01-projects/longevity

founder health assessment v1

Date: 2026-05-21 Subject: Ben Wilson (founder, born 1990-06-02; age 35, turning 36 on 2026-06-02) Data sources: D1 rdco-health database (385 FHIR records 2018-10-24 to 2025-03-18 + Apple Health daily_metrics 2020-01-01 to 2026-05-21 + 261 workouts 2023-01-02 to 2026-05-21) Frame: Informed-patient interpretive synthesis. NOT a diagnosis. NOT a prescription. Doctor (Dr Chaz Ambrose, PCP) stays the decision-maker. Author: Ray (COO agent)

Age correction note (2026-05-21 20:15 ET): v1 sub-agent inferred age ~38 from context; founder confirmed actual age is 35 (DOB 1990-06-02). Specific age references in section 1.1, the VO2max paragraph, and the CAC screening discussion patched below. Substantive findings unchanged — clinical reference ranges in this doc are adult-broad and don't materially shift at 35 vs 38. CAC screening recommendation timing UPDATES: instead of "you're 38, screening starts at 40, so close-to-window," it's now "you're 35, screening starts at 40, so you have ~5 years before age-based indication kicks in (still worth discussing with Dr Ambrose if any individual-risk factors point earlier)."

0. Important caveats up front

1. The data: what we know

1.1 Most recent lab panel (2025-03-18, age 34)

Lab Value Reference Flag
Glucose (fasting) 105 mg/dL 70-99 HIGH (ADA impaired fasting glucose: 100-125)
Sodium 146 mmol/L 134-144 HIGH (likely dehydration on draw)
AST 46 U/L 0-40 HIGH (was 20-29 in prior panels)
LDL Chol Calc (NIH) 108 mg/dL 0-99 HIGH (borderline)
Hemoglobin A1c 5.4% 4.8-5.6 Upper normal
Uric Acid 7.9 mg/dL 3.8-8.4 Upper-normal (near limit)
Cholesterol, Total 174 mg/dL 100-199 OK
HDL Cholesterol 45 mg/dL >39 OK but low-side
Triglycerides 116 mg/dL <150 OK
Total chol / HDL ratio 3.9 <4.5 OK
ALT 34 IU/L (2021) <50 OK
Creatinine 1.0 mg/dL 0.7-1.3 OK
eGFR 101 mL/min/1.73 >60 OK
Albumin 5.0 g/dL 3.5-5.5 OK
Hemoglobin 15.7 g/dL 13.5-17.5 OK
Hematocrit 45.1% 41-51 OK
Platelets 223 K 140-400 OK
WBC 5.9 K 4.0-11.0 OK
TSH 0.945 uIU/mL 0.4-4.5 OK
Total bilirubin 0.5 mg/dL 0.2-1.2 OK
Alk phos 63 IU/L 40-150 OK

1.2 Longitudinal lab trends (the 5-year story)

Glucose trajectory (mg/dL, fasting):

Pattern: glucose was elevated in 2018, dipped to normal 2019-2021, climbed back over impaired-fasting threshold by 2025. Three out of four readings since 2018 are at or above 100. HbA1c was 4.9% (2018), 5.0% (2021), 5.4% (2025) – clear upward drift, still under prediabetic 5.7% but moving toward it. This is the single most actionable longitudinal trend in the chart.

Lipid trajectory (mg/dL):

Pattern: lipids returned to 2018 levels by 2025 after a notably better mid-period. Whatever changed 2019-2021 (more activity? diet?) regressed.

Liver enzymes trajectory (U/L):

Pattern: ALT was elevated in 2018 (55), trended down to normal. AST trended down too then suddenly jumped to 46 in 2025. AST without ALT context is hard to interpret. AST is in skeletal muscle as well as liver, so a hard workout in the days before the draw can drive AST up 30-50 U/L without ALT elevation [PMC7438350]. Also: founder was diagnosed with Fatty liver on 2021-07-26 (chart entry). Whether the 2025 AST is exercise artifact, MASLD progression, or both cannot be determined from this single value.

Sodium trajectory (mmol/L):

Pattern: trending up. 146 is mildly elevated. Most-common cause: dehydration on the morning of draw. Consistent rising trend over 7 years is also a mild signal worth a follow-up reading after good hydration.

Blood pressure (from clinical encounters, 6 readings):

Pattern: clinic BP varies widely. 142/90 is stage 1 HTN by 2017 ACC/AHA. 148/74 was during an acute encounter. No recent BP readings in record. Strong candidate for a home BP cuff and 30-day average – cardiology guidelines now use ambulatory or home averages, not clinic-only readings.

1.3 Active conditions in the chart

Date Condition
2018-10-24 Headache + Health maintenance
2021-07-19 Side pain (likely the ER visit with cipro Rx, may be a kidney stone or UTI workup)
2021-07-26 Fatty liver (MASLD) — founder confirms 2026-05-21: "not better or worse," stable. Actively tracking retatrutide (LLY) as future treatment option once MASH indication granted (~2027-2028 expected).
2021-07-26 Diverticulosis
2021-07-26 BMI 25.0-25.9 (overweight) — see Weight Status section below for current 202 lbs reading + 180 target
2021-07-26 Screening for depression (procedure code, not diagnosis)

1.3a Conditions NOT in chart but disclosed by founder 2026-05-21

Pattern Detail
Gout 4 documented flares over 2022-2026: both big toes, left elbow, right knee (most recent right-knee ~April 2026). Classic polyarticular asymmetric distribution. Dehydration is the identified trigger; hydration mitigation works (founder can head off most flares with water before they fully manifest). Chart's serum uric acid 7.9 mg/dL (high-normal lab range) is NOT just high-normal — combined with 4 documented flares = hyperuricemia with clinical manifestation = clinical gout diagnosis. Per 2020 ACR guidelines, founder is in the urate-lowering-therapy-indication zone (≥2 flares/year + serum urate >6 mg/dL).
Weight gain trajectory Current 202 lbs (founder's first time ever cracking 200). Wedding-day baseline 175 lbs (his lightest since high school). Target 180 lbs — described as "much more comfortable place." Delta 22 lbs = ~11% loss = past the threshold for meaningful cardiometabolic intervention (see Tier 1 section).

1.4 Medication history

Notable items:

No chronic prescription medications in the record. No statin, no metformin, no antihypertensive, no antidepressant. He is not on any background pharmacotherapy that we have a record of.

1.5 Activity history (workouts table, 261 entries)

Monthly volume picture:

Month Workouts Notes
2023-01 37 peak intensity year-start
2023-02 17
2023-03 7 dropping
2023-04 14
2023-05 1 crash
2023-06 4
2023-07 to 2023-10 0 gap
2023-11 2
2024-08 9 restart
2024-09 to 2024-11 8-19 building
2024-12 7 dip
2025-01 22 strong
2025-02 20 strong
2025-03 5 dropping
2025-04 to 2025-11 0 gap (7 months no workouts logged)
2025-12 2
2026-01 14 restart
2026-02 12
2026-03 17
2026-04 19
2026-05 (so far) 13 on pace

Recent (May 2026) workouts: almost all 20-30 min walks + one strength training session. Solid Zone 2 cadence (Apple Watch "Walk" / "Outdoor Walk"). Light on intensity. Light on lifting.

1.6 RHR + HRV (sparse)

Conclusion: today's RHR is at the better end of his historical range. The early-2026 average was modestly elevated (~65) vs his 2020 baseline (~62). The May 21 reading is reassuring.

HRV: 2020 readings ranged 21-147 ms with mean ~58 ms (this is intraday Apple Watch HRV, which spans a wide range). Today's three readings: 58.2, 62.1, 62.1 ms – within normal range for his age.

Honest caveat: with this much missing daily data, "90-day trend" claims can't be supported. The chart simply does not have daily RHR for the 90-day window.

1.7 Sleep (63 days total over 2.4 years)

Pattern: variable, with significant short-sleep nights. Median is below the AHA-recommended 7-9 hrs. Founder's wife teased him about late-night work ("novel-length iMessage replies"), and the prior vault note feedback_brief_imessage_link_to_hq.md confirms he runs late.

1.8 VO2 max

Single reading: 40.3 ml/kg/min in Jan 2020. For a male aged 29-30 at that time (DOB 1990-06-02), that's "below average / lower-end-fair" range on the Cooper benchmark (norms for 30-39yo males: <39 poor, 39-43 fair, 44-51 good, 52+ excellent). No follow-up reading.

VO2 max is the single strongest mortality predictor in observational data: each 1-MET (3.5 ml/kg/min) increase = ~13-15% lower all-cause mortality risk. [DexaFit summary of JACC 2018 and JAMA NetwOpen studies]. Strong candidate for re-measurement.

2. Plain-English interpretation

2.1 What's actually strong

2.2 What deserves attention (ordered by actionability)

1. Fasting glucose creeping up. 105 mg/dL in 2025 + HbA1c rising from 4.9 → 5.0 → 5.4 is the most important longitudinal signal. He's been formally in ADA impaired-fasting-glucose territory at 3 of 4 readings since 2018. This is modifiable with high confidence – tier 1 (diet+exercise) has the strongest RCT evidence of any preventive intervention.

2. Fatty liver diagnosis from 2021 with no follow-up in chart. Diagnosed 2021-07-26, no ultrasound, FibroScan, or repeat panel since. AST jump 22 → 46 in 2025 might be exercise artifact (he was working out heavily in Jan-Feb 2025), but with the prior MASLD diagnosis it's worth a real follow-up. AASLD 2023 guidance: lifestyle modification + 150min/wk moderate exercise is first-line; vitamin E 800 IU/day RRR-alpha-tocopherol is the only supplement with biopsy-proven NASH evidence (not all MASLD).

3. LDL 108 mg/dL with no apoB or Lp(a) in record. LDL alone is a coarse marker. 2025-2026 ACC/AHA updated lipid guideline now recommends once-in-lifetime Lp(a) measurement for all adults and selective apoB for risk refinement, plus CAC scoring for men 40+. He is 35 now – ~5 years from the age-based CAC recommendation kicking in, but Lp(a) is the load-bearing once-in-lifetime test that should happen now regardless of age.

4. Stage 1 HTN signal from clinic BP. The 142/90 in 2021 is enough to warrant a 30-day home BP series. Founder lifestyle includes high-stakes work + late nights + variable sleep – all known BP elevators.

5. Sleep < 7 hrs median and variable. Single most actionable Tier-1 lever after diet. Short sleep increases fasting glucose, BP, HRV-suppression, AND craving-driven food choices the next day.

6. Stale VO2 max and no recent cardiorespiratory fitness measure. Given VO2max is the strongest mortality predictor we have, "what's my number now" is worth knowing.

7. Missing lab markers. Vitamin D 25-OH, testosterone (total + free), ferritin, hsCRP, apoB, Lp(a), homocysteine. None ever ordered in the FHIR record. For an executive-style annual panel, these are standard adds.

2.3 What is NEW that the data quietly reveals (non-obvious)

3. Three-tier plan

TIER 1 – Founder-direct (executable starting today, no doctor gate)

HEADLINE TIER-1 INTERVENTION: 202 → 180 lbs (added 2026-05-21 founder context)

Founder confirmed current weight 202 lbs (first time ever over 200), historical baseline 175 lbs (wedding day, lightest since high school), comfortable target 180 lbs. Delta = 22 lbs = ~11% body weight loss. This single intervention is the highest-leverage move in the entire longevity plan because it directly addresses FIVE chart findings simultaneously:

Chart finding Mechanism of weight-loss benefit Expected magnitude
Fasting glucose 105 / HbA1c 5.4% (rising) DPP NEJM 2002: 5-7% loss → 58% reduction in T2D progression in prediabetics. Insulin sensitivity improves linearly with weight loss in obesity-spectrum patients. Likely reversal of glucose creep
MASLD diagnosed 2021 (stable, not improving) 5-10% weight loss is THE gold-standard MASLD treatment per AASLD 2023 guideline. At 11% loss, fibrosis regression becomes possible (vs just steatosis reduction). Stable → trending-toward-improvement
Gout (4 flares 2022-2026, urate 7.9) Every 10% weight loss = ~0.6 mg/dL serum urate drop per ARD 2017 meta-analysis. 11% loss → urate from 7.9 to ~7.3 (still above target <6 but moving the right direction). Reduced flare frequency; doesn't replace urate-lowering Rx if frequency stays high
LDL 108 (borderline high, trending up since 2021) Mediterranean-pattern weight loss typically drops LDL 10-15%. Independent benefit beyond LDL: apoB particle number tends to fall further. LDL likely back to <100 range
BP trend (was 142/90 stage-1 HTN in 2021) Weight loss is the single most effective non-Rx BP intervention. ~1 mmHg systolic per kg lost in the 5-10% range. ~10 mmHg systolic improvement plausible

Single intervention. Five simultaneous improvements. Plus reduces gout-flare frequency. This is the most-leveraged Tier-1 goal in your plan; everything else (diet specifics, exercise prescription, supplements, sleep) is supporting infrastructure for hitting this number.

Realistic timeline: 22 lbs over 6-9 months at 0.5-1 lb/week is sustainable, doesn't tank training capacity, and lands at the 180 target. Track weekly on same scale same time. The diet + exercise specs below are designed to support this trajectory.

Diet

Mediterranean / low-glycemic biased, with intent to bring fasting glucose back under 100 and HbA1c back to ~5.0%.

Specific protocols:

Exercise (specific prescription per current data)

Current pattern is 4-5 x 20-30min walks/week. Solid Zone 2 base but missing intensity and resistance.

Add weekly:

Don't drop walks – Zone 2 has independent mitochondrial benefits per Attia framework + multiple longevity researchers. The 80:20 principle (80% Zone 2, 20% high intensity) is well-supported.

Sleep

Supplements (specific doses + evidence quality)

Founder-direct, no Rx required:

  1. Vitamin D3 2,000 IU/day – likely deficient given no prior testing + indoor-worker pattern. Get a 25-OH-D level first (lab; see Tier 2). Evidence: many RCTs for bone, mood, some cardiovascular. Cost: $5/mo.
  2. Magnesium glycinate 200-400 mg/day at bedtime – may improve fasting glucose [Asbaghi et al meta-analysis 2020] and sleep. Cost: $10/mo.
  3. Omega-3 EPA+DHA 2g/day combined – triglyceride reduction is the strongest evidence (REDUCE-IT for EPA specifically used 4g/day icosapent ethyl, but that's Rx; 2g/day OTC fish oil has consistent triglyceride and modest LDL-particle effects). Cost: $15/mo.
  4. Berberine 500mg 2x/day with meals – RCT evidence shows glycemic efficacy comparable to metformin in prediabetes [PMC10483788, ijbcp.com 2024 comparative study]. Best on lifestyle background, not as a magic bullet. Discuss with Dr Ambrose before starting since it has real pharmacologic activity. Cost: $20/mo.
  5. Creatine monohydrate 5g/day – ironclad RCT evidence for muscle preservation + strength + cognitive benefit. Will mildly elevate creatinine reading (false-positive for renal dysfunction); flag this to Dr Ambrose. Cost: $8/mo.

Skip / lower priority: NAD precursors (NR/NMN) – evidence is preliminary in humans. Resveratrol – disappointing in human trials. Multivitamin – not needed if diet has variety.

Monitoring (founder-direct, no doctor gate)

Metric Cadence Threshold
Home BP cuff 2x/day for 30 days, then 1x/day Mean > 130/80 = lab follow-up
Apple Watch RHR Daily passive Trend over 4-wk window; rising 5+ bpm = recovery check
Apple Watch HRV Daily passive Trend; drop > 25% from rolling mean = recovery day
Continuous Glucose Monitor (CGM) Optional: 2-week wear via Stelo OTC or Levels Identify which foods/timings spike glucose
Body weight 1x/wk same time Trend
Subjective sleep score Daily <5/10 = bedtime hygiene reset

TIER 2 – Founder-researches, doctor-signs (ask Dr Ambrose at next visit)

Lab orders to request

These are the gaps in his existing panel that an executive-style annual screening would include:

  1. Lp(a) – once-in-lifetime per 2025 ACC/AHA dyslipidemia guideline. Genetic factor; massive variance across the population; if elevated, it changes the whole risk picture. [ProfessionalHeart 2026 guideline summary]
  2. apoB – more accurate atherosclerotic-risk marker than LDL-C in same panel. Especially relevant since his LDL is borderline-high but HDL is also low-normal – apoB cuts through this ambiguity.
  3. hsCRP – inflammation marker. With fatty liver + creeping glucose, this is the cleanest inflammation snapshot.
  4. Vitamin D 25-OH – never measured in 7 years of records. Get baseline before supplementing aggressively.
  5. Testosterone total + free + SHBG (AM draw) – >40 yr old screening per Endocrine Society. Will inform whether sleep / training / energy issues have a hormonal component.
  6. Ferritin + iron studies + B12 – fatigue/energy workup, also relevant given Mediterranean-diet plan (iron from plant sources less bioavailable).
  7. Repeat ALT alongside AST – the 2025 panel didn't include ALT, which is why we can't interpret the AST 46. Get them paired with CK (creatine kinase) to rule out muscle-source AST.
  8. GGT – complementary liver marker, can suggest fatty-liver activity even when AST/ALT borderline.
  9. Fasting insulin + HOMA-IR – with glucose 105 and rising HbA1c, insulin resistance is the upstream driver. HOMA-IR is calculable from fasting glucose + insulin.
  10. 2-hr OGTT (oral glucose tolerance test) – more sensitive than fasting glucose alone for catching early IGT/IGT-but-not-IFG. Consider given the trend.

Imaging / screening to discuss

  1. Coronary artery calcium (CAC) score – non-contrast CT, ~$100-200, no insurance required at most centers. Per 2025 ACC/AHA, recommended for men 40+ for risk stratification, especially with borderline LDL. Single-snapshot, then reassess in 5 yrs. Founder is right at the recommended age.
  2. Liver FibroScan (transient elastography) – non-invasive ultrasound-based assessment of liver stiffness + steatosis. Given the 2021 MASLD diagnosis with no follow-up, this is the AASLD-recommended monitoring approach. ~30 min, no radiation.
  3. DEXA scan – body composition + bone density baseline. He's in BMI 25 range; DEXA differentiates whether that's muscle or visceral fat (the relevant question for MASLD progression).

Prescription medications worth discussing (with Dr Ambrose, not pre-decided)

These are options to discuss with citations behind them, not recommendations:

  1. Metformin 500-1000mg – ADA 2024 Standards of Care section 3 recommends metformin for adults aged 25-59 at high risk of T2D, particularly if fasting glucose ≥110 OR BMI ≥35 OR history of GDM. Founder is borderline on the criteria (FG 105, BMI 25-26). Tier-2 option. The Diabetes Prevention Program (DPP) showed metformin reduced T2D progression by 31%, vs 58% for intensive lifestyle. Lifestyle still beats metformin. But metformin is well-tolerated with decades of safety data and increasingly used as a longevity-adjacent medication. [PMC11562588 meta-analysis 2024]

  2. Low-dose statin (e.g., rosuvastatin 5-10mg) – LDL 108 alone wouldn't trigger this in most guidelines, but with apoB / Lp(a) / CAC data, the calculus changes. If CAC > 0 in a 40-year-old, statin is strongly favored. If CAC = 0, can usually defer.

  3. Bempedoic acid – LDL-lowering alternative to statin for patients who can't tolerate statins or want non-statin path. CLEAR Outcomes showed 13% MACE reduction. [PMC10900064] Not first-line, but discuss-worthy if statin is contraindicated.

  4. SGLT2 inhibitor – primarily for established diabetes, but expanding indications. Side benefit of lowering uric acid (relevant given founder's UA 7.9). Probably not warranted at his current glucose level – more relevant if he progresses.

  5. Allopurinol (urate-lowering therapy) – NEW PRIORITY ASK 2026-05-21 given founder-disclosed gout history. Founder has had 4 documented gout flares 2022-2026 (both big toes, left elbow, right knee) + serum urate 7.9 mg/dL. Per 2020 ACR gout guideline, urate-lowering therapy is STRONGLY recommended for patients with ≥2 flares/year OR ≥1 tophus OR radiographic damage OR CKD3+. Founder is in the indication zone. Allopurinol is first-line: typical start 100 mg/day with gradual titration to target serum urate <6 mg/dL (often requires 300-600 mg/day). Started AFTER acute flare resolves, NOT during. Cheap generic, well-tolerated, decades of safety data. Skin-reaction monitoring in the first 8 weeks (rare but serious SJS/TEN risk). Discuss starting alongside acute-flare meds for breakthrough (NSAIDs / colchicine). Important: starting allopurinol can paradoxically trigger a flare in the first months — colchicine 0.6mg/day prophylaxis is standard for the first 6 months.

  6. Retatrutide (LLY triple agonist, ~2027-2028 expected approval) – NEW ASK 2026-05-21 to bookmark, NOT for today. Founder is actively tracking this drug as a potential MASLD-specific treatment. Phase 2 retatrutide data showed strong MASH/MASLD improvement (glucagon-receptor arm of the triple agonist specifically targets hepatic fat oxidation). If FDA grants MASH indication alongside obesity around 2027-2028, founder becomes a real candidate for combined obesity + MASLD + cardiometabolic intervention in one drug. Until then: resmetirom (Rezdiffra, Madrigal) is the only currently FDA-approved MASH drug, thyroid-receptor-beta targeted, can be discussed if MASLD progresses faster than the retatrutide timeline. Discuss with Dr Ambrose at first visit so the clinical record reflects active interest; revisit annually as retatrutide trial readouts progress.

Acute-flare meds to have on hand (gout-specific, added 2026-05-21)

Referrals if any

TIER 3 – Doctor-domain (awareness, not action)

4. Questions to bring to Dr Ambrose

  1. "My fasting glucose was 105 and HbA1c 5.4 in March 2025, trending up since 2018. Can we order a 2-hr OGTT and fasting insulin to characterize whether this is impaired fasting glucose, impaired glucose tolerance, or early insulin resistance?"
  2. "AST jumped to 46 in March 2025 with no ALT in the panel. Can we re-draw AST + ALT + GGT + CK and rule out muscle-source elevation vs fatty-liver progression?"
  3. "I was diagnosed with MASLD in 2021 with no follow-up. Can we do a FibroScan to get a current liver assessment?"
  4. "I'm 38, I've never had Lp(a), apoB, vitamin D 25-OH, testosterone, ferritin, or hsCRP ordered. Per 2025 ACC/AHA guideline updates, can we add these to my next panel?"
  5. "What's your view on me getting a CAC scan now versus at 45?"
  6. "I'm considering berberine 500mg 2x/day for glucose management while I work on lifestyle. Any contraindications you'd flag?"
  7. "Clinic BP has been 142/90 once. I'm planning to do a 30-day home BP log. What threshold should trigger a follow-up conversation?"

5. Citations + literature anchors

6. Disclaimers + boundaries

End of v1