Patients arrive at peptide therapy expecting it to be the intervention. Often they have already decided which peptide, having read about it, and they want a prescription rather than an assessment.
Dr. Stephen Cosentino, Empire's founder and president, uses a proportion that reframes the whole conversation in one line — and it is the single most useful sentence in this field for managing expectations without dampening enthusiasm.
Peptides Are the Last 10 Percent
“The way I think about it, peptides are the last 10 percent,” Cosentino says. “It's the icing on the cake. But you can't ignore the first 90 percent, which is your general health.”
He is specific about what the first 90 percent contains: “Focus on, take care of your cardiovascular, your metabolic, your cancer screening, muscle preservation, preventing prediabetes. That's the first 90 percent. And then the last 10 percent is the optimization.”
The conclusion follows directly: “The peptides are going to help with the optimization. That's not the main focus. These other things should be primary.”
Why This Framing Works Better Than a Warning
The alternative to this sentence is usually a lecture about diet and exercise, which patients have heard and discounted.
The proportion does something different. It does not tell the patient their interest is misplaced — it tells them their interest is correct but out of sequence. Peptides stay in the plan. They simply stop being the whole plan, and the ninety percent becomes the thing standing between them and the result they asked about.
It also sets up a defensible clinical position. If the foundational work has not been done, a peptide is being asked to compensate for cardiovascular risk, untreated metabolic disease, muscle loss and missed screening. It will not, and when it does not, the patient concludes the peptide failed.
The Substrate Problem: Why Peptides Underperform
Dr. Jennifer Thomas-Goering takes the same argument further, into physiology. Her point is not that the foundation is morally prior — it is that without it the peptide is pharmacologically hamstrung.
“It's also not just the peptide,” she says. “It's also our other internal regulation that has to be in balance. So your sympathetic and parasympathetic internal system has to be in balance. And so to get a lot of these benefits from the peptides, it's not just taking the peptide. It's doing the other hard work that goes along with it, like your rest, your nutrition.”
She names the mechanism plainly: “Getting the sympathetic stimulation and your cortisol levels to go down so that the peptides are then able to work.”
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And she extends it to hormones, with a worked example: “You can't just say, hey, I'm going to put you on these three peptides because you want to have stronger bones and bigger muscles. But I have to know what your testosterone level is. I have to know what some of your cortisol levels are and make sure that those are optimized, because otherwise the peptides aren't effective.”
That is the clinical case for the sequence rather than the moral one. A patient with a chronically elevated cortisol and an unaddressed hormone picture is not a patient whose growth-axis peptide is going to perform.
What the First 90 Percent Actually Contains
Drawn from what both describe, the foundation is not vague lifestyle advice — it is a checklist:
- Cardiovascular risk, assessed and managed
- Metabolic health, including prediabetes identified and addressed rather than deferred
- Cancer screening, age-appropriate and current
- Muscle preservation — resistance training and adequate protein, which also determines whether a body-composition goal is achievable at all
- Sleep and autonomic balance, since cortisol sits directly in the path
- Hormone status, measured rather than assumed
- Nutrition, adequate to support whatever you are asking the body to build
Several of those are screening rather than optimization, which is worth saying out loud in a wellness practice: the patient who wants longevity peptides and has not had age-appropriate cancer screening has an ordering problem, not a peptide problem.
How to Use This in the Consultation
- Lead with the proportion, not the refusal. “Peptides are the last ten percent” keeps them engaged where “you should focus on diet first” does not.
- Take the peptide off the table as the first item, not off the table entirely. It stays in the plan, later.
- Order the labs that determine whether it can work. Cortisol and hormone status are not optional extras; they predict response.
- Name the endpoint. What would tell you it worked, and when will you look?
- Be honest about which bucket the specific compound sits in — see proven, plausible, promoted.
The related failure mode — the patient who did start peptides and saw nothing — is covered in why your peptides are not working.
Empire teaches the assessment and the underlying science across the anti-aging and regenerative medicine academy.
Frequently Asked Questions
Should patients optimize diet and hormones before starting peptides?
Yes, for a clinical reason rather than a moral one. Elevated cortisol, autonomic imbalance and unaddressed hormone status reduce the response you can expect, so starting a peptide on that substrate frequently produces a disappointing result that gets blamed on the compound.
What is the “first 90 percent”?
Cardiovascular risk, metabolic health including prediabetes, age-appropriate cancer screening, muscle preservation, sleep and autonomic balance, hormone status, and nutrition. Peptides are positioned as the final layer of optimization on top of that foundation.
Does this mean peptides do not work?
No. It means their contribution is optimization rather than substitution. A peptide asked to compensate for untreated metabolic disease or chronic stress physiology is being asked to do something it was never going to do.
Disclaimer
This article is educational and intended for licensed clinicians. It is not medical advice and does not establish a clinician-patient relationship. It is not a substitute for individualized assessment, and nothing here should delay appropriate investigation or treatment of any medical condition. Regulatory status varies by compound and changes over time.
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