies — engineers, these kinds of types who are interested in data but want to interpret it and want that health coaching experience. So we started focusing on that segment. We ditched the whole diabetes and metabolic syndrome angle and focused on our actual real interest, which is longevity and optimising general health. Once we did that, we started seeing growth, and that's when we really started hitting our stride.

Everyone knows you go for the early adopters and then go down the curve, but identifying who the early adopters are for your product — that's the problem. In our case, our initial hypothesis was wrong, and that's where a lot of user research comes into it. There's this article by Paul Graham, one of the founders of Y Combinator, where he talks about how you should do things that don't scale. That just means rolling up your sleeves and delivering the service yourself, even if it doesn't scale. You can't have the founder of Uber driving Uber cars — that doesn't scale — but initially you should do the thing yourself and have that close interaction with your customers. That gives you insights you might not discover if there's a distance between you and the users.

That's what we did right early on. We were in a bad position as a startup, growing very slowly. And the problem with very slow growth is it's not bad enough that you say, "We need to change right now." It gives you this false idea that with minor tweaks you're going to be able to accelerate growth — maybe it's a marketing problem, maybe a branding problem, maybe we deploy a few tricks here and there. That can go on for a long time, and it can kill companies. In our case, we eventually identified that we had to do something radical, otherwise we'd never reach the growth we needed to be sustainable.

Yes. There's a big user persona of older folks, probably in their sixties or even seventies — not bros, but interested in their health. They're starting to face serious medical issues, or potential ones, and they want to do something about it. They're optimised when it comes to most general guidance around nutrition, sleep and exercise, so if they go to their GP, the GP says, "Your weight is good, your BMI is good," and so on. But they want to take the next step of optimising every single thing to gain that extra mile of healthspan.

There's a lot of personalisation that goes into it, and that's where an actual human coach comes into play. We're not at a point yet where we can make all these predictions and recommendations automatically — a lot of it is individualised and comes from the coach and their experience. And a lot of it, at the end of the day, comes down to accountability. People know what to do in many cases, but they like the reassurance of having someone check in with them regularly who knows what they're doing, who can look at their data and identify early warning signs of something going off, or give them correlations they might miss on their own.

We changed the branding of the website and the messaging — we focused it on longevity, longevity fitness, we called it. We started providing insights on sleep, nutrition and exercise, whereas before we were only focused on nutrition. Marketing-wise, we started looking into these communities of tech bros and startup people, and we started creating content. The main driver of users was the content we created — we'd write quite specialised content on our blog. A big part of my job was actually writing content for the Span Health blog, where we'd go into the details of different aspects of longevity and health. So we built a bit of a community around our content, and that would drive the subscriptions.

I think it's more that you need to identify already existing communities and cater to those, rather than try to build a community around your own brand when you're a small brand. What we were doing relatively well was identifying people who were interested in what we were talking about and giving them that information for free — in the form of a blog post or social media content. Podcasts were a big part of our strategy as well; we did quite a few podcasts in the US, talking about our approach and our story.

There isn't a longevity specialty. I went down internal medicine because I felt it's more representative of general medicine, and then decided to specialise in oncology, because the science behind it is very similar to the science of aging. The science of oncology is well established, and you can spend a lot of time learning about cancer. In the hallmarks of aging paper — a landmark paper in the longevity and aging space, published in 2013 — the opening paragraph talks about how the science of aging is basically similar to the science of cancer. That's why they modelled the hallmarks of aging paper around the hallmarks of cancer paper. So that's what led me into oncology.

But if I was starting over, I think endocrinology is probably one that's high up, because a lot of the aging stuff plays into endocrinopathies. So endocrine is high on the list, or GP. The problem with GP is that you train a lot on following guidelines, and longevity, in my view, is ultra-ultra-ultra prevention. Instead of just targeting people who are at risk and providing economically viable screening programmes, longevity takes a step earlier and starts super, super early. There are a few groups around the world developing protocols and guidelines around this, but there's no consensus yet.

Maybe — or start a company. I think it depends on what you're looking at. Do you want to have an impact on average, or an impact on one person, on individuals? On the individual level, you have to go down the route of internal medicine, maybe oncology, or endocrinology or geriatrics.

Because it's a way of creating real impact that is sustainable and doesn't need governmental support or the backing of large organisations. Early on, we were thinking of doing a version of Span within the NHS, for people who have pre-diabetes or diabetes. In order to do that, you need to run a relatively large-scale clinical trial, provide the outcomes, show the solution is economically viable, and so on. Which is fine, because you're dealing with public money — but that's a really long road for a startup to establish itself. The quickest way to start trying your solution is to go the startup route and go directly to consumers. The most important thing with finding a solution to anything is to reduce the time between the idea and your hypothesis and actual implementation. And the fastest way to do that and iterate quickly is by building a company.

Early on we also tried some marketing through influencers on Instagram and different social media platforms, and that didn't work for us, for a few reasons. First of all, we weren't talking to the right audience. Someone who was on — what's that reality TV show? Something Island.

Love Island, yeah. An ex-Love Island contestant probably isn't going to be talking to our audience. We were quite naive in the beginning — we'd reach out to people just because of their numbers, and they'd have a bit of a health background, they talked about health and fitness. But what we didn't do well is really narrow it down. Not everyone who's into health and fitness is going to be into wearables and health tech and optimising for longevity. It's quite a niche segment — growing, but still quite niche. After that we started focusing on micro-influencers, and that really didn't work either — micro-influencers targeting our niche, and it still didn't work that well. The reason, I think, is that we were just on the wrong platform. Instagram is probably not a great platform to go deep into the nerdy stuff. But what really worked well for us was Twitter.

Twitter became our main acquisition channel — the top of our funnel for a big part of it. We'd start interacting with people on Twitter, and it seemed that people on Twitter were just more like the people we were targeting, more like our customers. We found that most of our customers, if not all of them, had Twitter, but a lot of them didn't even have an Instagram. That should have been a signal early on: okay, we're probably focusing on the wrong medium here.

We started growing, we found our stride. This was around early pandemic time. We focused on our niche and continued to build the business, expanded the team. We did a few rounds of funding — a pre-seed, then a bridge round, then we started a seed round, and we also did a crowdfunding round around that time. But then we started to develop a relationship with Eight Sleep — with Matteo, the CEO of Eight Sleep. We found that we aligned on many things: they had the same vision as us, we just liked the team, we vibed with them a lot. Eventually they suggested that we join forces, and it just made sense to do so. We were aligned on the mission and had a lot in common, so we had to make that decision: do we continue building on our own, or join someone bigger than us who can accelerate the mission? We decided to go for it.

That's a good point. I don't deliberately try to network, but I don't shy away from reaching out to people, asking them questions if I have them, and even helping people. If I see a post from someone who has a certain problem, I'll offer a solution. I do stuff like that, and I guess that's a way of building relationships. But mostly, I think the most important thing is that people want to meet other people who have done stuff, who have built something. Once you put yourself out there and show your work to the world, people start reaching out to you. So the best network is a network of people who are building similar products and want to learn from each other.

That is so true, and it's something that's actually lacking in the health tech space — more doctors with actual clinical experience coming into the space. This happens so often: I talk to someone building a solution, and, as you said, you just have this intuition that this isn't something that really solves a problem for clinicians or patients. It's a really important skill to be able to translate that experience and intuition into clear advice. I talk about this a lot with doctors who want to transition out of medicine into industry or startups — our experience as clinicians is actually really valuable, but we don't really use it outside of our narrow careers.

I always focus, in any project I work on, on my strengths, which are my clinical practice, and my experience in reading medical literature and translating that into actionable tools. The thing I do best is using those tools and applying them to different areas of health — being able to extract clinical tools and turn them into actionable insights you can use in a tech context. Super important, and really underutilised in health tech.

That's a good question. A lot of doctors have a lot of ideas, but we lack the knack of building something from scratch, and we like to follow already-set rules — because that's how we're trained throughout our careers. In medical school you have exams, you jump through the hoops, and then you start your training and it's the same thing: you tick all the boxes and that's how you progress to become a consultant. The startup world is totally different. So demonstrating the ability to come up with something outside the system, and build something outside the system, is a really important tool. Being able to go between those two modes is really important, and demonstrating some kind of evidence that you've done something like that matters.

I think 80% is definitely the lifestyle stuff — and the lifestyle stuff is an ongoing thing. You're never going to get it 100% under control, and it changes with time, so it's very dynamic. The lifestyle stuff is the core. But the way I look at it — and this is actually a friend of mine's way of categorising longevity interventions into three levels. Level one is the stuff with higher evidence, and it's mostly the lifestyle stuff: sleep, nutrition, exercise, avoiding harm like smoking and alcohol, and maybe a mental health and stress component too.

The next level is treating existing medical diseases, and that's where classical medicine falls. And then level three is things that have less evidence behind them but might be available in the future — interventions that target the aging process itself. We can split that into the super-futuristic, like epigenetic reprogramming, and things that are actually available today but maybe don't have the evidence we'd want — stuff like rapamycin, metformin, and compounds like NMN and resveratrol. We can go through those if you want. I think rapamycin might be a potential anti-aging drug; the rest are probably more hype than anything.

There's a lot of hype in the longevity space. There are the super-optimists who hype things up, and then the pessimists who say, "Yeah, this is bullshit, longevity is just another grift." I think the pessimists are right on most things right now, but the optimists are the ones who'll probably push the field forward. There's definitely a lot to be done in longevity that hasn't been done yet — it's still in its infancy.

The two main mistakes people make: the first is confusing mechanistic evidence for clinical evidence. If you have evidence that something works mechanistically, you have a nice theory behind it, but you don't have randomised clinical trials showing benefit with hard outcomes, then you can't really make the call that this is an actual beneficial substance. But in some cases, doing a randomised controlled trial is difficult, so you have to rely on lower-quality evidence. For example, rapamycin has a high level of evidence in mice and other organisms, but not a lot of evidence of benefit for longevity in humans — because the trials haven't been done.

So in that case, what do you do? Do you rely on the animal studies and maybe prescribe it, or wait until the clinical trials are done? I think it comes down to an individual basis: if the person is well-informed and understands the risks, and that the benefits might not be there, then there is potentially a role for experimental substances like rapamycin or metformin in clinical practice even today. Metformin is less of an issue, because it's a very safe drug and used widely. Rapamycin isn't used widely, especially in the UK, and liability laws in the UK are stricter, so people are way more apprehensive about prescribing things like rapamycin.

I was going to get into that. When we talked about how important lifestyle is versus the more clinical interventions — obviously the lifestyle stuff is more impactful and has more evidence at the moment. But the problem is, when you look at averages, most people aren't really interested and don't have the motivation to follow the lifestyle stuff.

So is the solution to find clinical or chemical alternatives to the lifestyle stuff that might help with people like that? Or do we use psychological and tech-based solutions? That's what we tried to do at Span. The way we approached it, we were very focused on habits. You'd log your daily habits, and then your coach would start modifying them one week at a time — introducing new habits, habit-stacking on top of an existing habit. We'd do one intervention at a time and measure the impact that intervention had on your metrics. The aim is to see if there's a positive impact, and if there is, that closes the habit loop of doing the action and then seeing the outcome. That's what wearables do — they shorten the cycle of seeing the outcome, and that reinforces the behaviour and builds a habit.

But the step before that is automation of your environment. The best thing to do is automate your environment, so you don't even have to rely on habits.

You can do that with simple things. For example, we advised people to dim their lights at night, so you have less circadian rhythm disruption, and that can improve sleep — for people with sleep problems, and even people who don't. You can build a habit of dimming lights at night, or you can replace your bulbs with automated light bulbs that you set to go dim at a certain time. That way you're automating your environment to do something you don't even have to build a habit for. So that's step one, and after that is building habits.

The way I think about interventions is benefit versus cost. I'd start with interventions that have the highest benefit regardless of cost. If you have a medical condition right now that can be resolved, even if it's going to cost you a lot, you should do it as soon as possible, regardless of cost. Exercise is one of those interventions that's high in cost — not money-wise, but time-wise, because you have to exercise for nearly an hour a day, most days.

That's a lot of time, but it's worth the commitment because the reward is going to be high. Then after that I'd focus on things that are less cost but high benefit — diet, weight loss, that kind of thing. After that would be lower-benefit, lower-cost things, like a cheap vitamin D supplement. And at the end of the pile would be things with unproven or low benefit and high cost — expensive supplements that might help, might not. The problem is a lot of people flip that. They start with these unproven supplements that are easy to take but probably quite expensive, and they forget they should be starting with the low-hanging fruit of high-benefit interventions. So we focus on those, and then try to build that habit and, step by step, slowly introduce them into the person's life.

Then I'd maybe focus on interventions that require less time commitment. It depends on what you're trying to treat, but if you're starting with environmental changes and then building on those, that would probably be my approach. But at the end of the day, many people who develop chronic conditions develop them because they might lack that motivation. It's a big problem, and I don't think there's really a solution — other than trying to put the word out there and come up with easy ways of implementing important healthcare interventions.

Yeah, it's a really difficult problem to solve.

I think it depends on two things: your budget, and how much you want to know. Some people can develop health anxiety — the more information you give them, the more it builds up their anxiety, and that might not be for them. But I personally want to know more; the more I know, the better. So I'd fall in the category of doing all those tests. Even if you find an incidental finding that might not be of any significance, I'd rather take that risk. But going into it, you should know there's a risk.

The problem with these screening tests that aren't indicated for most people is that you're at risk of finding, for example, incidentalomas — tumours of unknown significance that can introduce anxiety. They might lead you to further, more invasive procedures like biopsies to understand what these lesions are, and eventually you find out it's nothing to worry about. If you didn't know about it from the beginning, nothing would have changed. But, as I said, there's that small percentage where you might actually find something that was undiagnosed — people do find cancers that have spread, stage-four cancers or whatever, and if they'd found them earlier, that was probably better. So there's a happy medium between the two, but it also depends on the person and your budget. A lot of these tests are quite expensive, so if you have the spare money, I'd go for it. But if not, I'd start with the basic stuff.

The basics are cardiovascular markers, things like weight and fat percentage — general health markers. There are many tests you can do that are quite cheap that can tell you a lot. I'd start with the cheap blood tests, and then maybe functional tests. Functional tests are mostly fitness-based, and you don't need any special equipment. VO2 max is a really informative test, because it gives you your level of cardiac fitness, and changing your VO2 max can have a really big impact on your health and longevity. Those are tests everyone should do at some point after maybe 30 or 40. But when it comes to more expensive tests, like whole-body MRIs, that's probably later in life. Whole genome sequencing, probably once in a lifetime — just to make sure you don't have any big genetic variants you should know about. So it depends on the person, depends on the budget.

I'm relatively young, so I haven't done that much. I use wearables — a Whoop band to monitor my sleep, HRV, heart rate, et cetera. I use an Eight Sleep mattress that also gives me these markers. That's for my fitness markers. Then I do bioelectrical impedance tests every few months, which isn't super accurate but gives you directional evidence of your body fat percentage, and I pair that with my weight — I measure my weight maybe once a month.

And then blood tests. I do quite extensive blood tests, but that's just my personal preference. I also like to do a few epigenetic tests — biological age tests that are blood-based, where you populate your blood markers into these algorithms that give you a biological age. They're also not super actionable, but I like to experiment with them because I'm interested in the space.

No, I haven't done any imaging.

When it comes to healthcare economics, it definitely doesn't make sense to do these tests. But healthcare economics are driven by averages. So if an inexpensive test only detects one case in a million, it's not economically viable, so it shouldn't be done on average.

But if you have the means and you want to do that test, even if there's a one-in-a-million chance you'll detect something actionable, you should be able to do that.

It's really difficult. I'd basically work at the hospital in the morning and then work at night on Span. I'm maybe a bit of a workaholic, so it's not a lifestyle I'd recommend to everyone, but I think at certain periods in your life, being a workaholic might be a good thing.

I think it's more just about the grind, but it's also about finding the right people to work with. One of the things I do well is partner with the right people and not try to do everything myself. That's a really important thing to do as someone working a day job with their own side business — or for doctors in general. Focus on what you do well, and find the right people to work with.

Honestly, PubMed is a pretty good source — that's where I go if I want to learn about anything. I don't read books. Books about health are not worth reading, in my opinion. They're always super biased, based on outdated data and studies. Medicine is evolving so quickly, and there's so much amazing work in publicly available research papers — people put their entire life's work into a few pages, and it's available for free, or cheap, on PubMed. So that's where I go.