All right, everyone. So my part of the talk, I'm going to talk about strength training, nutrition, particularly protein intake, and how we can use that to combat age-related sarcopenia. So my objectives, we'll give a definition of age-related sarcopenia, discuss how its impact leads to functional decline in our patients, we'll review some current recommendations for both protein intake and strength training, and then we'll explore some solutions to the prevention and management of age-related sarcopenia in our aging population. So age-related sarcopenia is the progressive loss of skeletal muscle mass, strength, and function as we age. It leads to a decrease in function, loss of independence, and ultimately decrease in quality of life. You know, when we turn 30, we start to lose muscle mass, right? And the numbers on this are a little bit variable, but 3% to 5% is what we see starting at around the age of 30 per decade, or about 1% per year after 40. It's not just the loss of muscle size, but more notably, the loss of strength and power, which are the most concerning things, because that's what we need technically to function and get around, right? There are two main contributing factors to this. There's a large reduction in motor units when we don't use the muscle. So the first part of it is the fact that as we age, we become less active, we stop lifting weights or never started, and we're just not moving heavy objects. The second part is something called anabolic resistance, where the same amount of protein intake has less of an effect on our body and the anabolic response and protein synthesis as we age. So as I mentioned, it has a large impact on our patients, our population. It makes our daily activities more difficult to do, carrying in groceries, going from sitting to standing, getting off the toilet, leads to impaired mobility and increased fatigue. And it essentially just weakens our muscles, making activities that used to be effortless hard to do, which leads to us doing less, making it difficult to sustain physical activity and reducing our energy levels. As muscle mass decreases, an unfortunate side effect is that the body's metabolic rate also slows down. This makes it easier to gain weight, harder to lose weight, leads to obesity, which further exacerbates the decline in physical function. Lower muscle mass and higher body fat is associated with a number of chronic diseases. We lose the ability to regulate our blood sugar, leading to diabetes, cardiovascular health, and we lose that support in bone density, leading to fractures. So more importantly, there's also a large cognitive impact. You know, the loss of the ability to perform ADLs leads to loss of dignity and independence, feelings of depression and isolation, and ultimately a decrease in quality of life. Essentially what happens is we get caught in a cycle of decreased function, leading to muscle wasting, and muscle wasting leading to further decreased function, and it's very difficult to break that cycle. If we look at some CDC data, one in every five falls cause a serious injury, such as a broken bone, 800,000 patients are hospitalized because of falls, and most often because of a head injury or a hip fracture. So there's a strong correlation between age-related sarcopenia and fall risk and fractures. Osteoporosis and decreased muscle strength, as I just mentioned, are two of the strongest contributing factors to this. And so kind of thinking about that is, you know, where do we go from here? These are just some quotes about prevention, but we all know that, like, prevention is the best medicine. So how do we get on top of this and stop that age-related decline in muscle mass, therefore obviously decreasing falls and fractures and increasing the function in our aging population? You know, when I started this, I would say, can you completely prevent age-related sarcopenia? I mean, I think that's a challenging question to answer. I would lean more on the side of yes than no when I started, but there's definitely some compelling research that we can do a lot more than we think. So the goal is to slow the rate of muscle loss as much as possible when we age. The earlier in life you start building muscle, the better off you'll be. I say this to a certain extent because although early adaptation will provide greater benefits, studies have shown patients in their 90s can tremendously benefit from starting a strength training program. The caveat to that is when it comes to bone density, if you can get to people in their 20s and 30s, it has a lot stronger of a long-lasting effect. And so I'm going to focus on two key things for the rest of the talk, one being protein intake and one being strength training and how we can use those to combat muscle loss. So as you guys know, there's three macronutrients. Protein is one of them. It's made up of amino acids. It's the essential building blocks for everything that we do. In order to feed the muscles, we need to have protein and allow the muscle to grow. It also plays a strong role in helping us to fight metabolic disease by helping to better regulate blood sugar levels. So some of the benefits. So enhanced satiety. So with protein, it's a very inefficient energy source to use. So that's actually a good thing if you think about it from a weight loss perspective. If you eat 1,000 grams of protein, it can take up to 40% of that energy to just digest. So for example, if you eat 250 grams of protein, that's about 1,000 calories, your body might only end up seeing about 600 of those calories after it's done digesting the protein. So inefficiency in that regard is good because it helps to increase energy expenditure. The available protein the muscle can use for protein synthesis and building. We also get improved glycemic control. When you take our protein source with a carbohydrate source, it helps to stabilize the blood sugar so you get less fluctuations in blood sugar and then hence less insulin release. And then you can also see favorable changes in lipid profile, including increases in HDL and decreased triglycerides. I'm kind of preaching to the choir here about the role of protein in healing. I mean, I know you guys know it increases tissue repair and growth, collagen production, boosts immune function. It provides energy. But like I said, it's sort of an inefficient energy source and can decrease swelling in the extremities by changing the osmotic gradient. So currently, the RDA for protein is really low. And I think, honestly, it's extremely low to some regard, 0.36 grams per pound. And we'll talk about some reasons why our particular patient population might require a higher protein intake. There have been studies looking at this. If you look at the two different populations, let's just say athletes because it's what a lot of these studies are done on, you need more protein because they're breaking down more muscle. There's more muscle turnover. There's more protein degradation than protein synthesis. So you want to have as much available protein in the body as you can at one time. The second is that decrease in the anabolic response that I talked about, the anabolic resistance in the elderly population where they need more protein to get the same effect. So just some research looking at this, they've put numbers up, you know, 1.4 to 2 grams per kilogram or 0.6 to 0.9, which still can be kind of low. And then 1 to 1.2 grams per kilogram looking at older adults. So if you look at our protein intake in general, if we look at like an IRF or a SNF setting, the average meal is 15 to 20 percent protein from total calories and largely carbohydrate-based. So this provides a challenge when we have patients in rehab because we're trying to get them to build muscle, to get stronger, and we're sort of fighting against ourselves with this. And in order to combat that, I mean, protein around 30 to 35 percent, depending obviously on the number of calories that you're consuming, is adequate for most people. But we have supplements that we can use, right, in our inpatient and SNF settings. Unfortunately, those are more carbohydrate supplements. So Ensure and Boost, both of these, Ensure has 9 grams of protein but 41 grams of carbs. Boost has 10 grams of protein and 33 grams of carbohydrate, which as you can see, these are clearly, there's a 4 to 1 ratio. They're clearly carbohydrate sources. So there's some things that I prefer. This is Prostat. We all use it in like wound patients, but I think it could be used for everybody. So just a protein supplement, 15 grams of protein per 1 gram of carbs. What I really prefer, obviously we don't have access to this, but these Fairlife protein shakes, some of them have up to 42 grams of protein and just 2 grams of carbohydrate. So a very easy way, especially for people who have low appetite, to increase their protein. And then another thing that always comes up is, is a higher protein diet safe? And the literature they looked at where it wasn't, and people kind of got fixated on that, had to do with some observational studies of people with pre-existing kidney disease. In those individuals, they showed that the high protein diet could accelerate kidney damage due to increasing the GFR. Anyways, they've done a lot more of these studies, and in people with healthy kidneys, even those at risk for kidney disease and hypertension or diabetes, there's no evidence that a high protein diet can have any detrimental effects. And they go up to like 3 grams per pound in the studies. So my recommendation for protein intake, and this sort of started as bro science and now it's becoming real science, is just to start with 1 gram per pound. It's very easy for people to understand, you know, you just have 1 gram per pound. They know their weight, they know how much they should be eating. It's achievable for a lot of people, and it's relatively easy to do. I always recommend trying to start with whole food sources, complete sources of protein, so focusing on whole foods and lean meats. And then if we have patients that are admitted to the hospital or are in the SNF, let's look at what kind of protein supplementation can we get them so they're hitting these numbers. Now I'm going to kind of segue a little bit here into strength training, which truly is a lifelong investment in muscle health. I've been lucky enough that I started strength training at a really young age and kind of fell in love with it, but it's something that I think is extremely beneficial. It's gaining more in popularity, I would say, using weights, especially amongst the female population, but still we have a long way to go, as you'll see here in a minute. So the benefits of strength training, obviously you're burning more calories, improves your insulin sensitivity. When you exercise, you get those glute receptors that come to the top of the muscle, allow the insulin-independent uptake of glucose, so you're not spiking your insulin, reduces your visceral fat, and can help to regulate your hormone profile. Not to mention, as I talked about earlier, the improvements in bone density, increasing your muscle strength, balanced coordination, helps to reduce the risk of falls, improving our posture, which can help prevent spinal fractures in those with osteoporosis. The weight-bearing effect in improving bone density is seen the strongest in the studies when you can start early in the 20s and 30s. But you still do get benefits all the way up through 90 years old, there have been studies. So one in five people in the U.S. population engages in strength training at least twice a week, which is an extremely low number, in my opinion, given the benefits. There's a lot of stigma and misconceptions around strength training, which Amy and I and I think a lot of people have been working to change. But it's still very difficult. Some of that is weight training is dangerous or leads to injuries when you do it properly. There's really not a good evidence to support this. Well, then there's also the fact that any time you move and do things, you're at risk for an injury, right? But in a well-controlled environment, this is really not something that should be a concern. Weight training makes you bulky. A lot of guys want that, a lot of women don't. But the truth is you're not going to become gigantic from lifting weights a couple times a week, a few times a week. We just don't see that sort of response. Also one thing that I failed to mention earlier is there's a huge difference between the muscle size and the amount of strength and power output that you can have from a muscle. So you can still get really strong without getting really big. Probably the best example of that would be like an Olympic weightlifter. A lot of them are, oh, I shouldn't say, in different weight classes, they move extreme amounts of weight, and they're a lot smaller than some of these bodybuilders that we see. Weight training is only for men or for young people. So we're seeing a lot more women doing weight training now, which is awesome, very empowering, and is overall really great for public health. We are seeing more young people starting early. And then I guess another misconception is, and I may have failed to mention this earlier too, is that there's only really one way to stimulate your muscle to grow, and that's through weight training. There's separate benefits to aerobic exercise, but with aerobic exercise, you simply aren't going to build muscle because you're not giving the proper stimulus and activating those anabolic pathways. So there's really no age limit to where you'll not get benefits from strength training. Most age-related muscle loss is due to simply lack of training. And I think we can do a lot more than we think in our aging population. You can see major changes and improvement in just three to five weeks, even in those over 90 years old. And this is actually Dana's mom. She is 76? She is. You'll be 74. 74. So, amazing. Okay, so how do you introduce strength training? You know, I put a little bit about this. I think it's important because one of the barriers to, you want to lower the barrier to get people exercising, right, as much as you can. But also, there's a lot of stigma that we need to be careful of. So I think if you're new, you know, finding someone to help you out, a fitness professional or even like a physical therapist to start, kind of ease you into it, start slow, do a gradual progression. In CrossFit, we use things like scaling, but it's simply just like start low and go slow, just like the old adage that we use for like medications, right? And then focus on technique, not weight, and then make sure you're balancing your training with rest. You know, one area where we can introduce strength training even is in the inpatient rehab setting. There's so many barriers in the earth right now, and we're so busy, and it's crazy, so I don't want to focus too much on this. But it's a time when you have good supervision over the patient or, you know, the therapists at least are always with the patients, so, and helping them to learn how to do things properly. So yeah, I mean, obviously, if there's a recent injury, you want to be careful. You can just start doing gentle exercises, movements, which we're already doing, promote mobility, prevent muscle atrophy. And then as their condition improves, though, start to introduce some of these more complex movements, loading squats, maybe some axial loading to get them moving and bearing weight. And then as strength and endurance improves, we make the exercise more challenging on discharge, just provide some education, maybe a basic program. We want the patients to keep their gains. If they're doing home health, provide recommendations there, but really empowering the patient to take an active role in their recovery and letting them know that they can make gains and do a lot more than they think. And then if you know, like, a local fitness community or, you know, you know personal trainers directly, that's a good way to plug them in and get them working with the patients. So knowing one in five people do strength training at least twice a week, that's where this data kind of came from looking at these recommendations. So there's two right now that will focus on the World Health Organization and the ACSM. Both of them are essentially just saying two days a week. The problem with this is, Amy will talk more about this, but they're just really not specific. And if you're only training two days per week, you would need a very strong stimulus. So you would need to have a high volume and intensity to sort of offset the rest periods. So it can be challenging. And I think we could do better in this regard in terms of frequency. There is research showing higher frequencies combined with adequate protein are the best way to go. And then, you know, three times per week in showed improvements in the aging population. But I guess it's important to note that the number one predictor of success, regardless of what people are doing, is their adherence to the program. So if they're unable to do it, you know, if you say go six or seven days a week, it's just not a reasonable thing to do. They're not they're not going to find success. And we want to help them as much as we can, obviously. So the other component to this is so we have our weightlifting, you know, strength training and protein intake, and then looking at how that impacts metabolic health from a chronic disease perspective. So they work together nicely. When you increase muscle mass, you improve your insulin sensitivity. We talked about the insulin independent uptake of glucose. You have better body composition, increased muscle mass, decreased body fat. And then it really lowers the risk of essentially metabolic disease tremendously. I threw in here just some recommendations. For strength training, I think, you know, more is better to a certain extent. Like you want to overload without excess. So progressive overload is the term that we use right in the bodybuilding community is just simply adding weight that you can handle while allowing the connective tissue to handle that load and going slowly. And then balance how intense you're going with volume and frequency. If you're doing high volume, high intensity workouts, then you want to lower the frequency to give yourself time to recover. And then consistency is key here. So it's the number one predictor of success when we get our patients strength training. All right. So quick summary here. You know, age-related sarcopenia leads to high risk of falls, fractures, decline in our aging population. Weight training and adequate protein intake are two of the most underused yet most valuable resources we can offer patients to prevent functional decline. And then providing patient education and incorporating strength training into our rehab programs can make a large impact on health and well-being in our aging population. Cool. All right. So with that, I'm going to turn this over to Dana. Okay cool. All right. Hey everybody. So we're gonna switch gears a little bit and that was that was a really amazing summary of so many different things that go into maintaining metabolic health and function and I think in a lot of cases our focus is just a little bit skewed and so much of the attention is placed on the patient's body weight. So we're going to talk a little bit about some of the pitfalls of this approach specifically with reference to the BMI. Can you hear me? Okay. So we're going to talk a little bit about why BMI is an ineffective measure of health and it's inappropriate for use on individuals yet it's used incredibly widely on metrics on outcomes and in association with other health markers. We're going to talk about how weight stigma is rampant and deeply ingrained in both society and medicine and we're going to try to understand the association or the lack thereof between mortality and BMI and I may say things that you're not super happy with so try not to get too mad or too defensive because I know everybody's really doing their best. So just as a bit of a prologue I think we can all recognize that bodies come in a ton of different shapes and sizes and levels of ability and that no one deserves to be shamed for their appearance or for their size or for their ability or for having medical conditions and weight is a metric just like height with a range of normal values. And in terms of definition of terms the term obese the current CDC definition and I say current because it has changed over time is a BMI greater than 30 and we'll talk more about specifically what a BMI is in a second although I'm sure you all know. However the word obese is actually derived from the Latin obesus or having eaten until fat which I think is more judgmental than we would hope for a term that's used as a medical term. And I'm sure we all know people who have a BMI of 30 that have not eaten themselves until fat. The term overweight is also based on an idea that there is an appropriate weight and that an individual weighs more than that and again the current definition is BMI of 25 to 29.9 which has also changed over time and was at some point based on how a person's BMI related to the larger population. The term fat it's a descriptive term it has been reclaimed by like many terms that have been used to historically sort of marginalized communities it has been reclaimed and it is sometimes in certain circumstances considered a neutral term or even an affirming term depending on who's saying it and how. And it's really only an insult if you consider it to mean undesirable or unlovable or slovenly or lazy. And if you want to be really neutral you can just say someone's living in a larger body and think of like how you say that someone uses a wheelchair. So anti-fat bias, weight stigma, fat phobia, whatever you want to call it, it exists and I think we all have to recognize that it exists and it's really rampant in society. This reference up at the top left what we don't talk about when we talk about fat is an excellent read it's by Aubrey Gordon and it really goes through the experience of living life in a larger body in America and the sort of bullying and insults that people are subjected to. It exists in the workplace, it can affect wages, it affects an institutional policies which I'm sure you can imagine if you've ever flown on an airplane or sat in a doctor's office. In the legal system body weight and gender can both influence judgments in the courtroom. It was actually used as a defense in the Eric Garner case that he would have died anyway because he was obese. You can think of the way that larger people are portrayed in the media and then certainly in medicine which could be an entire hour-long talk on its own. There are many factors that affect sort of a perception of a larger person and and the attitudes towards those patients and a lot of it has to do with the physician's own body weight surprisingly. So there's some really good research about there on the stigma of obesity and there's this bizarre logic of anti-fat bias which is that it's okay to treat people this way because they chose to be fat and I think people don't even realize the amount of harm that they're causing and maybe even think it's actually motivating for people like maybe if we just kind of keep telling like hey do you want to come take a walk with me or you want to come to the gym like it's gonna be motivating them to just like go ahead and lose some weight as if it's really that simple. And if it's not coming from the people directly around you it's prevalent in really every like corner of culture and and the degree to which diet culture surrounds us and permeates every aspect is is just mind-boggling and a lot of this is for-profit because people are so desperate to change their bodies that they're willing to resort to you know paying money for different things and sort of being duped in that way. And people including athletes and we have to you know a number of sports medicine docs probably here they have all body types and thin is not the default and often it's the exception. So I think it's important to remember that weight is not a behavior when we when we talk to our patients we want to look at sort of their behaviors right. So weight isn't a behavior it's not in most cases under the ultimate control of the individual. It's really frequently oversimplified and an inability to maintain a weight loss is probably not a major failure on the part of that individual. This on the top right is Myrna Valerio who's an ultra runner and some of the things that she you know she's very present on the social media on the internet and she she had said once that like I never realized how many people were concerned that I might have diabetes. She's an ultra marathoner but people just based on her appearance I'm just concerned for your health. The bottom image is from actually one of Amy's friends who didn't he's a personal trainer and he didn't qualify for 200 bucks off of his health care premiums because his BMI was too high. So let's talk about BMI. So I'm sure you already know this but BMI is a is a metric it is your weight in kilograms over your height squared for some reason in meters and these are the current BMI ranges here so below 18.5 it's underweight 18.5 to 24.9 is healthy weight and then 25 to 29.9 is overweight and then 30 or higher puts you into the obese category. So a quick word on the history of the BMI and if you've if you've never heard this you're in for a treat I hope. So in the late 1800s Catelet who was a Belgian mathematician his his passion was really describing characteristics of different aspects of life from a mathematical standpoint. So he was describing the population of Belgium using I guess what the equivalent of big data in the 1800s so whatever sort of numbers were available to him. I think it had something to do with allocation of government resources to the country and he to his credit distinctly stated that this was not a measure of individual health. I think the problem with this is that he also had a few sketchy other interests like he was interested in what you know what constitutes average what does the average person look like which then sort of leads the to what's above average and then what's below average and you quickly get into eugenics territory after that. He also was real into phrenology so like the bumps on your head and what those mean or like the facial features that make you a serial killer and that kind of little little sketchy. It's a first red flag right there. So in the 1900s people started to become interested in what is there an ideal weight. So who might be interested in an ideal weight. It was actually life insurance companies because they wanted to figure out was there a relationship between someone's weight and their risk of dying because they were going to choose to insure different people. So they started to create these actuarial tables to try and associate weights with risk of dying and these data were of course based on the people that had the ability to buy life insurance. So those were primarily white people men and with money. They came up with these ranges and they were related to frame size. So for example someone who was 5 foot 8 and has a small frame versus 5 foot 8 and has a large frame clearly there would be a difference in weight. There were no clear norms and every company had their own set of normal values and there was also no evidence or any scientific basis for this. These were just like accountants. In the 1950s and 60s medicine got hold of this and said oh cool some like normative values why don't we just bring this into the clinic and so they started to actually use the insurers rating tables which again like weren't standard or evidence-based to evaluate patients weight and I guess health maybe although there was no direct relationship. And then after that we started to become more interested in body composition. So ways to measure body fat and most ways to measure body fat are a little bit more complex and certainly in the 70s they were very complex. So things like underwater weighing or air displacement or bioelectric impedance analysis where you run a current through someone. These are all relatively complicated measures that involve equipment and a lot of math and the BMI is pretty easy and inexpensive or free but is it effective and there was a big study to look at whether this was actually correlated with other measures of body fat and it was sort of like moderately correlated like in some cases it is in some cases it isn't and at the extremes it's probably more correlated right if you have a really low BMI you probably don't have a ton of fat if a really high BMI you probably have more. But again like none of this is considering an individual's health so lots of red flags. So it gets a little bit worse and so in 1985 the National Institutes of Health redefines obesity. They changed their definition of obesity to be based solely off of the BMI and then following that they actually changed the category definitions. So they lowered the threshold that used to be like the obese was like 32 or something they lowered it for both obese and overweight categories. So now there are more people falling into those categories so why why would they do that and to have to think like why do they want to put more people into these categories. This led to the most amazing CNN headline which is millions of Americans became fat Wednesday even if they didn't gain a pound and then they go on to say as the federal government adopted a controversial method to for determining who is considered overweight. So why would they do this? Why would they lower these thresholds? And if you're already suspicious and putting your tinfoil hat on you are correct. So there was this International Obesity Task Force which is linked it was came from the the WHO and this got a lot of drug company money and right around that time in the late 90s there were a number of different drug companies that had weight loss drugs in the approval process and about to come out on the market. And Roche and Abbott in particular had Orlistat and Reductal or Meridia and in this case you need to establish that being a larger person is a medical problem and these people need medical intervention and you have to establish criteria for prescriptions and for insurance coverage. And so the fact that these things all happen together I think is not to be ignored. So main drawbacks and you know all of this is that BMI doesn't consider bone muscle and adipose tissue in the body. It has a little bit like I said correlation with body fat measures not great. Within the middle it's pretty poorly called correlated and at the extremes it's a bit better. It creates these distinct categories with very sharp boundaries where if you're you know 24.9 or 25 you know you're in a different in a different group. It has this J-shaped relationship with mortality and if you need to sort of think of a mnemonic to remember this just think of like the Nike swoosh that's what the that's what the BMI relationship with mortality looks like. So at the lower BMIs your relation your mortality goes up quickly and at the higher it goes up very slowly. We know it's a poor marker of metabolic health and the evidence is not as clear in black Americans where they can have higher BMIs without the concurrent increase in mortality. So that leads us into this public health panic of the 2000s. So remember we've lowered the categories so when we say obesity rates are going up remember the definition was changed. So MockDead came out with this article that gets cited all the time that tobacco is still the main preventable cause of death but poor diet and physical inactivity will likely overtake tobacco as the leading preventable cause of mortality. 4,000 deaths attributable to poor diet and physical activity. The problem with this study is that was not well done. It was extremely flawed. It used self-reported data and remember if you're off by just a little bit in your weight you're gonna be in the wrong BMI category in the first place. But older unrepresentative data sets they screwed up their coding of like smoking in one group. They literally just had math errors right. This was just not a well-done study and thank goodness Catherine Flegel came along and if you don't know who Catherine Flegel is I encourage you to look her up because she's fascinating. She's a statistician who worked for the NIH and she basically kind of redid the study but using more representative data sets. She used the National Health and Nutrition Examination Survey and she was good at math so she did better statistics and what she found is that obesity and being underweight were associated with slightly higher mortality. It was way less than the previous estimate so less than 5% of deaths and being overweight in the BMI scale was actually associated with lower mortality than being what we consider a normal weight by BMI. These estimates were accepted right away by the CDC. She actually got the highest award that the CDC can offer and this created an absolute firestorm because nobody wanted to hear this and in particular folks from my institution so the Harvard Harvard Medical School and Harvard School of Public Health called it a pile of rubbish and no one should waste their time reading it and launched a ton of personal attacks on her. It's wild. So she went on to do another study a few years later and this is a mega meta-analysis. So 97 studies international almost 3 million people and again found that being overweight had lower mortality than normal weight and actually grade 1 obesity so 30 to 35 had no increase in mortality. The increase in mortality started above the BMI of 35 and one of the peer reviewers there's a quote from from them in some of these articles about this. They said that this documents the conclusion that I suspect most people who follow the health and obesity literature have concluded because this is not totally brand new this has been shown in other research have concluded but not formalized. In spite of the labeling of BMI 25 to 30 with the pejorative title overweight the data on mortality do not support that this category of BMI has an increased mortality and if you're interested in a good read the article on the lower right Catherine Flegel wrote in 2021 after she retired which sort of is her perspective on the entire firestorm that followed her original study. So we know that BMI doesn't equal health so up to like half of people considered obese are metabolically healthy and a quarter or so of non overweight people are considered the lean unhealthy and so some studies show that people who are unfit but lean are twice as likely to get diabetes as larger people so and that's with a very long follow-up. So here we are labeling this huge swath of the population is somehow aberrant just because of their weight even if they're perfectly healthy and originally BMI was meant to be a surrogate for other markers of health and now those markers are easily measurable so we can look at A1C we can look at blood pressure I have a ring that will tell you how much I slept last night right people can look at their resting heart rate on their watch right in the office with you so this is not a super useful number unless you're trying to be exclusive right and essentially all research on health related to body size uses BMI so be extra cautious and especially if it uses self-reported height and weight and just to sort of as a final word on this weight loss is really hard if not impossible I think we all know this and there really is no technique no single predictable sustainable strategy to change your body to get a different body long term you can make changes in your behaviors that may result in some change but if you're trying to just physically just change your body there's not an easy way to do it someone who is in the obese category has an extremely low probability of attaining a normal weight a 5% reduction is much more likely and this is in part because of what we call adaptive thermogenesis meaning a decrease in metabolic rate accompanying the weight loss and this is seen extremely well if you ever read the biggest loser studies so there are two studies that were done on the biggest loser contestants from the origin of that show and what it showed is they lost a bunch of weight their resting metabolic weight plummeted it went way down and even if they gain the weight back it stayed low so now they have to burn even more calories to maintain the weight that they were to start with rough rough out there and this just leads to failure it leads to gaining the weight back at least a self-blame people feel judged by their medical professionals they get encouraged to try again and they just do the same process over and over and weight cycling is also tremendously risky because the cardiometabolic stress that accompanies these changes and fluctuations in weight have a lot of risks associated with them so what can we do in the clinic so I think it's important to consider how you might incorporate a weight neutral paradigm so can we remove the assumption the assumption about thinness being a goal and can we sort of reframe our concerns about health to be about the medical problems and not to be about the body size we know that exercise and sport have a ton of health out and functional benefits that are completely separate from body composition and can we detach our treatment plans from the pursuit of thinness so just ask yourself would my treatment plan for this patient be different for a thinner person because what we say to these people matters and if you sort of toss in that they should lose 10 pounds you might just lose your chance to actually help that person with something that you can treat so approach the diagnosis the same way it would be for a thin person don't assume that their body weight is the cause of the problem in terms of your physical exam approaches the way you would approach anyone who's a little bit more difficult to examine someone who's got more mobility challenges adapt as you would with any impairment get the patient to help you procedural skills super important so I do a lot of procedures I do a lot of joint injections I do spine injections and I've made it a goal to get good at doing these procedures on larger people I can parallel park my car and my car is kind of big and I just practiced it and now I don't hit stuff right so you can do a good job if you just work at it and practice and refine your technique there is some data including the study by a ting Chen showing that larger patients sometimes respond even better to peripheral joint injections and sometimes you need those techniques to help get get people moving and change their behaviors and in terms of your decision-making weight loss is not a substitute for medical management and it's not a contingency for medical management and then finally weight loss is not always a positive sign and it's not always purposeful and try hard not to congratulate people if they feel good good for them because they feel better but don't just congratulate them on the fact that they managed to lose some weight so in summary BMI as an ineffective measure of individual health it's used extensively in research and applied to individuals anyway BMI categorizes people into progressively more stigmatized groups the mortality is no higher in the overweight and grade one obese and is lower for the overweight group weight stigma is rampant in medicine and is deeply ingrained in all of us pay attention re-examine your thinking and try and use other metrics which you'll hear about in about five seconds and try and empower your patients and these are some really great resources if you've never heard the podcast maintenance phase and you're interested in this topic I encourage you to listen to it and there's some really great people out there to follow on social media as well thanks talk tinfoil hat stuff get ready All right, so what I'm going to focus on is our current exercise guidelines, and also some possible vital signs that we can use in the clinic to assess our patient's mobility, but also their functional movement. So right now we'll discuss the utility of the current exercise guidelines, primarily the CDC exercise guidelines, ways to improve exercise recommendations, and then also describe functional movement vital signs that we can use in the clinic. So when we're talking about the exercise guidelines, we're talking primarily about the CDC guidelines. The most recent version came out in 2018, and they've had a couple of versions of this at this point. They don't change very much from draft to draft, so every five years they kind of retool them a bit, but ultimately sort of the same general principles remain. And then we're also going to be discussing the ACSM's Exercises Medicine Campaign, which essentially is a campaign to help providers talk about the exercise guidelines with their patients, encourage the patients to follow them, and ways to connect patients with the community in order to fulfill an exercise prescription. So we'll talk about that as well. So the exercise guidelines as they exist, 150 minutes, which is about 2 1⁄2 hours, up to 300 minutes, which is 5 hours, we give moderate intensity aerobic exercise per week. So that's sort of the baseline recommendation. They also say instead of this, you can do 75 minutes of vigorous aerobic activity, and they qualify that as basically things that as you're doing it, you can't really speak at the same time. And then they add in more than two days a week of muscle strengthening activities, which are essentially muscle isolation exercises, and the other guideline in there is that more is better. So if you want to be more fit, just do more of these things. And the thing is, it's not really working, and there's multiple reasons that it's not working. The primary thing is that people don't follow, less than 50% of people actually adhere to these guidelines, and it's actually more about like around 25% of adult people actually able to adhere to these guidelines. So if you're not really able to adhere to them, they're not very effective guidelines regardless of what the outcome is. So that's one problem with it. Also one in three young adults is not fit to serve in the military at this point. It's actually a national security emergency at this point, that our military, our first responders are not in good enough shape to actually to serve if needed. And then this also leaves patients and providers frustrated, like we want to recommend exercise, people want to do it, they don't know how to do it, we don't know how to talk about it, and it just sort of gets into this cycle of, and in the meantime, metabolic diseases is getting out of control, but yet we keep sort of recycling the same ideas about exercise and what it is. So pitfalls in these recommendations, there's no discussion of the different metabolic pathways, or little, minimal discussion of the metabolic pathways. The weight training specifics are vague, there's a lot of talk of isolation, muscle movement in there, and we'll talk about why that may or may not be a good thing. The use of intensity is not very much emphasized. There's lack of talk of functional movement, I think the only functional thing they refer to from what I saw is extreme gardening, but beyond that there's really no talk of functional movement. Volume training, like I said, their recommendation is basically, well if you want to be more fit, just do more of this stuff, which to an extent does not really work. And then there's industry influence in these guidelines and in the programs that promote them, and we'll talk a lot about that. So the guidelines are very much aerobically biased. So like I said, a lot of emphasis on this moderate intensity, steady state activity, which has its uses, but there are other metabolic pathways that we need to be exercising in order to produce a fitter population, and one is the phosphagen pathway, so that's something that activates within 10 seconds, that's something like a one rep max deadlift. Why this is important is if somebody is, for example, putting their bag overhead on an airplane, as I witness, watch people do that, it's pretty pathetic actually, but put their bag on the overhead compartment on an airplane, if someone's crossing the street and they see something coming in, they have to activate very quickly, so this is a pathway that needs to be trained, just like any other pathway. Then there's the glycolytic pathway that activates between 10 seconds and two minutes, these are your anaerobic activities, and then the oxidative pathway, which is the traditional sort of aerobic oxidative pathway, endurance sports, et cetera. Another pitfall is isolation movement, so life is not done in isolation, right, so bicep curls are great, but that's not a functional thing to do, so just activating or training muscle groups in isolation doesn't train you to use those, or help you coordinate those muscle groups when you're actually doing stuff in the world, so it has its place, but it's not the sole way to strengthen your muscles, and the recommendations are pretty vague, so this is what's on their website, it's two or more days a week that work all major muscle groups, and then they list these muscle groups, and last night we were all looking at this and we were like, what does that mean, so we're pretty savvy as far as exercise goes, and ultimately this is something that, can you explain this to a patient, because I can't, and there are specifics in their guidelines if you go through them about sets and reps and types and blah, but it's difficult to explain, and also if you gave these guidelines to a patient, would they know what to do, and they won't, unless they have some kind of background in personal training, so again, you get vague guidelines, you get vague results, nonspecific results. Next is intensity, so intensity is not something to be feared, and I think, you know, I've been going to these conferences about ten years, and I do remember some of the talks in the past where they've been talking about intensity as a big kind of, like, oh, this new thing we've heard about, but we don't know if it's safe, and it turns out, you know, since then, there's been multiple studies in patients with CHF, CAD, stroke, diabetes, obesity, it's all shown that it's safe and effective in these populations, it's actually being used in rehab settings more frequently, and, you know, it's being something that's been beneficial, and then benefits include all of these, all of these things, Martin Cabala is a scientist who's done a lot of work in this realm, talking about the different benefits, including things like mitochondrial growth, fat oxidation, cognition, even some anti-metastatic effects of intense exercise, so it's also time efficient, and that's really key, because when you're telling people, the number one reason that people don't exercise is because they don't have time, so by telling them to just keep doing steady state aerobic activity that takes a really long time to do, they're not going to do it, so it's shown that in intense exercise, you provide the same, if not more benefit in a shorter amount of time, which makes people more likely to do it, or to get it done, and then on top of that, it's more, it's been shown to be more enjoyable, so people like doing it, they're more likely to do it, and they're more likely to adhere to it. So, and then, again, this idea that, you know, more is better, so this is on their website, you know, you do 150 minutes a week, or 75 minutes of the more vigorous stuff, and you do more, and you'll just get better, which is not necessarily true, so volume does not equal fitness, and that's also very time consuming, I mean, I've seen recommendations of doing 300 minutes a week of aerobic activity, which is a lot, that's a lot of time, and I'm someone who likes to exercise, and I do not want to run for 300 minutes a week, that's a lot, so, and if you do, great, but like, that's really hard to stick to, and that also makes people prone to overuse injuries, so, you know, show me someone who's getting on the treadmill for 300 minutes a week, and I'll show you someone who's got knee pain, So, this is not something that is necessarily, doesn't necessarily make sense, but also could be dangerous, and there's no discussion of function here, again, there's like, just keep doing more, but not exactly how you're using the gains that you're making. And perfect example is that just because you have a great VO2 max, just because you can run for 300 minutes a week does not mean you're healthy, so the perfect example of this is Ryan Hall, so he was one of the best American marathon runners for quite a while, and he actually had to go into early retirement because his health was failing, he essentially had what, you know, we would call female athlete triad, or in men, red S, and he developed, A, you can see muscle mass, not great, but also getting injured, he was infertile, his health was failing, and then he ultimately gave up the endless running and started weight training, this is him now, and he's made quite a change in his health, now can you run a marathon in the same amount of time, probably not, but I would argue that this person's much more healthy, metabolically. And then, you know, just because someone is strong, so on the opposite end of that, just because someone can lift a lot of weight does not mean they move well, and we're doctors of function, and that should be a priority for us, so this perfect example of this is, so 50 Cent, this is him back in the day, and he was kind of in better shape than he is now, so when he looked like this, he was asked to throw out an opening pitch for the Mets, and I know some of you are laughing, because you know what happened, but, that's bad, so I'm just saying, just because someone looks like they're strong doesn't mean that they move well, right, so that's something to keep in mind, so, and then lastly, looking at, so this is the Exercise is Medicine campaign, and again, this is a campaign that basically gets, it basically encourages providers to talk about exercise prescription to, it helps people find fitness professionals, and it also helps people find the correct certifications to fulfill an exercise prescription, and I want you to pay attention to something very closely, but look who the, one of the main founding partners of this campaign is a sugar company, okay, so oddly enough, and they didn't hide it, they were pretty obvious about it, and you go, why would a sugar dealer, essentially, why do they have a vested interest in telling you how to tell people to exercise, well, there's a few reasons, right, so, and one of the main things that Coca-Cola has been notorious for doing is investing money in science that points people away from their product as a cause of obesity and diabetes and chronic disease, and tells people, it's not because you drink this, it's because you don't exercise enough, let me tell you how to do that, and let's fund scientists that say you can have sugar in moderation, you just have to exercise it off, and here are the providers that will tell you how to do that, meaning you, they're using you to do that, and that's part of, and then now they've sort of gotten a little bit savvy of the fact that maybe they shouldn't put their logo on everything, so then they just start doing this, so one of the main partners of the ACSM, of which I was a member, not so much anymore, is the Gatorade Sport Science Institute, that's Coca-Cola, everybody, that's what that is, so they're getting better at hiding their name, whether it's the American Beverage Company or the Gatorade Sport Science Institute, but it's all the same thing, they're all sugar dealers, they're all talking about Coca-Cola, so, and they've done this with other, you know, other exercise, with other medical societies, they are buying off medical societies, exercise, nutrition guidelines, so one of the main things in the Exercise as Medicine plan is they tell people that they, A, are very specific about which fitness professionals are certified to talk about exercise with patients, and they also make it very clear that nutrition is not within the purview of a fitness professional, that you must seek guidance from a registered dietitian, which, by the way, they are buying off as well, so this is, it's, they're very smart about it, it's actually kind of, kind of crazy to see, but, but they, they are, they're investing money in cancer treatments, they're investing money in cardiology, it's kind of scary, actually, when you think about it, so, you know, the first thing that we can do as far as, you know, combating this is talking about it, I mean, how many people here knew that? Okay, a smattering, the fact that everyone here did know that already is a problem, the fact that most people at this conference don't know that is a problem, so we need to start talking about it, and also start, you know, start looking at the research that you're looking at, who's funding it, who's sitting on, who's sitting on these consensus guideline statements, who's funding them? Who's influencing how they recommend your guidelines and your exercise plan? And then we wonder why these things aren't working, right? So I'll step down off my soapbox for a second. So what do we do, right? So OK, there's control and everything, and that sucks. So we can talk. So first thing is talk about that. Tell your friends, tell your peers, tell your coaches. I see I go, I have worked in some high schools doing gang coverage, and they have these Gatorade signs on the wall that they tell kids, make sure you're drinking your Gatorade before and after. And most of these kids do not need to be pounding around sugar drinks, right? But so you sort of educate what you can locally. But then what do we want for our patients, ultimately, right? So we want to sort of look at them on this continuum of sickness, wellness, and fitness. And right now, we're really focused on the wellness, sickness side of things. And we say, OK, well, you're quote unquote well, you're not sick yet, good for you. And we really should be pushing people towards being fit rather than just not sick yet. And what does that look like? And that also involves not just managing diseases, but also kind of trying to help move them towards curing them if we can. And what that requires is us looking at fitness more holistically rather than just a VO2 max, rather than just, oh, you walked to the store today, good for you, that's your exercise. It's more than that. And we have to really look at function, and guess what? We're experts in that. How convenient that we can all assess that. So when we talk about functional movements, these are movements that are done every day. They're not explicitly taught. Babies are notoriously really good squatters. They squat perfectly, most of them. And no one ever taught them that. These things tend to erode with age. So I'd ask yourself, when's the last time you got your butt below your knees like this? Some people, it hasn't been recently. And these involve complex joint, complex patterns. So there are multiple joint movements requiring coordination of those joints. It's often how people injure themselves. So as a sports medicine provider, most people hurt themselves doing really mundane things. It's like, I was putting my pants on, and I felt my back go, or I was putting something in the dishwasher. So these are all based in functional movements. It's really very rarely something that's cool, where they injure themselves. And these are really a predictor of independence and mortality. So if you lose the ability to squat independently, you lose your independence completely. So if you're not able to squat on your own or get up and down out of a chair on your own, toilet yourself on your own, it's the same movement, you lose your ability to live by yourself. And so that's something that we need to be thinking about and looking at in our patients. So these functional movements, how we train them, so like picking something off the ground, that's essentially a deadlift. So grandma needs to deadlift. She doesn't need to deadlift a lot, but she needs to learn how to do it so she doesn't hurt herself picking up the pen that she dropped. Again, so sitting on a toilet is a squat. Carrying your bags to and from the car or up the stairs, you can train that. Getting up and down off the floor, this is a life-saving maneuver. In the gym, we call it a burpee. We just do it for time, right? Similarly, same thing with sprinting. And you say, well, my grandma can't sprint, but she needs to get across the street quickly if she has to, right? So like, these are all things that need to be trained beyond just do your 150 minutes of walking around the block every day. There's more to it than that. And also, so as a physiatrist, can you define what moving well means? And can you define that in your clinic when you see somebody? Because it's a predictor of productivity, independence, function, fall prevention, your ability to interact with your environment. And we assess movement all the time, but we usually leave it to the PTs to do. There are some interesting tests, get up and go, functional movement screen, withdrawal are great and have the utility. But at the same time, they take some time to do, set up and things, I don't have time to do that, you don't have time to do that. So how can we sort of assess these things quickly? And that's what the use of vital signs. So it's about identifying problems before they become worse and they're useful for you as a clinician, but they're also useful for your patients to sort of show themselves the things that they can't do. Because I think a lot of these things that I'm about to talk about, you can think of things to yourself, like, could I do that if I asked to? And if you can't, you're like, oh, wow, I can't do that, that's a problem, right? So we're gonna talk about some vital signs. These are some of them, they're based out of this book, which is called Built to Move. My friend of mine is Kelly Sturet, who is a physical therapist, who actually took a lot of these vital signs that he based off of physical therapy tests. So, and they go into more detail and there's more of them than what we're gonna talk about. But the first one is just getting up and down off the floor. So what is this called, the sit and rise test? And basically it's, can you stand, cross your legs, sit down, and then, with your legs crossed, then stand up again, without touching the floor or yourself. So, think about that for a second. Can you do that unassisted? So having a patient do that or attempt to do that, or see, like, if someone's like, I can't even attempt to do that. Okay, that's a problem, it's a problem. So that's one thing. And then also, there's a whole point system to all of these about, you know, if you touch your leg on the way up, or if you touch the floor with two hands, but the general idea, can you get up and down on the floor without any assistance? And if you can, I mean, there's multiple reasons for that. But one of the ways to start kind of practicing it, just, like, sit on the floor. So start, like, while you watch TV, sit on the floor, just kind of get a feel for what that is like to sit on the floor and get up and get down. The next is hip extension, something called the couch test. So you can do this against a wall, in the top picture there. Basically putting your knee on the ground with your leg flat against the wall or a box, and then trying to kind of lift your torso upright. So we all have really tight hip flexors because we spend all day sitting. So we're all kind of hunched over, our hip flexors are super tight, and we lose that ability to extend our hips, which causes pelvic tilt, and then this can lead to back pain, hip pain, and just poor posture overall. So this is another thing that you can have someone do, or attempt to do. Another vital sign is just kind of looking at movement in general, and now that everyone has a device that tells them how much they move, you just want to get an inventory for that. How much are you moving a day? And I'm not a huge fan of step count as a marker of fitness by any means, but it does tell you if someone's moving or not moving, and that's a start. Some movement is better than no movement, and we want to talk about that. And the idea is sort of creating this movement-rich environment, and making it such that in your office you have to walk from place to place, or limiting the amount of hours spent sitting at once without taking a break. The next is called the airport scanner arm rate test. So can you just stand and put your arms over your head, extend your arms overhead, which sounds fairly simple, but go to an airport, see what happens, and at the same time keeping upright torso with your shoulders behind your ears? That's actually really hard for a lot of people to do. And for a wheelchair user, for example, they lose that ability, that's a very significant functional deficit. And people with shoulder pain, neck pain, thoracic pain can all be linked back to this. And this is sort of a more advanced test called the Superman, if you have someone lay on the floor with their hands overhead. It's essentially the same idea with your sort of forehead touching the ground, being able to extend your shoulders overhead behind your ears, which is, again, another sign of shoulder mobility. Next thing is a squat test. So again, this is super important because this is something that really predicts your ability to live on your own. And some cultures that being in a squat is just sort of the default, but for us, not so much. So it's really important that we know what the points of performance are in a squat. So one is maintaining a neutral spine, so keeping the back of your head between your scapula and your tailbone, I'll call it in one line, your weight in your heels as you squat, tracking your knees over your toes as you go up and down, initiating the movement with your hips, meaning what that means or how I describe it to people is if you're trying to close a car door behind you, the way you sort of initiate that movement is kind of sticking your butt out, and that's how you should initiate every squat. And then ideally, you want a full range of motion, so getting your butt below, essentially below your knees. Another test of stability is called the standing on one leg eyes closed test or a SOLIC test. So having someone stand on one leg, pick up their foot and cross their arms and close their eyes for 20 seconds. Can you do this? And a lot of people have trouble standing on one leg. A lot of people have trouble doing it, including athletes that I see who say, yeah, I run all the time. They cannot stand on one leg without falling over. And this, we'll talk more about why that is, but you can tease out a lot about someone's pain if they can do this or not. Another version of this is called the old man shoe test, which I have a video of, so. So the rules for the old man test are you want to stand on one foot, pick up your sock, put your sock on, then pick up the shoe from the same side and put it on. Tie it without touching the ground. From there, you want to jump onto the other foot, pick up that sock, then pick up your shoe, tie it without, again, touching the ground. If you touch the ground or touch in any other way, you fail the old man test. So, and that's obviously a more advanced thing, which is actually really hard to do, but sometimes I'll just have people stand on one leg and they say, oh, I have really bad balance. And I go, have you had a stroke? No. Do you have some kind of brain lesion? No. Do you have an inner ear problem? No. So very unlikely to be a quote unquote balance issue. It's a stability issue. It's your glutes not holding you up. And you see this a lot in runners. So runners will present with a lot of knee pain, back pain as a result of their glutes being very weak. Because when you think about it, running is a series of single leg squatting. And the muscle that stabilizes you when you single leg squat are your glutes. So if they're weak, you're essentially having this moment where every time you hit the ground, your knee's kibbing and your hips are dipping. So you do that thousands of times per run and you will have back pain, hip pain, knee pain, et cetera. And the glutes especially, they aid in side-to-side movement, which we don't do a lot as people. We go in this direction. And that's why people say, oh yeah, I do my Peloton every day. So that's great. You're sitting in one plane of motion doing the same thing over and over again. What are you doing to strengthen your glutes? What are you doing side-to-side? And it's usually nothing. And they're also super difficult to isolate. So if you think about just hip abduction, you can actually cheat this muscle and override it with other muscles. So people say, oh yeah, it's no problem. I can bring my leg out to the side. Well, can you bring your leg out to the side and then extend your hip behind you at the same time? And also when you test this muscle, you have to do that. You have to abduct and extend the hip and then provide resistance because you'll see a very big strength difference in most people. And there's all different kinds of exercises you can do. Sideline, clamshells, monster walks, lunges, a lot of single leg things, single leg squatting, single leg lunging. People should really feel that when they're finished doing that their butt should hurt essentially. The last sort of vital sign is thinking about sleep and nutrition. So that's a huge topic, but basically if you're asking about someone's exercise and their health and you're not asking, A, are you sleeping and are you eating well? Like, you know, you're in trouble. So when we think about some of the most fit people in the world, like Navy SEALs, these men essentially are basically broken by basically they'll keep them up for days at a time until they break. They can be the most fit people in the world, but you're not sleeping well, you're gonna feel it. You're gonna be in pain. You're not gonna be able to perform well. You're not gonna see the same kind of results from your exercise if you're not sleeping well. And then nutrition, like Matt was talking about, protein intake. If you give people two pieces of advice about their diet, get enough protein and avoid processed foods. You do those two things, you'll be better than most of the people in this country. So, and then ideally you want someone to be tracking this stuff. So you can't really change what you don't track. So there's wearables, there's apps, there's all kinds of ways to track it. So giving people that power to sort of look at their own data to help themselves is really powerful. So conclusion. So exercise guidelines, they're missing a lot of things. It's more than cardio, it's more than muscle isolation. Beware of the industry influences in the things that you are recommending in the research that you're reading, in the products that are being pushed upon you that you don't even know about. Functional movement training is important in preserving strength, function, independence. There are movement vital signs, can be used to identify faulty movement patterns before injury and dysfunction occurs. And then sleep and nutrition can't be ignored when we're talking about this stuff. So you must track it in order to change it. So, thank you. So. So we will open it up to questions with the time we have left, so. Excellent talk, and I know Dana and I were chatting yesterday, and I could talk for hours about this. One thing that I have noticed is that in a lot of ways, because of so much bad advice over the last couple of decades, like, oh, eat everything processed and low-fat, oh, women shouldn't strength train because you're going to get bulky, that we really have a lot of work to do in terms of taking back the ability to have some authority about this, because the medical industry gaslit people for decades. Do you have a method of approaching patients in order to try to help come from that place of empathy and trust in order to really help acknowledge all of the struggles that, as a profession, we've put on them and then really help to unwind a lot of that? Okay, well, one of the things I, I mean, if we're talking specifically about weight loss, if someone has a question about that, I like to focus on what they can do with the weight loss rather than the absolute weight loss, right? I like to talk about sort of the functional things that they want to be able to do, the goals that they have in that respect, rather than just, like, absolute numbers. And then also my, you know, I'm someone who likes to lead by example. So, you know, I like to share sort of my personal experience with them to sort of break down, like, this is what I did for years and what didn't work. This is the things that have really helped me. Here's a community of people that I can steer you towards who are doing these kind of things that I'm talking about. So that's what I found to be most effective. I don't know if you guys have some. I think also we talk about the importance of community in having healthy behaviors and in fitness in particular. So if they can, there are so many great communities out there, both sort of gym communities and, you know, online communities and groups, and I think that's incredibly helpful for people to sort of find their people who can also empathize. Yeah, I'll just piggyback on that in saying that Amy and I talk about this all the time, but, like, lowering the barrier to admission is a huge thing. If somebody walks into a gym that's intimidating, right, they're going to be way less likely to want to pick up weights and do that. If you can somehow get them moving and introduce them slowly to concepts like weight training and stuff and then get them around a group that's doing it, you're much more likely to be successful. I mean, if you walk into, like, a CrossFit gym, it sort of looks like a circus. And so people would just kind of walk out, right? But, I mean, everywhere you go, if you go to, you know, a global gym or whatever, so it's how do we lower the barrier to get the patients in? I think that's challenging. It's something we're working on. But coming from the physician, I think it makes a huge difference. Just telling them, explaining to them, you know, why high-protein diets are effective or why weight training is safe and what that can do to prevent osteoporosis and, you know, age-related decline, I think is really important. So having conversations like this, but also, and then using, like, right now social media is huge, right? I think one reason we see a lot more women, particularly younger women lifting weights, is because they'll go on TikTok or Instagram or whatever, and they'll see all these people that have done transformations, other women that are working out. So they'll find that community online that they may not be able to find in their local community and then kind of join in like that. So I think using social media to our advantage and going out there and voicing your opinion on some of these things will make a huge difference as well. But it's very challenging. I agree. Hi. Hi, Amy. Great talk. I guess I would tend to take somewhat of a nihilist perspective when thinking about this. I mean, it's enough to say that us in this room and the patients that are on board sort of before entering your office with receiving those types of recommendations, but for your sort of average, saying obese just for the sake of what's on their history, but, you know, obese, perhaps they're a smoker, they have very poor dietary habits, perhaps low socioeconomic factors or challenging socioeconomic factors. It can easily come across as a lot for that patient to say, hey, these are all the things you ought to be doing. And so if you could distill it down for those that aren't already drinking the, again, poor terms, drinking the Kool-Aid, what would sort of be the top three things that you would or how you would approach maybe a key three things or like a really distilled version of this on where to even start with some of those patients that, you know, we're talking about TikTok. We're talking about all the ways we can expose people there. These people might not have any access to that or any awareness, right? Yeah, sure. Another great question. So I think it's just the number one thing is having people move. So we could sit here and talk about all the nuances between aerobic, anaerobic, should you do endurance, should you do weight training. The number one thing is to get people moving, get them in action. That's going to help tremendously because that will also kind of change their mindset around things, right? So if you can just get them walking, just walking, that's it. Huge victory, right? And then try and eat some protein and lift heavy things. If that's it, those are my three things I would tell anybody. If you can try and incorporate those, you'll be good to go. I mean, also, I mean, there is an element here is like if the person doesn't want to help themselves, like you can't do it. So you have to sort of accept that some people are just not on board with it yet. But the way that I find talking about it, guess what? Like as physiatrists, we have the perfect in. It's like what do you want to do that you're not doing right now? Whatever that is, right? So one of my friends teaches a course about this, and she's saying so an eight-inch landing, so that's the standard landing in most houses. And if you're unable to traverse that eight inches, lifting your leg eight inches off the ground, that means you might have to live in a nursing home. And that's scary for people, you know. So focusing on that stuff. You have kids that you want to play with. You have an event you want to go to and be able to walk around all day. So stuff like that. I think they're more likely to admit that, yeah, I want to do that, and I can't, or I'm afraid to. But, yeah, if you start talking about like all kinds of things, they might not necessarily like really want to get on board with it. And if they don't want to, ultimately, if it's their decision and they don't want to do it, you say, okay, well, that's your choice. Hi. Have you read the new book, Outlips? Ah, Peter Attia. Have you read it? Uh-huh. I've actually. Oh, I'm sorry. It covers all the stuff you all have covered. And it's something that I've recommended to my patients. I've asked them to download it on their phones and listen to it while they exercise. The other thing I do, and you're right, just get them to walk. I have them document it. And when they document it, when they have to document it on a calendar, on a notebook or something, it puts more emphasis. I even get family members into it so that they will monitor what that patient's doing because it's very important for family members. Also, I'm a rheumatoid. I've had joint replaced all over the place. And I don't have a normal body. And so it's very hard sometimes to really get to the point. And we deal with people all the time whose bodies are not anywhere near normal. When you talk about this, it's more like a normal body. And the other thing I've learned is you can't. I try to preach at them. I always say, I need to come out of my pulpit. But they have to accept that you have to change their behavior. And sometimes it's just persistence with you bringing it up every time. Just persistence over time. Sometimes you can make a breakthrough. The other thing is being able to educate the family members not to enable them. They want to help them and not to enable them. And that's been really important. But I just totally agree with what you're doing. And let me ask you one question. When you have a connected tissue disorder, is there more likely a muscle mass wasting over time? You don't have any studies about that? No. No studies? Not that I know of. Okay. I mean, I'll say this too. Functional movements are not just for people with normal bodies. That's the whole point. So everyone has to do those things in some capacity in every way to be independent or to do their ADLs. So I think that's part of the idea is that you can't do these movements unless you're in great shape. And that's the exact opposite. You have to do these things. You are doing them every day. That's the whole point. Outlive? Outlive Peter. It's here. Hi. Could you address the issue of weight and pain or weight loss and pain management? A little bit of conflicting out there. And it's hard to advise patients on that and fellow colleagues, to be truthfully honest, on having people lose weight and that will make their pain go away. Well, I can speak to as far as, you know, so fatty tissue in addition to providing extra load on joints does secrete inflammatory cytokines, which increase pain signals or, you know, worsens pain signals. So that is a real correspondence. So, I mean, I always tell people, you know, every 10 pounds on your body is 40 pounds of pressure on your knees. And I'm surprised how many people really respond to that idea. They really go, oh, my God, really? So I'm like, yeah, so any weight loss is fourfold on your joints. And they seem to really respond to that. I think that starting with weight loss as a goal is not probably your best bet because there are lots of people who weigh lots of different amounts and not all the heavier ones have pain, right? Like Matt probably weighs more than I do, but he doesn't necessarily have more knee pain than I do because he has the strength to carry his body around, right? Not to put you on the spot. So if we think about starting with function and starting with getting stronger and doing more and having healthy behaviors, the weight may change, but the weight also might not change, and the function will probably get better regardless. I think we're at time. Any questions, you can come and talk to us here. Thank you.

age-related sarcopenia

muscle strength

falls

fractures

diabetes

cardiovascular diseases

strength training

protein intake

body mass index

exercise guidelines

industry influence