The Necessary Nine


When it comes to lifelong health, there really isn't that much you have to do to be healthy. Yes, there are always unforeseen circumstances and illnesses that may come up and are out of your control, but when it comes to preventative medicine, less truly is more. Social media may make it seem like you need to have a "fully optimized" morning routine that takes 2 hours to complete, or you need to "biohack" yourself to be the best version of your self, but in reality all you need to do is master some basic concepts and you get 95% of the benefits of all those other complicated routines people talk about. The Necessary Nine is a term I made up to discuss (what I feel) are the nine most important aspects that you need to consider to stay active and healthy for life. If you master these nine things, then I truly believe that you will be covering the vast majority of your bases when it comes to health. I've always believed that the key to any health change is that it needs to be practical and sustainable, and that's why I believe so strongly in the Necessary Nine because if you have these items locked in, then you are giving yourself the best chance at having a healthy life. Obviously nothing is guaranteed, and you still will need to do some other things with your doctor (like cancer screenings, immunizations etc...), but if you want to take your health into your own hands, then this is where I would recommend everybody to start. Let's dive into them right now.

1: Build a Health Promoting Diet

The first concept is eating a health promoting diet. I'll repeat that again and say that the number one most important thing we can do is eat a health-promoting diet. When I did not say is that you need to eat keto, carnivore, vegan, Mediterranean, or intermittent fasting, but what I said is that you need to eat a health promoting diet. I'm sure you know this is a very hotly-debated topic throughout the internet, and all you have to do is Google any of the aforementioned diets or enter them on Twitter and you will quickly wade into a cesspool of arguments, anecdotes, and almost religious like fervor. I think there's definitely Merit to healthy debate, but it just seems that the overall body of evidence tends to indicate that there are multiple ways to eat healthy to maintain an ideal body composition throughout the lifespan.

So, what does a health promoting diet look like? A health promoting diet includes eating a wide variety of  unprocessed foods that helps you maintain a healthy body weight, leaves you with no nutritional deficiencies or grossly abnormal lab values. Once again, this could be an entire semester along class, but the first step in this process is to make sure you aren't eating the Standard American Diet (SAD). The way I describe the SAD is that you eat whatever you want, whenever you want. That's it. If you are doing that, then the first step is to create a plan of attack for you to get out of that pattern of eating. I recognize that can be hard, but I promise you it will be so worth it. Personally, I believe that at any given time someone should be either controlling the type of foods they eat, the quantity of food to eat, or the time in which they eat those foods. This means that you are either eliminating certain foods (not eating meat, or dairy, "sweets", etc), how much they eat (counting macronutrients and/or calories), or when they eat (fasting). At the end of the day though, the most important thing is adherence, so that's why I have no specific diet recommendations. It does no good if I recommend a certain diet and you are vehemently opposed to that diet because then that diet never had a chance and there was never any way that would work for you. Find something that clicks with you, and go from there. I put this topic as number one because the old saying that, "you can't outrun a bad diet" is true for most people, and if we start here, it's really laying a foundation for everything else that comes.

2: Get Enough Physical Activity

Moving on to number two, I think the next most important thing is that people get adequate amounts of physical activity throughout the day. I like keeping it broad and not specifically talking about exercise, because it does look like activity is much more encompassing than just what you do at the gym. However, I will never shy away from the topic of exercise, working out, and going to the gym, however I do feel that people can get  enormous benefits from getting unstructured physical activity throughout their day, even if they don't have a specific training program. However, in an optimal world I do think people should be participating in resistance training, cardiovascular training, and generally should  have some sort of logic behind why they're doing that activity. The general physical activity recommendations are at least 150 minutes of moderate cardiovascular activity, or 75 minutes of vigorous cardiovascular activity, AND 2 days of resistance training per week. I want to clarify this a little bit and break this down. I have lots of patients tell me that they "walk" a lot at work, or around the block, but this typically doesn't count as "physical activity." Why would I say that? Well, most people are just walking at a leisurely pace, and that doesn't qualify for "moderate" activity based on their exertion levels. In order to hit the moderate you typically will be breathing a bit harder, and most people aren't doing that during their everyday tasks. Now I'm not saying that baseline walking is bad, far from it, but it doesn't meet our criteria, and we know that dedicated exercise has so many positive benefits that I want to drive that point home.

I think the recommendations should be the baseline we should all shoot for, and the general consensus is that the more you do the better. However, the average American does not get anywhere close to the recommended levels of physical activity, so we can shoot for this as a bare minimum and if we go above that, then we are in great shape.

3: Get Enough Sleep

Sleep is finally starting to get recognized for it's importance in your day to day well being and long term health. However, it still isn't thought of as being as important as exercise or nutrition, but I promise you that is your sleep is jacked up, you are going to feel it no matter how much you work out, or how well you eat. I place these three in the top three for a very specific reason, and that is because if any of these three main pillars are off, it will affect everything else.

So, how do we determine what is an adequate amount of sleep? For most adults this is anywhere from 7-9 hours, but there will always be some variation. I'm making such a big deal about this because sleep is so crucial for our health. Sleep not only helps us physically by helping our body heal, increase our immune function, repair injuries, and a bunch of other things, but it also helps us mentally by consolidating memories and assisting with learning and mood. Sleep medicine is it’s own specialty for a reason, because the topic of sleep can be very confusing, but I don’t want you to get bogged down by that as I just want you to realize that sleep is so important for our overall well being. If you aren’t getting 7-9h of sleep a night, or you don’t feel rested during the day and need to rely on tons of coffee or naps, then you might need to talk with somebody about your sleep. It may be as simple as tweaking some of your sleeping habits, or it may be something like sleep apnea causing you problems, but regardless if you aren’t feeling rested or getting the recommended number of hours of sleep, then that is a great place start to help you immediately feel better.

4: Maintain A Healthy Body Composition

The next topic we're going to talk about and is maintaining a healthy body weight or body composition. I know it can be a very hot topic, and there are lots of very charged and polarizing opinions about body weight and BMI, however I don't think I can be intellectually honest and not at least bring up that body composition does seem to play a role in overall health and wellness. I'm not saying we have to base our behaviors off of BMI measurements, as we all know there are inherent issues with that, but we also have to remember that this tool is used for population level observations, and we need to be be a little more nuanced with individual people. That being said, I do think once you get to the extremes of BMI there are not many examples I can think of where that is an ideal situation for an athlete. Whether it is too low or too high, I think once we start getting it to the extremes, we are not at the optimal level for health promotion.  Now, this may be advantageous for a certain sport, but as we are building lifelong athletes and not temporary athletes, so I don't think that it's applicable to the general population. The general definitions typically say a "normal" BMI is between 18.5-24.9, but once again, a number will never tell the whole story. Instead, what can be helpful is to assess your BMI as a screening tool, and then evaluate further from there. If your BMI is elevated, we can use other tools such as waist circumference, or various measures of body composition to give us a more nuanced picture as to how you distribute your weight, and what type of tissue is making up that weight. For example, someone with a BMI of 28 who has 10% body fat and a muscular build is significantly different than someone who has a BMI of 28 and has 35% body fat. So, like most things, everything is a bit more nuanced and  requires a more individualized approach, however I do think maintaining a healthy body weight and composition is an important aspect of life long health as increased adiposity can play a role as a big risk factor for many medical conditions.

5: Don't Consume Any Tobacco

For point number five I'm going to make this brief and talk about  tobacco cessation. If you are consuming tobacco in any form whether it be smoking, chewing / dipping, or vaping,  I think it would be incredibly beneficial to stop doing that. I'm not here to beat a dead horse, and most people who use tobacco products already know that they should stop,  but I will say that this is one of the lowest hanging pieces of fruit that we have that we can change that would make an ENORMOUS difference in your health. I do recognize that it's incredibly difficult to quit, but quitting will undoubtedly make you a healthier person, and the benefits from quitting are substantial.  Like I said, I’m making this one brief because if you are reading this there is probably not a high chance that you use tobacco products, so let’s move on.

6: Maintain a Healthy Blood Pressure

Topic number six is that patients should manage their blood pressure closely.  There are very few topics in medicine that are as universal as the importance of blood pressure management.  In fact, it's so recognized for its importance that we recommend pretty much everyone get screened for their blood pressure every year. Poor blood pressure control can lead to lots common issues like heart attacks and strokes,  they can also lead to things like problems with your eyesight and kidneys as well.  I know this topic is not very sexy, but I promise you it's critically important. There are multiple professional medical organizations that have various recommendations for acceptable levels of blood pressure, but because anyone is listening this podcast considers themselves an athlete, or desires to be lifelong athlete, then we may want to hold ourselves to a slightly higher standard. The ACC/AHA have a recommended target of < 130/80 mmHg, and I think in general these recommendations are reasonable to set as a goal, but it appears that the lower we can get those values without having other symptoms like lightheadedness or dizziness, the better off you will be. This can definitely be a challenge as we age, as blood pressure can increase, however it's very important to keep an eye on our blood pressure to keep it in an acceptable range. Sometimes all it takes is a healthy diet and an active lifestyle, other times it does take some pharmacologic intervention as well.  If you notice, this is the first time I mention medications, and that is intentional. I think that we should all try to do the things that we can do on our own before relying on medication, but I also want to let you know that it would be foolish to not use all the resources we have available to us as a modern society.  I know some people are adamantly against medication, and I can  appreciate that, however my general philosophy is that if we can't get it fixed with lifestyle changes, then there's absolutely no shame in using medication to help us get to our goals. Now, maybe that means we are on the medication for a little while why we lose weight, increase our activity, or change our diet, or this means we're on the medication for the rest of our life, regardless I just want people to not be afraid of using medication judiciously. I know this is a hot topic, but I want to work with everybody and figure out a solution that works for them, while also giving them evidence-based information to help them be the healthiest version of themselves they can be.

7: Maintain Healthy Blood Sugars

As most people know, we're currently seeing a rise in diabetes, so that is why it is critically important for us to control our blood sugars. People with uncontrolled blood sugars or diabetes have significantly worse health outcomes, and they are at risk for problems with their heart, eyes, small blood vessels, kidneys, and pretty much any other organ system you can think of. This is another topic where there are specific numbers that are recommended, but for this introductory post I just want you to  keep this in mind when you thinking about your overall health picture. This is another one where  an ounce of prevention is worth a pound of cure, and maintaining healthy habits like we talked about before will go a super long way in helping you keep your blood sugars in a healthy level. Additionally, this is another area where occasional medications may be necessary if we can't get to our goal levels with just lifestyle changes. Sometimes those medications can be life-saving, or prevent something awful from happening in the future, so I do think they're worth considering for some patients after having a careful discussion with your physician. However, most of the time if we just take care of our diet and exercise that gets us most of the way there, and then we can talk about the other situations as they come. There are a couple of ways to check for (pre)diabetes and they are by checking a fasting glucose, a hemoglobin A1C, or by doing an oral glucose tolerance test. Pre-diabetes is just a precursor to diabetes, so I want to include those numbers too, as usually this condition is a harbinger for bad news that will be coming in the future. The cutoffs for prediabetes are a fasting glucose between 100-125 mg/dL, an A1C of 5.7-6.4%, or an oral glucose tolerance test between 140-199 mg/dL. Then to make a formal diabetes diagnosis, it would simply be any reading higher than the prediabetes cut offs. My personal stance is to be a bit aggressive if we detect any sort of insulin resistance, and so I treat prediabetes as a "come to Jesus" moment to really make sure we do an about face and bring those sugar values back down. However, there are other ways to detect potential insulin resistance before we get to the prediabetes state and that would include something called a HOMA-IR test, with a value > 1 typically indicating there may be some insulin resistance. This is a bit more nuanced, but overall I just want to let you know that blood sugars are super important for our lifelong health.

8: Maintain Healthy Cholesterol Levels

Moving on to number eight which is controlling our cholesterol. Now,  I know this is another  passionately discussed topic on the interwebs, but I decided to jump on this grenade for you give you my thoughts about it. I know there are people in the camp that think that LDL doesn't matter, and others who think that you must eat nothing but spinach for the rest of your life,  but I tend to think that overall, cholesterol does  play a role in your overall cardiovascular health. Now, this is a very nuanced topic, and requires further discussion, however I think in general trying to keep our LDL or apo-B levels in a normal level is a good idea to reduce our risk of cardiovascular events like strokes and heart attacks. In your typical lipid panel you will get your total cholesterol, HDL, LDL, and triglycerides, and overall I think if you can have “normal” levels on that then we are off to a great start. The nuance comes in when we have some abnormal levels, and then we need to figure out a plan on what to do next, but the overall point I am trying to make is that I don’t think you are putting yourself at a very high risk if we aim to get your numbers into normal levels, whereas if we ignore abnormal values that could lead to trouble down the road. My personal recommendation is that that our goals should be that our LDL cholesterol is less than 100 (some conditions even < 70), our total cholesterol < 150-200, our ApoB < 80, and triglycerides < 100. This is just the baseline goal, as we can go even lower as well depending on how aggressive we want to be. Lipidology is an ever expanding area of research and clinical discussion, so we are constantly learning new things, but as of this moment, for the 30,000 foot view I want to get across that I do believe that your lipids matter and that they play a significant role in cardiovascular disease. I think we are all starting to realize that cardiovascular disease is much more complex than just saying it is caused by cholesterol, and now we are realizing that inflammation and insulin resistance play a big role, but it does appear that your body’s cholesterol is a key player in this game, so I think it would be wise to keep an eye on it.

9: Maintain Your Mental, Social, and Spiritual Health

Finally for number nine I am going to introduce a kind of “catch all” topic, but really all of these ideas fit so well together and fall under the same umbrella that I didn’t think it made sense to break it up. This topic is all about mental/social/spiritual well being, and is an often overlooked aspect to optimal health. In my opinion, what good does it do for you if you are jacked, eat a perfect diet, have pristine labs, but are miserable with life? Nobody would sign up for that, and that’s why it’s important that we talk about it so that we can all be on the same page and recognize that your mental/social/and spiritual health are important. When I mean mental health I am talking about the more well known topics like anxiety and depression, and and wanted to let you know that these are incredibly common conditions that I see in my clinic every day. The more we normalize and talk about it, the better we will be and the faster we can start to take the right steps to move in the right direction. Finally I kind of group social/spiritual health together because often times they are complimentary. Typically, humans are social creatures, and we thrive when we have a community. Obviously there are exceptions, but I do really believe that we thrive as individuals when we have others we can talk with, relate to, and do life with. Sometimes this is a religious organization, for others it’s their CrossFit box, but in general I do feel strongly that we should have some sense of community, and that if we ignore this portion of our life, we won’t truly be living our best life.


So there you have it, my 30,000 foot view of the nine components that are critical to living a healthy life. My goal is that I can help be a guide for you on your health journey, and that you find this information helpful. Also, remember that this is just a framework, and that each and every person will have different struggles and successes.

To help you keep this organized, I've designed a PDF that you can print off and fill in to help keep you on track with your Necessary Nine. My hope is that you can use this as a roadmap of sorts to help identify the areas where you can improve, and to help keep you on the right track.