The Governance Map
You know your company's numbers to the decimal. Name your ApoB.
Ten questions or fewer. Two minutes. If you do not know a number, that is the answer.
Most executives run their health the way a founder runs a company before the first audit: on instinct, on how the quarter felt, and on the absence of bad news. The Governance Map is the audit. It places you on one of seven stages, decided by things you either have or do not have, and it names the single constraint of the stage you are in.
Every stage is opened by a count of things that exist. Nothing here is a feeling.
Find your stage
The quiz asks what you know, and shows the targets inside the questions so you learn them while answering. Your stage appears on this page before anything is sent.
Where are you on the map?
Ten questions or fewer. If you do not know a number, that is the answer.
You are here
The Leverage Ladder is here if you would rather start now.
The seven stages
The map begins in the dark, where most executives over 40 are likely to be standing, and ends in the only stage that is about someone else. Each stage names where you are, the one thing in the way, and the test that moves you up.
You are here
Stage 0 · Passenger
You are now what the map calls a Passenger. Risk is being carried, and nobody is reading the instruments. That is why this stage is called Unmeasured.
Get the six numbers. One laboratory visit, one tape measure, one home cuff, one fitness test. Spend nothing else until they exist.
Stage 0 feels like nothing. That is the problem with it. The moment it stops feeling like nothing is usually the moment it becomes expensive.
Stage 0 is a company that has never been audited. Revenue is coming in, the founder feels good about the year, and nobody has opened the ledger. On the population evidence, most executives over 40 start here. The last full panel was for an insurance application. The blood pressure was read once, in a pharmacy, in 2023.
Feeling fine is the whole of the evidence, and feeling fine is exactly what a rising blood pressure and a rising ApoB feel like for twenty years. Stage 0 is where the preventable deaths on the Leverage Ladder are still unpriced, and it has the cheapest exit of any stage on this map.
Approximately half of adults with high blood pressure do not know they have it. NCD Risk Factor Collaboration 2021, Lancet.
The Audit is the whole of Stage 0 bought in one visit. Every one of the six numbers, the precision layer, and a written report that ranks them. If the budget is the constraint, start with the cardiometabolic panel and add the rest later.
Ask about The Audit →What comes next. Stage 1, where the numbers exist and the danger changes shape.
You are here
Stage 1 · Recordkeeper
You are now what the map calls a Recordkeeper. The file is complete and nobody has read it against a target. That is why this stage is called Measured.
One physician reads the whole register against the optimal targets on the Six Numbers card, adds lipoprotein(a) once, and ranks the gaps by the Ladder, top tier first.
Stage 1 feels like diligence. It is the stage where you have paid for the information and stopped short of the meaning, which was the part you were paying for.
Stage 1 is the audited company whose audit report sits in a drawer. The numbers exist. They arrived with the word normal beside most of them, and normal closed the file.
A laboratory reference range describes the central 95 percent of a group judged healthy when it was sampled. It describes what is common. The targets on this map describe what the trials aimed for. An ApoB of 110 mg/dL sits inside the reference range and is roughly double the map's target for someone who already has plaque, which is under 60. A systolic reading of 138 is a footnote on the report and a 25 percent difference in cardiovascular events in a randomised trial. Stage 1 is the most reassured stage on the map, and for that reason the stage where the wrong decision is easiest to make.
Fewer than half of US adults with hypertension have it controlled. Muntner 2020, JAMA (NHANES 2017 to 2018, 43.7 percent controlled).
The Audit is the ranking you are missing. It reads every result you already hold against the optimal targets, closes the numbers nobody ordered, adds lipoprotein(a) once, and returns the one-sentence gap in writing. Bring recent results and they are credited against the panel.
Ask about The Audit →What comes next. Stage 2, where the gap has a name and the calendar has not noticed.
You are here
Stage 2 · Owner
You are now what the map calls an Owner. The gap has a name and it sits on your desk with no date beside it. That is why this stage is called Located.
One lever, the highest open one on the Ladder, executed to the written standard for 90 days, with the retest booked before the work starts. Medication is a lever where the number demands it, and a decision you take with the physician who owns the register.
Stage 2 feels like control, because you know. Knowing is the least expensive form of doing nothing.
Stage 2 is the company that found the material weakness. It is on the risk register, it was discussed at the last meeting, and it has no owner, no budget, and no date.
This is where the longevity spending happens. The blood pressure is 145 over 92 and the cold plunge was delivered on Tuesday. The lever with the largest return is known, and it is the one that costs the most discomfort, so the money flows to the levers that cost nothing but money. The Ladder calls this majoring in the minors. The clinic calls it the pre-event visit.
Fewer than one in four US adults meets both the aerobic and the strength guideline. CDC National Health Interview Survey 2020.
The Program is the graduation test with a physician attached: one lever, one written standard, one retest date, and scheduled reviews so the calendar cannot forget. It begins the quarter you start and continues while there are levers open.
Ask about The Program →What comes next. Stage 3, where the six numbers are at target and the risk you were never tested for is still there.
You are here
Stage 3 · Operator
You are now what the map calls an Operator. The controls are clean and the balance sheet still has a page nobody has opened. That is why this stage is called Stabilized.
The precision layer, once: lipoprotein(a), a calcium score, a hereditary cancer screen where your history calls for it, screening brought current, a micronutrient panel. Then Tier 2 of the Ladder, one item at a time.
Waits. The biohack of the month, The second cuff, The argument that the cholesterol is fine so the scan can wait.
Stage 3 feels finished. Tier 1 is closed and a family history is still open.
Stage 3 is the company with clean controls and an off-balance-sheet problem. Blood pressure, ApoB, glucose, fitness, and strength are at target. On the population evidence, the risk has fallen further than most people will ever take it.
What remains is the risk that never appears on the six numbers. A lipoprotein(a) that is inherited and untouched by diet. A coronary calcium score already above zero despite the lipid panel. A BRCA or Lynch variant that no lifestyle has any effect on. A micronutrient deficiency behind a normal blood count. Stage 3 is also where motivation fails, because the crisis is over and the numbers have become boring. Boring is the target.
Lipoprotein(a) is elevated in approximately one in five people and has been measured in well under 1 percent of them. Nordestgaard 2010, European Heart Journal; Bhatia 2023, JAHA (18,972 of 5,553,654 adults tested).
The Modules are Stage 3 bought one system at a time, once the Audit has named which one is open. The Heart Audit covers the calcium score and lipoprotein(a). The Family Risk Audit covers the hereditary screen, with the conversation that has to come before it. The Cellular Audit covers the micronutrient panel.
Ask about The Modules →What comes next. Stage 4, where everything has been measured once and nothing has been scheduled twice.
You are here
Stage 4 · Director
You are now what the map calls a Director. Everything was measured once and nothing has a next date. That is why this stage is called Optimized.
Cadence. Blood pressure quarterly, the six numbers annually, VO2 max and grip every six months, one register document with an owner, and a physician who reads it every quarter.
Waits. The heroic month that redoes everything, The register kept in your head, The new wearable.
Stage 4 feels like maintenance, which is the word for the work nobody does.
Stage 4 is a well-run company without a board calendar. Everything was measured once and fixed once. Nothing is scheduled.
Blood pressure drifts a few points a year, and nobody notices a few points. The ApoB creeps back as the statin is quietly dropped. VO2 max falls approximately 3 to 6 percent a decade in the thirties and more than 20 percent a decade after 70, and faster than either when the interval session becomes a walk. The precision layer is dated the year you did it. Stage 4 is where the gains of Stages 2 and 3 are lost, slowly, in a way no single quarter reveals. It is also the first stage where the mind goes on the register, because the numbers that drift first are the ones nobody wrote down: sleep, alcohol, mood.
In adults over 65 prescribed a statin for prevention, approximately one in four was still taking it two years later. Jackevicius 2002, JAMA.
The Program is the cadence. Your register, your retest dates, and a physician who reads the whole page every quarter and finds the drift before you feel it. This is the stage the Program was built for.
Ask about The Program →What comes next. Stage 5, where the register is owned and the work changes from fixing to holding.
You are here
Stage 5 · Chair
You are now what the map calls a Chair. The register is owned, the cadence runs without you, and the question is what it is for. That is why this stage is called Governed.
Hold the cadence, and write the mandate. One page: what the health is for, who it is for, and what you intend to be able to do at 70 that most people cannot.
Waits. The new protocol that replaces the review, The private register, The decade left to explain itself.
Stage 5 feels like nothing again. This time that is the evidence.
Stage 5 is governed. The register is reviewed quarterly, retested annually, and owned by a physician whose job is to find the drift before you feel it. Every lever the evidence ranks in Tiers 1 and 2 has been pulled and is being held.
The remaining work is the slow work: holding VO2 max against age, holding muscle through the sixties, keeping the ApoB at the level the regression trials aimed for. And the work that the numbers cannot do. Stage 5 is the first stage that asks what the decade is for, and requires the answer in writing. A mandate, one page, dated. It is the document a physician reads before the register, because it decides what the register is defending.
In 136,265 people, a strong sense of purpose tracked with approximately 17 percent lower all-cause mortality. Cohen 2016, Psychosomatic Medicine.
The Program continues, and at this stage its work changes from fixing to holding: the quarterly review, the annual retest, and the mandate kept beside the register.
Ask about The Program →What comes next. Stage 6, the only stage on the map that is about someone else.
You are here
Stage 6 · Steward
You are now what the map calls a Steward. What you hold is being held for other people, and it will keep funding what it was built for. That is why this stage is called Endowed.
Extend the map. Run it across the people whose risk affects yours, starting with the one who would be hardest to replace. Offer them the Audit if they would never buy it for themselves.
Waits. Governing alone, Advice given instead of measurement, The paperwork left for a quieter year.
Stage 6 feels like giving something away. It is the first stage where the work leaves your body, and the first where the numbers of the people you love sit on your agenda.
Stage 6 is an endowment. Capital that outlives the person who built it and keeps funding the thing it was built for. Your register is current, reviewed, and read by someone else. The remaining risk on your balance sheet belongs to other people. A spouse at Stage 0. A co-founder who has never had a blood pressure read. A successor whose own numbers would end the company you are handing over.
This is the stage where the map stops being about you, and it is the calmest stage on it. Two documents live here that no other stage requires: an advance directive and a will, both dated within five years. They carry no mortality evidence of their own, and the map says so. They are the calmest documents on it, and the ones most people put off for a quieter year that never comes.
Approximately one in three US adults has an advance directive. Yadav 2017, Health Affairs.
The Audit, given. They book it themselves, they consent to every test, and their results go to them alone. If a whole leadership team is at Stage 0 beneath you, that is a separate conversation and it starts in the footer.
Ask about The Audit, for someone else →What comes next. The Leverage Ladder, the free bonus: every lever on the map, ranked by effect and by evidence.
Working with us
Measure once, govern the levers, or buy a single system when the Audit has named it. Every stage on the map points at one of these three and never at a menu. Prices are set at booking, except the Cellular Audit, which is USD 900.
01
Everything measured once, and ranked in writing.
Stages 0, 1 and 6
The front door. Recent results you already hold are credited against the panel.
Ask about the Audit →02
A physician owns the register, the levers and the retests.
Stages 2, 4 and 5
Monthly. It begins the quarter you start, and its work changes from fixing to holding as the numbers come to target.
Ask about the Program →03
One system at a time, once the Audit has named which.
Stage 3
The Cellular Audit is USD 900 and credits in full against the Audit within 90 days. The rest are quoted at booking.
See the modules →How the map places you
A dated number. A ranked result. A booked retest. A written register. A named person. The quiz asks what exists. A number you cannot name has already placed you.
Every stage names a single bottleneck and a single graduation test. You get permission to ignore everything else, which is the permission most executives are missing.
A business roadmap only goes up. Health drifts. A number that slips re-places you at the next retest, so the map is read again every quarter. The top of the map is a cadence, and the cadence has an owner.
Four strands, seven stages
The mind, the people around you, and the purpose decide the last three. Each strand enters the map only where the mortality evidence is strong enough to gate a stage. It enters as something that can be counted: a screen on the register, a person who reads it, a page that says what the decade is for.
Illustrative. The dots show where each strand enters the gates.
Blood pressure, ApoB, glucose and insulin, waist, fitness, strength. Then the inherited and structural risks the six cannot see.
A fixed wake time. Alcohol counted. A mood and anxiety screen on the register, dated like any other number.
One standing weekly commitment. A person who knows your six numbers. A physician who owns the register.
A written mandate. A successor with a register. The paperwork that outlives enthusiasm. These are the map's proxies for purpose and social integration, which carry the mortality data. The evidence sits behind the things, not the paperwork.
The gates
Each is cheap to obtain, each has a target that differs from the laboratory's reference range, and each carries evidence in the hundreds of thousands of patients. The grade beside each is the grade of that evidence, on the same scale the Leverage Ladder uses.
Under 130/80 on a validated home cuff. Your physician may set a lower target.
In trial data, every 10 mmHg off systolic pressure is associated with 13 percent lower all-cause mortality.
AQuarterly
Under 80 mg/dL. Under 60 with a calcium score above zero, elevated Lp(a), or diabetes.
Every 1 mmol/L of LDL removed cuts major vascular events by 22 percent. ApoB counts the particles that do the damage.
AAnnually. Every six months on treatment.
HbA1c under 5.6 percent. Fasting insulin under 10 µIU/mL.
Diabetes nearly doubles all-cause mortality. Insulin often rises years before glucose does. HbA1c reads low with sickle cell trait and some anaemias, so your physician checks the variant once and adds a fasting glucose where it is called for.
AAnnually
Under 0.50
Visceral fat is the earliest visible marker of the metabolic problem, and a tape measure finds it.
BQuarterly
Above the 50th percentile for age and sex. The top quartile is the aim.
The least fit fifth carries four to five times the mortality of the fittest. Moving from below average to above average is associated with approximately 30 percent lower risk.
BEvery six months
The top half for your age and sex. The EWGSOP2 sarcopenia floor is 27 kg for men and 16 kg for women, and regional norms differ.
Every 5 kg lost from grip strength tracks with 16 percent higher mortality.
BEvery six months
The gate. Smoking, and nicotine in any other form except replacement therapy used to stop, holds you at Stage 2 regardless of the six numbers. Nothing on this map compensates while it continues.
Sources for the six: Ettehad 2016 Lancet; Cholesterol Treatment Trialists 2010 Lancet; Emerging Risk Factors Collaboration 2011 NEJM; NICE 2022; Mandsager 2018 JAMA Network Open; Leong 2015 Lancet (PURE); EWGSOP2 2019. The full references sit at the end of the page and on the Ladder.
The free bonus
Twenty levers against mortality, ranked by how much each moves the number and by the quality of the evidence behind it, with a discard pile at the bottom. The rule that runs through it: never buy a Tier 4 solution to a Tier 1 problem.
Left off the map
A map is also a list of roads it does not show. Each of these is sold to executives every week, and each is missing here for a reason with a grade beside it.
Evidence
A: randomised trials or meta-analyses of them. B: large prospective cohorts, consistent across populations, with a dose-response. C: one cohort or cross-sectional. D: mechanism only. Nothing on the body gates a stage below grade B. The two documents at Stage 6 are governance, and the map says so.
Questions