Articles on what comes before.
Clinical notes, excerpts from the book Antes and short essays on preventive nephrology, longevity, and integrative functional medicine. Content originally published on the Plenya blog, mirrored here in full.
Training to age well: the formula is Zone 2 and strength
Most people train inverted: too much medium effort, little low-intensity aerobic base, poorly directed strength. The recipe the literature supports is simple: 80% Zone 2, 20% high intensity, strength two to three times a week. It makes a difference in who you will be at 75.
The inverted pyramid of longevity — strength matters more than aerobic after 40
Most people train the body inverted — too much aerobic, too little strength. The mortality data of the last two decades say the opposite: strength and lean mass predict how long you will live with more precision than running 10 km.
Supplementation after 40: what makes a difference
I see, recurrently, patients arriving with a pharmacy bag and the right question: I spend a fortune a month, is any of this doing anything? Four substances have robust evidence after 40, and the indication of each comes out of clinical assessment, not from a fad.
Protein: the target you're not hitting
Most Brazilian adults consume 0.8 g/kg of protein per day — survival RDA, not health RDA. To preserve lean mass after 40, the literature points to 1.2 to 1.6 g/kg, distributed across three to four meals of 30 g each.
Pre-diabetes is not a phase. It is a five-year window.
An HbA1c between 5.7% and 6.4% is usually treated as a vague warning — "let's repeat it in a year." The literature is more uncomfortable: every year without action increases the probability of progression and narrows the window in which reversal is still the most likely outcome.
Morning light — the free medicine that resets metabolism
Ten to thirty minutes of natural light in the first hour after waking anchor morning cortisol, nighttime melatonin, and the biological clock. It is the cheapest and most ignored signal of circadian medicine.
Menopause needs a team — not just a gynecologist
The menopausal transition is not only hormonal. It is cardiovascular, skeletal, metabolic, cognitive, sleep, mood — all at the same time. Treating it as the problem of a single specialist is the reason so many women in their 50s feel they are being managed in pieces.
Meditation that works in 8 minutes — and the kind that doesn't
The strongest evidence sits with 8-week MBSR. But consistent studies show that short daily practice, done with regularity, already shifts cortisol, blood pressure, and amygdala reactivity. The point is not the time — it is the consistency.
Loneliness as a cardiovascular risk factor — the data missing from the visit
The Holt-Lunstad meta-analysis showed that fragile social bonds increase mortality as much as smoking. The American Heart Association adopted the point in 2022. And almost no cardiology visit asks about it.
Lp(a): the test your father's cardiologist didn't order
One in five people has elevated lipoprotein(a). It is genetically determined, doubles or triples the risk of heart attack and aortic stenosis — and almost never appears on a checkup. Measuring it once in a lifetime changes decades of clinical decisions.
Intermittent fasting: who benefits, who is harmed
Intermittent fasting is not a universal diet. For the 45-year-old man with insulin resistance, it usually helps. For the perimenopausal woman, the strength athlete, the sarcopenic elderly, it usually makes things worse — and the difference lies in details few people look at.
HRV: the discreet thermometer of your nervous system
Heart rate variability is not an app metric. It is a direct window into the balance of the autonomic nervous system — and persistent drops precede disease, overtraining, and burnout by weeks or months.
Healthspan versus lifespan — why the right target is to compress morbidity
Living a long life is not the goal. Living well for a long life is. The difference between how many years you live and how many you live in full health reaches 12 years in developed countries — and almost no one is looking at the number that matters.
The four silent killers that take hold after 40
Cardiovascular, metabolic, oncologic, neurodegenerative. I have lost too many patients to diseases that had been advancing in silence for a decade. None of the four appears suddenly. Each has a 10- to 20-year window — and almost no one looks at it in time.
Ferritin between 30 and 100: the normality that drains women
The 'normal' stamp on a ferritin result is one of the most expensive errors in contemporary medicine. I have seen too many women pushed toward the psychiatrist with disabling fatigue — when the problem was the wrong ruler at the lab.
Coronary calcium score: the test that changes a decade
I have seen too many heart attacks arrive with a 'normal' blood panel from the previous year. The coronary calcium score is the closest thing to a time machine I have in preventive medicine — and it costs fifteen minutes.
Burnout is not fatigue — it is a measurable neuroendocrine response
Tech-company partner, 49 years old, cried in his car after picking his daughter up from school. He said he was 'fine, just needed a vacation.' His salivary cortisol said something else. Burnout is not tiredness — it is an endocrine system asking for help in a language few physicians were trained to hear.
Apnea in those who don't snore: the invisible female form
A 42-year-old woman, lean, no snoring, treated for years for "anxiety." Polysomnography comes back "no significant apnea." But the clinical picture persists, and it is a scene I recognize from the speech, before ordering the first test.
Alcohol and sleep — why two glasses destroy six hours of rest
Mariana arrived sure she had perimenopause. Her ring told a different story — and so did every patient I've seen with the same complaint. The bedtime glass is the most polite saboteur I know.
12 tests a longevity check-up orders
ApoB, Lp(a), fasting insulin, calcium score. The basic check-up rarely includes these twelve, and they are the markers that most predict health trajectory over the next twenty years.
When "all normal" is not enough
The lab "within range" answers an important question — do you have diagnosed disease? But it does not answer the right question, which is what trajectory you are on.
What the annual checkup does not show about your heart
Half of all heart attacks happen in people with a "normal" checkup the year before. The problem is not negligence — it is that the routine exam was designed to detect obstruction, and the real disease is something else.
Training a lot and aging wrong
I have seen many amateur athletes arrive at the office at 45 inflamed, weaker, with testosterone falling. The effort was there. The result was not. Before changing the training, you have to read the panel that says it is wrong.
The sleep that doesn't restore
Sleeping seven hours and waking exhausted is not a lack of discipline or "a phase." It is a signal — usually of underdiagnosed apnea, fragmented sleep, or absence of deep sleep. And it is investigable.
Four professionals speaking the same language
Having four separate specialists is not the same as having a team. The difference is structural — and most patients discover this the hard way: feeling that someone is missing to put it all together.
Fatigue at 45 is not age — it is a diagnosis no one made
"I'm tired" is, by far, the most common complaint I hear. "It's stress, it's age" is, by far, the answer I most often see patients bring back from the previous physician. Almost always it is neither — it is a clinical signal nobody investigated to the end.
The ACTS Method — an introduction to integrated care
Fragmented care is, today, what most often makes the long-living patient sicker. The ACTS Method was the way I found to stitch four health dimensions into a single continuous plan — and it was born out of the discomfort of seeing the whole get lost.
The silent window between normal and optimal
There is a ten- to twenty-year interval in which serious disease assembles itself without showing up on routine labs. It is in that interval that longevity is built — or lost.
Sleep, energy, and longevity — why sleeping well is clinical strategy
Sleep is not passive rest — it is the interval where metabolic repair, cognitive consolidation, and hormonal regulation happen. Neglecting sleep is neglecting outcomes.
Medicine 2.0 vs. Medicine 3.0 — alarm or detector
The medicine that treated your father is not the medicine that will treat you. The difference lies in when it acts.
Normal versus optimal — the interval the lab does not print
The reference range on a lab report was built to detect disease, not to sustain health. The distance between the two is wide, and a great deal depends on it.
The drug that cuts mortality by 80% — and no one prescribes
I learned to respect this number examining patient after patient: no medicine I prescribed protects as much as cardiorespiratory fitness. And almost no one taught me to prescribe it in medical school — I had to learn it patient by patient.
Why the nephrologist sees it first — the cardio-renal-metabolic axis
Anyone trained in nephrology learns it early: the kidney is the system that warns first. The revolution of the last five years was the rest of medicine finally accepting it — and the trials of the last decade (DAPA-CKD, EMPA-KIDNEY, FIDELIO, FLOW) put the reading at the center of the table.
Content originally published on Plenya Blog. Each article here is a faithful version of the original, with canonical pointing to the source.
This content is educational and does not constitute medical prescription. Each case is unique — for individual evaluation and care, consult a physician.