Improve Your Fitness With Breath Analysis Tech

Panos Papadiamantis

Father of diamonds.

Joel Kahn, MD, FACC

Diamonds. I apologize. He is living in the Miami area, but he represents an interesting company that has the technology to help everybody listen, called PNOE, and you can see it on his jacket. PNOE comes from the Latin root for breath, like the word pneumonia or pneumatic PNEU for pneumonia, of course. He measures breath. He’s fascinated with breath. He’s got an engineering and business background, but it’s a very large company now that has over 3000 installations where you can go and get your breath measured for something called your resting metabolic. If you’re on a treadmill, your peak metabolic rates. I had the pleasure in Southern Florida of Panos coming over with a briefcase, a little briefcase, and measuring my resting metabolic rate. He may talk about that. I didn’t have a treadmill handy to do a maximal measurement. Some of your gyms may offer a mask treadmill test where all the oxygen and carbon dioxide are measured, and that’s kind of what we’re talking about. Anyway, enough introduction. Thank you for being at this summit. Panos. Thank you.

Panos Papadiamantis

Dr. Kahn, thank you so much for having me. Pleasure and honor are all mine. As you said, yes, I’ve spent the last six years of my life democratizing breath analysis. We started, along with my co-founder Apostolos, also from Greece, about six, or seven years ago, with the mission of making breath analysis something that is accessible to everyone. Breath analysis, also known as VO2 max testing or metabolic testing, is an assessment that has been around for about 100 years, and it has been extensively studied and researched in clinical and peer-reviewed research. But until recently, since devices were expensive and difficult to operate, and also because the data coming out of these devices was very time-consuming to analyze, it had remained on the sidelines. What we’ve done as a company is creating the world’s first portable, low-cost, easy-to-use, but still clinically accurate breath analysis device that is also coupled with a comprehensive service that analyzes the data, produces reports patients can understand, and also, very importantly, produces a personalized nutrition and training program that is individualized to one’s metabolism. In essence, we do what doctors would have to do without all the technology we have created now.

Joel Kahn, MD, FACC

I just want to say, in case anybody has to leave early, you go to PNOE dot com, pnoe.com. You’ll see that this company has extensive massive endorsements from places as academic as MIT in UCLA to as available as Equinox Gyms and Raffles Hotel and Resorts. Because this is so portable, it’s showing up in spas, offices, chiropractic doctor offices, and nutrition offices. It’s very easy, but I think you have a little presentation of five or six slides to share, because I’ll say for the audience, I served as medical director of two cardiac rehab programs combined over 15 years, and I still have time to put my head around the fact that there’s a better way to do it: testing. That’s what Panos is telling us. I’ve been through the treadmill mask test probably half a dozen times in my life. Go ahead and take the lead. If you want to share a couple of slides with us, I’m going to learn too.

Panos Papadiamantis

100% if you can enable the sharing settings.

Joel Kahn, MD, FACC

Everybody hangs tight. If I go to share the screen, multiple participants go for it.

Panos Papadiamantis

Awesome, thank you very much. Once, on second.

Joel Kahn, MD, FACC

If anyone is wondering, Panos is only 33 years old.

Panos Papadiamantis

But my biological age is way less so.

Joel Kahn, MD, FACC

As far as I know, he’s single and won’t put his phone number in the chat. You’re sharing that you’re looking for a presentation, a secondary desktop. Everybody hangs tight. Again, I just sat down in a chair, put a mask on my face, and breathed quietly for 10 minutes. I got some interesting data about where we are. We’ve got the report.

Panos Papadiamantis

Pretty much, this is what breath analysis used to look like before we came along. As they said, it’s been around for about 100 years. This is what it looked like almost a hundred years ago. On the right-hand side, you can see how it used to be in most clinical settings. What we’ve been able to do is shrink it down to this small portable device that you can operate through your iPad or iPhone and get real-time metabolic information from your patients. We collect all of this information in the cloud. We analyze it and then produce reports that identify what the problems are with someone’s biology and then specify what kind of nutrition, training, and wellness regimen they should follow. 

Now, to understand why breath analysis is such a holistic assessment and why it is considered one of the most valuable but underutilized assessments in medicine, we should first understand the concept of aerobic metabolism, which is the foundation for every form of animal life on earth. Aerobic metabolism is the concept of using oxygen to burn nutrients and release the energy they contain. Because aerobic metabolism is something that releases significantly greater amounts of energy compared to other biological processes, Life on earth had the energy it needed to evolve from single-celled organisms to complex organisms like humans and other mammalian life. Now, because aerobic metabolism is such an important thing, our body, as well as that of pretty much any other creature on earth, has developed the mechanism to absorb and utilize oxygen. We could build lungs to absorb oxygen, blood, and hearts to pump it, and then cells with mitochondria to use it. This is what we like to call the oxygen chain. It’s not a coincidence that every deadly and costly chronic condition, except for cancer, is either manifested or caused by a disruption of oxygen transport in one or more parts of that oxygen chain. Now, breath analysis at a fundamental level looks at three signals of oxygen concentration. CO2 concentration and flow volume that you’re measuring continuously in every breath that you take. What you produce from these three sensors is CO2 and O2 and a flow sensor is this waveform, which is how breath changes from inhalation to exhalation. Now, by analyzing these waveforms in addition to heart rate variability, heart rate, and power output, which is how much faster going on the treadmill is, you produce 23 biomarkers. Some of these biomarkers are things that are quite popular. For instance, VO2 max: a lot of people know VO2 max or metabolic rates, but others are way less popular. But equally important, for instance, is the O2 pulse, although a big thing in cardiology is how much oxygen our heart can pump into our body per heartbeat. This is the O2 pulse, and it’s one of the key indicators for identifying non-invasively ischemic heart disease and coronary artery disease. Now, by taking these 23 biomarkers and grouping them into specific categories, we can start to understand the health of the systems comprising the oxygen chain, heart, lungs, and cells, as well as the health of other systems that are immediately affected by how we breathe. For instance, our brain, our nervous system, and our posture. 

One other very important thing that breath analysis gives us is our biological age. VO2 max, according to the American Heart Association, is considered one of the most reliable indicators of how long and well someone is going to live because it produces one of the best measures for the likelihood of mortality and morbidity. As a result, it can tell you how old you are. Now, the beauty of breath analysis because of all of this is that it provides probably the best combination of a diagnostic spectrum. It covers a lot of different critical systems, but also diagnostic specificity and sensitivity, meaning that for the systems that it can analyze, it gives you a very high degree of certainty whether there’s a problem or not. It does so noninvasively without any bloodwork or specimen, and as a result, in a very cost-effective way. In addition to that, breath analysis, as I said earlier, is the gold standard for understanding how many calories your body is burning. If you have a slower metabolism or a faster metabolism, it’s the most reliable way of understanding that. It’s also the only way that we have to understand fat and carbohydrate metabolism in the human body. As a result, it is considered the most foundational assessment for prescribing personalized nutrition, training, and breathwork regimens. That’s kind of the science behind breath analysis because a lot of people are like, I do this test, just get my VO2 max, or do I just get my metabolic rate? Nope. There’s a lot more to it. This is the basic science that allows us to derive all of these insights.

Joel Kahn, MD, FACC

Well, that was excellent. Maybe you stop sharing, which is great.  Like I’ve said a couple of times, there’s a resting component, and then there can be a maximal treadmill component, or I imagine you could probably do it on an exercise bike if somebody has a problem with a treadmill. Because of the situation of you bringing this small briefcase to my home, I only did the resting PNOE. There was no treadmill, and I got from you a very easy-to-read report. I was wondering if it said I would estimate about 15–18 pages. I’m looking at it, and I have a lot of green bars. I was happy to see my resting metabolic rate, my fat-burning efficiency, and my metabolic fitness, lung fitness, breathing fitness, and posture fitness, put me at low metabolic risk. You have health coaches and nutrition coaches that can work with people who have a PNOE. I’ll say it’s quite an inexpensive test overall. We’re talking in the low hundreds of dollars. If you find one of the 3000 locations that offer this, maybe you want to go to one of these resorts and spas, or maybe you have a caretaker health care professional in your area that’s offering it. Do you usually counsel people on resting alone, or do you often require peak exercise in addition to getting the full picture?

Panos Papadiamantis

Great question, doctor. Most people start with the resting test because it has a much lower barrier to entry. People get an understanding of what’s potentially a problem. One of the areas that we assess, and in case there is, there is great motivation for people to follow up with an exercise test. Now, this is the case with our affiliates, our clinics that deal with the general population, where the typical goal of the person visiting the facility would be either weight loss or longevity. These two groups of people comprise about 80 to 90% of the people conducting our test. Now, we do work with professional athletes. We do work with professional teams. In that case, we see almost everyone doing both resting and exercise tests because this population is way more familiar with VO2 max testing and stress testing. But that’s how the sequence of testing works.

Joel Kahn, MD, FACC

Excellent. Some people might be interested. I’m looking again, and I’m using my report only as an example because it’s the only PNOE we report I’ve seen. My metabolic fitness was rated as good, but there is a section for excellent. I didn’t quite make it. This report has recommendations on exercise. I should increase my resistance with my endurance training, and I’ll say I work out every day, but there’s room for increasing timewise. Now I want everybody to listen. They made three nutrition recommendations, and I’ll ask the panelists why I should add more flaxseeds to my diet, more lentils to my diet, and more dark chocolate to my diet. Everybody’s going to love that third one. Frankly, I’m pretty regular and disciplined about flaxseed and lentils. Once or twice a week, I have a little square of dark chocolate. Why do you think those three nutrition recommendations came up?

Panos Papadiamantis

All of the nutrition, exercise, and lifestyle recommendations provided in the reports are science-based tools to improve the metric that we put them under. For instance, if you’re looking at these recommendations under your resting metabolic rate or your fat-burning efficiency, these are foods that have proven to have some sort of impact on improving these metrics. Are they making you burn more calories or helping you with mitochondrial biogenesis and mitochondrial function, which ultimately leads to better fat oxidation? Ultimately, your metabolic fitness score is a combination of how many calories you’re burning and also how effective you are at burning fat as a fuel source. Combine these two, and you have a very, very good understanding of how good your metabolic fitness is, which is kind of a segue to them. Metabolic. What I was saying is that all the recommendations you see there in terms of nutrition, exercise, lifestyle, or science-based recommendations that are known to improve the metric that we have, place them under, for example, these specific nutrients that have been shown to improve metabolic rate. improve, like, how many calories you are burning and/or how effective you are in utilizing fat as a fuel source by improving mitochondrial function. What I was going to say is also that this is a seque to the metabolic dysfunction risk score that we provide. This is something that we get asked a lot about. Studies have shown that people getting measured at arresting states are also at a much greater risk of developing type 2 diabetes. That is something that occurs even before elevated blood glucose levels start to occur. Looking at how effectively you’re burning fat and carbohydrates in a resting and fasted state can give you quite a bit of insight into whether your cells are on a trajectory to develop some sort of metabolic dysfunction, such as type 2 diabetes. Now, in addition to that, metabolism is one of the things that we measure.

Another thing that we look at is lung and heart fitness. These are the areas where, if we see some sort of issue, we will direct someone to an exercise test. Because, just like in traditional EKG stress testing, when you put the system under stress, you can understand a lot more about its underlying pathology, if there is one. that’s pretty much it.

Joel Kahn, MD, FACC

It’s interesting because I’m flipping through my report and different parameters. Almost all the nutrition recommendations—everything but one common but fatty fish—are plant-based. Oatmeal, flax seeds, cinnamon, broccoli, fermented foods, Swiss chard, matcha, and avocados. There’s Heart Disease-Reversing Summit, is largely a whole-food plant-based, diet-oriented group. Is that the predominant data that your cardiopulmonary fitness can improve largely from plant-based foods?

Panos Papadiamantis

This is what exists in the literature. We’re not coming up with any of our recommendations ourselves. It’s like we have an extensive document that outlines all of the peer-reviewed research that backs our recommendations. The reality is that, yes, a plant-based diet is perhaps one of the most effective ones in terms of improving cardiorespiratory health. We use cardiorespiratory health as a term because these two go hand in hand which is another big thing about breath analysis. A lot of people show up with either dyspnea,  chest pain, or an inability to move and work out. But with traditional cardiac testing, you’re not seeing if it’s a pulmonary problem versus a cardiovascular problem. The only way to identify which underlying system is a problem and triage accordingly is through a cardio-pulmonary exercise test.

Joel Kahn, MD, FACC

Two last questions for the general audience: You have again on your website, pnoe.com. Step one is getting a test. Step two is consultation. I can’t believe every person with 3000 locations gets a consultation with a PNOE employee. Is it the center that they’re at that provides them with a consultation, or how does that work?

Panos Papadiamantis

As a company, we do provide consultations and services for many of the clinics that work with us, but many others choose to do the consultations on their own. We do not interfere with the business operation of how the clinic is run. What we do provide, in case you don’t want to do a consultation with one of our members, is the ability to get something like a cheat sheet, quote-unquote, or talking points that you can use in your discussion with your patient. We fully understand that a lot of our clinics want to maintain the client-facing aspect of their business, and we do not interfere with that, but we still provide them with the background they need to have meaningful conversations with their patients.

Joel Kahn, MD, FACC

The last question I have for the general group is 3000 locations—some are at resorts, and some are around the corner. You’re adding a location function to your website and/or Stan so you can put it in, I presume, your zip code and find where you can go to have a PNOE because many people say they’ve never had one. Most people who’ve never had this kind of testing want to, and that will be up and running soon.  I mean, people can use that same expectation.

Panos Papadiamantis

Absolutely. We’re going to start helping people find local facilities. that’s going to happen later this year.

Joel Kahn, MD, FACC

I think that will make it much easier, though. Again, you might find that, as you’ve told me, there are some health and wellness clinics. I mean, medical clinics. Spas, I think you said there are even a few nail salons that are into health and wellness.

Panos Papadiamantis

Yes

Joel Kahn, MD, FACC

Fantastic. I’m sure there’s a chiropractor’s office, as we said. a great range. Panos, don’t go anywhere. We’re going to come back with the premium group and go just a little deeper on a few topics. This man is wonderful. I can tell you firsthand that it’s a very simple and very powerful test. If you just get the resting test, there are still 23 biomarkers that are measured on that test.

Panos Papadiamantis

The 23 biomarkers are what you are constantly analyzing when you’re putting the mask on. The big difference is whether you’re measuring at a resting or exercise stage.

Joel Kahn, MD, FACC

Very good. Thank you, everybody. We’ll be right back. 

All right, Panos, tell us a little bit about why we didn’t talk a lot about the exercise aspect. We get referred to a PNOE clinic that has a treadmill. You come with your gym shorts and your gym shoes, and you’re ready to knock it out? Is this generally a maximal stress test?

Panos Papadiamantis

We recommend that you take people to about 70 to 80% of their maximal capacity, which is indicated by a specific metric that you’re measuring with a device called RER, respiratory exchange ratio. When this thing hits one, you are very close to your anaerobic threshold. We took 80% of the maximal effort. This is enough data to provide someone with a very comprehensive cardiopulmonary assessment. So we made it of that. Now some people want to see what their VO2 max is—the absolute VO2 max they can achieve in two years—and these people will push it further. But for us to be able to tell you that, hey, here’s a comprehensive report that is a very good overview of your health. Going up to 70 to 80% is a good deal.

Joel Kahn, MD, FACC

Since you have this big funding knowledge, tell us a little bit about, as you said, one of the most important things people are doing: biological age testing, checks blood work, and one sitting at my desk at home that I’m going to be doing. But just the general understanding of how a peak oxygen consumption test like a PNOE offers, if there’s a treadmill around, will offer that insight.

Panos Papadiamantis

When it comes to assessing your biological age, which is a metric that has come into our lives quite recently, we’re effectively talking about how likely it is for you to die in the next ten years or a specific timeframe. All of the different biomarkers that we have that are there to quantify our biological age are effectively an assessment of the risk of dying in the next decade. VO2 max is something that has been widely studied even before DNA testing, DNA sequencing, and all of that stuff became a thing. Dozens of decades-long longitudinal studies have looked into the likelihood of mortality and morbidity based on VO2 max. The way that works is that you test a group of people, you see what their VO2 max is, and then you track them throughout ten, 20, or 30 years, and you start to see how these people start to get sick or die. that creates your risk profile based on the different levels of VO2 max that these people achieve. VO2 max all of this body of research turns out to be one of the most reliable indicators for how long and well someone is going to live as a result. It is a very good indicator of the risk of mortality and morbidity. This is why the American Heart Association and multiple different organizations around the world are actively pushing for its institution as part of our annual physical, but also as part of stratifying risk in the health insurance world and elsewhere. This is kind of the fundamental science and principle behind how we can derive a biological age score based on VO2 max.

Joel Kahn, MD, FACC

I will say, for those of you still listening, I scroll down closer to the bottom of my report, and some of you may say again, Why do I want a PNOE exam? It tells me right here that on days I don’t work, my resting breath test says I burn 2300 calories a day, and I want to lose weight. I probably should eat about 2000 calories a day to achieve sustained, healthy weight loss. On the days I work, I’m burning about 2700 calories a day. If I want to work and lose weight, I probably should eat about 2300 calories a day. Of course, there are ways to measure this with various apps, and the rest says that about 60% of my gallery should be fat and 40% carbohydrates. Protein doesn’t fit in here because it’s not a major source of energy production; it just fuels other parts of our brain. Some of you will say that’s higher than I’d be willing to eat because we have a whole audience; that’s a lower fact. Dr. Ornish, Dr. Esselstyn, 10 to 15% of calories in the diet are from fat. You may have to modify that a bit if you’re on a heart reversal program and all. But it’s fascinating, simple data. I think many people will want to schedule this simple test after having had the other kind of rest. I can tell you firsthand, a major technological advance. The report is a major education advance. I want to thank you, your partner, and your team that are scattered all over the world, with many members in Greece that are supporting all this. Thanks for bringing this breath analysis to mom-and-pop people around the place—physical therapy centers, wellness centers, doctor offices, and other locations—but great. Any last words, Panos?

Panos Papadiamantis

Thank you so much. Nothing else on my end. I appreciate the opportunity and your time.

Joel Kahn, MD, FACC

One last question. I have been tested, and I want to change my program. Maybe I should add in more fasting, maybe I should increase my exercise, and maybe I should eat more lentils and dark chocolate. God knows that sounds fine. How long would you suggest you wait to be retested? Because it is so simple to get retested.

Panos Papadiamantis

Great question. depends on how acute the changes are in your life. If you’re doing, say, a very intense diet program and you’re cutting calories pretty aggressively and you’re also working out a lot or just one of the two, then we would recommend getting tested in about one month to maybe 45 days if things are milder and you’re changing things in your nutrition and training. Three months is what I would go for in terms of retesting, period. then, at a minimum, again, based on the American Heart Association recommendations, getting a test once a year is the absolute minimum because it is information that should be part of your annual physical.

Joel Kahn, MD, FACC

Very good. We got the expert. The Father of Diamonds, Panos Papadiamantis. We have so much to learn and this has been fascinating. Thank you for sharing, and I look forward to those location finders. We can all easily schedule.

Panos Papadiamantis

Thank you, doctor. Thank you.