141. Progress Note #15: 2024 Health Trends, 100 Grams of Protein in One Meal & Visceral Fat Causing Joint Pain

Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha, and I'm Dr. Altamasharaja, where your hosts, hair to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization, but also zoom out to enhance systemic change. Join us as we look to break the status quo, move the needle forward, and put the help back in health care. Hey everyone, real quick, we are closer rolling out a newsletter containing high yield notes for our guests and tips and tricks from us. We want to put the health back in health care and want to help you do the same by giving you the necessary information to live your best lives and provide value to those around you. Go to MedicineRedefined.com where you can input your email and stay up to date. All right, thanks. Time for the episode. All right. Dr. Altamasharaja, here with me, back for progress note 15. Wow, 15th one we're doing here. What's going on, man? Back in the studio, in the studio, I mean, just in my bedroom. It's funny because a couple people ask me every time I tell them, like, wow, where do you do the podcast? I'm like, yeah, just from home. Just in my living room. Yeah. Yeah. We haven't made a big time quite yet. Although somebody, a person that, I don't know well, but I'm getting to, because, and we might have him as a future guest, I won't disclose yet, but yeah, he had a podcast and he just started about it today. He was like, hey, man, I got a studio upstairs if you want to use it. I was like, oh, that sounds interesting. So we might take him up on that. Ooh. Yeah, I'll tell you offline. Yeah. Interesting. All right. Yeah, excited for this one. PM 15. So that's cool. Yeah, let's get into it, right? So our last progress note was about things that we learned in 2023. And you and I both have picked up new tricks from that. We use a Morpheus heart rate monitor now. By the way, how are you liking it? Now that I guess we've been doing it for about a couple months. Come on. I love it. Yeah, I know. I really do love it. I think it has helped allow me to dial it in my training a little bit more. Again, really, I think always underestimated myself in terms of aerobic capacity and just recovery. Oh, so I started using my ordering again recently just to check the heart rate of variability to see if it tracks. And yeah, last couple of days, I'm going my training base more often more fierce than I am with ORA because I think ORA doesn't do a great job, but they are relatively close in terms of our variability. And again, we talked about how they measure a little bit differently. So I just, I'm trying this experiment for two weeks to see where the ORA HRV is. And I'm really trying not to look at the readiness score. I'm just looking at the HRV. And the more fierce HRV to see what that is like. You said the Apple Watch was pretty concorded though, right? Like what it was pretty identical to more fierce for a heart rate. Heart rate. Now, interesting. Oh, update on that. So just for the listener, I had noted that for me personally, the Apple Watch until I got up to like 150, 160, which is like really intense type stuff, my, it was a one-to-one correlation with the Apple Watch in my heart rate. And the more fierce M7 heart rate monitor, which is across the chest for those who are just tuning in and don't really know. However, when I have noted twice in the last two weeks when my recovery is low, so I had a day was like 56% stress and tired and not getting the quality to leave. And then other days 75% in those days, it is not. It is discord. And so the Apple Watch, I forget where it was, was a far lower number than my actual heart rate. And that's how I found that to be interesting that, you know, when I'm under recovered and where my HRV is lower as well, that it's not doing a good job. But again, that makes sense. We can talk about that on a different day of like why that makes sense in terms of checking in different polls, you know, arterial waveforms, but maybe on a different day. For sure. Cool. Okay. Back to my original point, right? So this episode is going to be about 2024 health trends. What we think is going to gain traction, where we think the pulse is going to be, I think these episodes are fun, because come December when we look back, we can say, hey, where we write, where we not, and kind of what may have changed. So do you want to start us off with kind of what you might think the, not even the next big thing is, but what will gain traction this year? Yes, I'd love to go first, because I'll take the easy ones first. And I think that the trends of, for the last couple of years, particularly because of COVID, right? So telehealth and digital health. And so these are not one of the same as we've talked about, right? But John Bacteri, digital health is kind of its own clinical entity, not even just clinical but technological entity that some people have been in the game for quite some time. And I think it's going to continue revolutionizing how we practice medicine. And we're just scratching the surface with EMR and all these types of things and even including how we get data, right? But I will put that in a separate category. Telehealth is interesting because we had strict rules for telehealth in terms of, like in at this point, everybody has experienced this, particularly because of COVID, because the restrictions got very, very loose across state lines. You could see patients and those have tightened up because of the medical emergency or the public emergency when Biden lifted that was like somewhere around May of 2023. And so state lines, like you can no longer do physician, patient visits across state lines anymore. But I do foresee that changing at some point. Again, people who are practicing outside the conventional business model of medicine are doing this, right? As long as you're licensing that state, you can see patients. But it does get a little bit tricky, particularly because there are a lot of other, you know, back things that people have to look at. This is something I'm looking at now. So for my medical trainees and people who are going to practice, right, when you're considering a malpractice insurance, like that also gets really, really tricky. And you know, insurance providers don't want to cover for that. But that being said, this is something that I think has made it easier for people, we're just going to build into my second point, who are more consumer conscious and are seeking out expert knowledge, right? So we talked about with Alfred as well about consulting and telehealth type stuff and how you can be a consultant for other things and now you're not doing direct patient care. But it does make the whole world a smaller place and gives more cost efficient care and better care to the patient. So I do think that's going to be something that's going to continue to improve with time and then digital health, right? So this is within this subcategory of digital health, I won't take all of the health monitoring variables, which is what we started talking about this stuff. And every single person that you talk to has some health monitoring wearable on them, right? And how do we incorporate that into our data, right? I think recently some article came out about apples, is it EKG strip is even more accurate than some of the monitor, or was it, I forget, I'll have to link it so I don't want to, so nobody can misquote it here. But, you know, it's getting to be more and more precise and the technology is getting better. And I can see that being incorporated into our medical practice quite routinely. Wow. Yeah. And because, you know, when I was in naive PG I won, and I thought about how I wanted to practice in the future, and, you know, having a brick and mortar and having, doing the physical exam, those were definitely things that were like top of mind, right? Because the people I shadowed within functional medicine all had their own little office and they had patients coming in and like such a nice setup. And now, as I think about the transition to Tampa and getting that coaching business and getting that wellness business started up, I'm most definitely probably going to start up with telehealth because I think of where people's attentions are, right? And especially if you're going cash base, being able to price across state lines and things like that, where you can now just kind of seek out providers and get the help you need, right? And get the coaching that you need. I think there's more opportunity for providers to go online so that you're not really forcing people to come and see you. And then, sure, if there is a need, if it's injections, things like that, medspot, etc., having that capital to at least then go ahead and make that investment knowing that you already have a good population or a good client tell to come in. So, yeah, I only see telehealth booming and it's interesting. Our chair, actually, at Penn State is doing a lot of research with the physical exam, be a telehealth and how virtual reality is starting to become a bigger component to help out with the physical exam, even with things like squatting, with things like distance, with even the strength exam, right? So, grading it from zero to five, how do you get, how do you distinguish between a three or four and a five, essentially? So there's just a lot of cool things that people and technologies or companies are developing. That is, yeah, yeah, I can see AI being built into that really well, actually. Which reminds me, I was just watching commercial either yesterday, the day before, whenever the Sunday games were, I guess. Did you see this Apple is putting these classes out that allow you to kind of do everything? Yeah, what do they call it? The Vision Pro? It's a mind blowing. I think it's called Vision Pro, right? Yeah. Yeah, I think that's what it's called. Yeah. I mean, so you can see that type of stuff. I mean, there's already software that you can, and apps you can download onto your iPhone or whatever it might be where you can do measurements on radiographic images, right? So when we're looking at certain angles for the hips to see if they would be a criteria for it to have a distillation, what not, and for those who don't know what that is, it's right, this pathology of how much coverage or lack of coverage you have in the ball and sock and joint. So I'll just leave it there. And that might have certain implications for management or surgery and nonoperative management and stuff. And so we've kind of been doing that. But you know, if you can put on a pair of glasses and it can give you the statistics and what something is, you can quickly document it or dictate it, right? Imagine having that AI measuring the angles for you. It's like having a guniometer on your glasses. And then being able to scribe it to your AI, scribe AI or some version of that. And then, yeah, I mean, the future is bright. Do we see that happening in 2024? Probably not. Obviously not. However, it's not far off. Sweet. Okay. So uptake in, telehealth is round one for you. For me. Okay. So it was a cold December day in New York City and premieres birthday. I take her to the Williamsburg bathhouse. So in Brooklyn and you know, we walked down stairs and there's just a bunch of people. And Mira's like, what the heck? I thought this was like a private thing like I had massages booked. The whole point of a bathhouse is, you know, back in the day, there's a communal type, you know, area where you go in a sauna, take a bath, you know, kind of like a wellness thing. And so this Williamsburg one kind of brought that idea back. And so they had three hot tubs, one steam room, one sauna, a cold plunge, and then like four or five massages in the back. It was funny because Mira was taken aback by how many people were there and she didn't realize that we would be sharing these facilities with them. So it's phenomenal experience. I mean, being able to do contrast therapy, go into the sauna, go to the steam room and really just kind of figure out how your body really adjusts to these different things with super fascinating, super just like wellness focus. And then we ended up getting a massage as well, a pro massage, meaning that, I don't know, they knew what they were doing. And it was like a very athletic massage, range of motion, things like that. But Mira for, you know, cannot stand cold water. Like it's very difficult to get her to get into a cold plunge. Whereas for me, I'm like, all right, let's just do this. Like the water's not going to get any warmer, right? So she ends up going in after like the fifth attempt and actually just dunks her face and entire head in there. And this water is probably like 38, 39 degrees. It was freezing. Like my feet were going numb. But for me, I kind of knew the benefits of cold plunge and the contrast therapy I've been doing it for some time. I have, you know, the new recover cold plunge in my house that I use. But for Mira, after every time she's gone into cold water, she's like, wow, I just feel like happy. Like I can see the bright spots in life. And that's a common thing you start to hear when people actually go into the cold plunge as anti-anxiety, anti-depression effect. So bath houses are a very big thing in New York. This is just a ploy for you to convince me to do ice. Not too. I mean, that was, that was the, so the top trend of 2024 is ultimately doing cold plunches. But in, in all seriousness, I think the bath houses are going to be the next big thing. There's a bunch of New York already with spas, cold plunge is my friends even subscribe to a place called, it's like recovery something or recoveryology, I believe, in New York where they join like a six minute ice bath club. So you go in there, you do breathing exercise for six minutes. It's a social thing. You wear your t-shirt when you go when you get into the facility and you get in that cold with other people. And so this whole cold plunge, we knew it was a trend in 2023. I only see more and more facilities building up to make bath houses, not only just for the contrast therapy, but it's a great way for singles to meet. It's a great way to just mingle. It's a great way to get massages. At the end, there's like a bar, you can get juices. So it's just like a very lively, fun experience. And so I was looking in Tampa and surprisingly, there's none of these like legitimate big facilities. And so I think one's going to start up there, if not, I'm going to start one up somehow. But I think this is going to be the biggest thing. It's crazy is there's a luxury apartment building coming up in Tampa called AER. And in there, they're already building a cold plunge in sauna for their residents. So attach their gym essentially. That's awesome. Yeah. So I think it's just, it's taken away now. It's super interesting that we're talking about this because my closest friends from kind of my college group, I think in that chat, we're on one Whatsapp group. They were talking about it last week. It was like, oh, there's one down. There's two in Jersey that I can think of right now, at least that they had mentioned. And we're asking who wants to go. I probably had heard about it before, but I didn't really know all the components that are accessible to you. So now I'm in treatment very much so, so my check that out. All right, I am going to take another easy one because I think, I think this is something that I'm seeing a drastic need for and it's not going to be a surprise to anybody whatsoever. But I think the conversation is getting more and more dialed up and the stigma is completely worn out, particularly with the younger generation of docs. So when they're Gen Z, they're coming in. Every single person wants to talk about the importance of this and that's the importance of taking care of your own mental health and well-being and seeking out help. So whether it's services such as better help, there's stuff of couples therapy like regain that are making it more and more accessible. We see all these commercials and ads for it on all social media platforms and TV, but really even males, so what they call the toxic masculinity of that kind of stuff, interesting that person that I was talking to you about earlier was talking about how one of the reasons that he wanted to start that podcast of his was because he had seven close combination of family members and friends, close people to him, commits suicide. And so the importance of this alpha male individual, this misconception that you know, quote, unquote, your week and whatnot, like we need to talk about when it's not okay. And so, you know, with services such as better help and all these things that are kind of at your fingertips, we can trial, you know, and trial and if it doesn't work out, then you can switch and just at the comfort from your own home, again, builds into the telehealth thing that we talked about earlier, it makes it, it reduces some of that friction, right? So James clear talks about, you know, if you have a bad habit that you're trying to get a real increase of friction, if you are trying to implement a good habit that you want to do more of reduce the friction. So this reduces the friction of that and I think that that's also, so if we get rid of the stigma, reduce the friction of getting accessibility to care, we make it affordable. That's the other thing that a lot of these subscription based models do, they make it affordable. Then this is something that people are going to be more inclined to opt for. And I think generally it's going to make it a better place to be, particularly because of how, how much emotional distress there is to go around. I think that's that is something important. Not only that, you know, what's crazy is I have colleagues like who are in psychiatry and or psychologist and most of them are can easily go to cash space and there really is no competition because the demand is so high, so, so high that they can charge an astronomical rate, particularly psychiatrists, right? Because you know, now you have nurse practitioners and PAs and all those other advanced practitioners who can do this job and so psychiatrists, alipads and osteopaths, their rates are just through the roof to be able to do that. So yeah, that's something that I hasten up taken. Yeah, I'm really interested in our upcoming conversation with Dr. Ravi Harji Prasad for the listeners is episode will be airing out a couple of weeks here. But also just talking about psychiatry and like one of the questions I have is about over diagnosing versus under diagnosing mental health. From my experience, I feel like I'm seeing a schism of personal bias, you know, determining the type of prescription that they're going to give. So for instance, for me, I lean more towards like yes, I do believe in mental health, but I think we're almost over diagnosing it to everybody. And I don't believe that certain stressors should be so easily given to prescribe X, Y, Z, but rather learn how to code, rather learn how to just kind of deal with those things. And then some people who may have seen depression in their family or things are very quick to give the medication even when somebody might not be experiencing the true criteria of depression or something. And so getting into that nuance is definitely something I'm really interested in learning about in that upcoming episode. Yeah, that's particularly interesting because I was having conversation with some close friends about, you know, diagnoses such as, you know, distracted stuff, ADHD. That it that again has a stigma and then again, is it over diagnoses, under diagnoses is a very complex and nuanced diagnosis, especially in a world where anxiety is an all-time high. And I always tell them it's so hard to tease out between under or untreated anxiety and then actually disorder thinking and, you know, symptoms of ADHD, which are like ADHD-like symptoms. And so that's very, very hard to tease out. The problem also becomes sometimes, and I saw this on my med petriotations is, it's actual children and adolescents would get diagnosed with that. And then nobody would ever re-evaluate if that's still a concern. And this kind of applies to things such as such as depression, right? So somebody has anxiety because they've been grieving because they've lost a loved one. They've gotten somebody sick. You both have had people in our lives where you might be feeling a certain way and you might get on a pharmacological agent because you've gotten that brief diagnosis, right? Not just adjustment disorder, but an actual diagnosis. In five years from now, do you still have that, right? You're not the same man or you're not the same woman, right? So we should be re-evaluating this constantly. We talked to Isaac Sol recently about re-evaluating our beliefs, but we should also be re-evaluating our diagnosis to see if they apply. And so that's also something to think about as well, and it gets really, really tricky with mental health stuff, right? Because if you say, oh, this person still has anxiety and depression, and if you say no, then they're like, oh, well, you're dismissing that. And so I think it's a really fine line that we have to, like, no, we're not dismissing that. We're not pooping it at the same time, sometimes that's not the case. Sometimes people use it as a crutch too. So I'm also excited for that conversation because I think he's going to give it a lot more color, and I think that'll be educational for us both. I want to jump to the next one, and I'll talk about health tech innovations. I'm taking the health tech stuff, and I think about some of the recent things that you've had, and what's super fresh and how to date this is, I think, a recently Elon Musk talked about. Neuralink has actually implanted the first chip, right? And so this is how to off the press. And so we're going to see, we did a whole episode on this, and so we'll link that for people who can go listen to our thoughts on that. But I think those types of technological advances, and this, you know, interface with artificial intelligence and machine learning, and I encourage people to also listen to our discussion with Joe Bhakti, and you learn a little bit more about what deep learning is, and healthcare delivery and diagnostics and treatment. And so that's something that I'm super excited about. I think on a daily basis, something new comes out, something innovative comes out, and I think as clinicians on the front lines, it's something to keep a pulse on. Awesome. I like it. Very cool. All right. I guess I'll finish it up here. So keeping on the front of medical technologies, you haven't got a chance to watch, you are what you eat, right? That new documentary on Netflix talking about plant-based, the twin study, yada yada. But in that, they actually have a company called Dexafit, and they actually take Dexaf measurements of the participants in the study. And so with the onslaught of health and wellness podcasts that are out there now, and so many people talking about the predictors of health span and lifespan, right? We know VO2 max, Peter Tia talks about all the time from an aerobic standpoint, is such a huge predictor of our health span. But also the combination of body fat, visceral fat, which we'll touch on a little later in this episode, as well as muscle mass and grip strength. Those are also big predictors. And so what I think is that, again, they're going to be more facilities, man, I'm like on my real estate right now, to be more and more facilities popping up that are now measuring these things. So for instance, for Dexafit, there's a company called Dexafit, right? Think about like $100 to $200, you can get a Dexaf scan. And so people getting that twice a year, just to see how they can change their body composition through their lifestyle. Another thing, or exercise physiologists, I think, are going to be back on the forefront, really doing VO2 tests, looking at zone two, looking at people's true measurements, similar to how we're using Morpheus and how we're using Woop and Aura Ring and Apple Watches. I think people are legitimately going to go to these clinics and get that testing done. And again, one of our future guests, Sherven Shake, he has a whole YouTube on testing out different wearables, different technologies, going to these exercise facilities and actually getting his zone two tested and doing cool different tips and tricks that he's learned to really see how he can improve his own health. So I only see more of these facilities fluttershink in the upcoming year and more and more people really looking into it. And unfortunately, there's no Dexafit in Tampa, so I'm going to have to find something around there, Orlando's the closest one. See, I'm already looking into these things. Once you can really afford these things, I think they're really great tools. Well you could get one before you go. There is one in Philadelphia. There is one in Philly. Yes. I just don't know when I'm going to make it back there. So. Yeah. That's fair. Yeah. You can make it an animal. You can be a snow bird. Come and get your Dexafit scan and go back. That's true. You can do that. You can do that. Yeah. Although actually snow bird, you'd be going down there. Yeah, the other way. Yeah. Reverse migration. Yeah. Yeah. The concept of net health, right? That is something that I think has sent to the podcast from John Barney recently on Legendary Life. Just people track their net worth, so track them their net health. And so is there an animal thing I'm thinking about making an animal thing, is it semi animal thing what you're talking about? Is that something that people are also getting super invested in? So that's cool. Amen. Let's, let's wrap this up by, you know, those who are pretty much all done with us at this point can tune out because the last thing we're going to do is we're going to talk about some two, two cool studies, but really one that's been getting a lot of lime lightly. And I encourage you guys to stick around because I do think this is something worth talking about. This is a very cool study, something that is trying to break the conventional thinking that we've had, or beliefs that we've held for such a long time and any time that comes out, everybody gets super excited, especially because this is the one that disprove a belief that's been held for, I don't know, decades, eons, if you roll. And so this is a study that was published, I think, in cell or cell, one of the cell variants. Cell reports medicine. And I think it's published either in December of 2023, so at the very end of last year. And ultimately, what they were trying to, to see, I forget what the title of the paper is, do you remember? I don't, but utilization or maximizing protein. Yeah, basically, essentially what they're trying to look at, right? So I'll just give it back on to people, right? So I think for a long time, there's been this belief, anybody who's done training that your body can only absorb a certain amount of protein. Or really, it's not the absorption piece of it, it's really that you can utilize for muscle protein synthesis. And that's the name of the game, right? Taking the protein, anytime you ingest protein into your body, there's a couple of things you could do, right? So protein gets ingested, it goes down into your GI tract, right? And it gets broken down into amino acids, which are just building blocks of protein. And that goes into your blood and then up into your proteins and there's uptake with that. And then that is utilized into making muscle protein. And the muscle protein synthesis is the key. And so for a long time, people have said, okay, look, that, that upper end limit for you to be able to use that protein for building blocks is going to be anywhere in the range of 30, maybe 40 in some of the studies and, you know, 50th at a very, very top end, assuming that you're not using any performance enhancing tools, right? So you're, you're drug free to be able to do that because we know people who are not drug free, they have a different, completely different system in terms of physiology, how they incorporate that. So that's been the belief and with that, the suggestion has been, okay, you should space out your protein for quite some time. So these guys, they said that, all right, well, that's not really how any other animal lives, right? They're going to feast and then, you know, fast for a while. And so like, if that's the case, then why are lions and tigers and all these other animals like how are they surviving, driving and snakes, right? I hate snakes. But why are they thriving? And so they're trying to, you know, dispel this notion that there is the upper end limit of absorption in muscle protein synthesis. And so with that, do you do care to kind of, you know, highlight with the study kind of tested? Yeah, sure thing. And I don't know if you mentioned about the oxidation, right, about the wasting. So the thought is, if you're getting over these 40 grams, let's say you get 60, or are you wasting these 20 grams of protein to oxidation, you know, was it worth the calories even, you know, if we're thinking about, you know, going ahead. But yeah, let's get to the study. So they took 36 healthy individuals ages 18 to 40. And essentially, they had three different protein shakes that they were testing after exercise. So one of them had 100 grams of protein, second one had 25 grams of protein, and the third one was a placebo with zero grams of protein. And so essentially, after giving these, they would take a bunch of blood samples and measuring different things, right? So they're looking at the absorption rate. They're looking at plasma concentration of this protein. And you might be asked, well, how are they measuring these things, right? So they actually use an isotope. They have a marker on this specific protein so that they can trace it essentially through the body to see, is it getting peed out? Is it getting pooped out? Is it going to the muscle? Where is it exactly? And so they pretty much use the 12 hour window here of measuring the protein at all these various different sites. And they use bovine milk. And this is going to be important, right? Because a lot of you may have heard about Casey or Wei, and there's different types of protein out there. But essentially, what they found was that in those 12 hours, taking that 100 grams of protein actually had very high in elevated concentrations and protein going into the muscle with very little waste, more so than the 25 grams of protein. And they still saw good results with the 25 grams of protein after working out. But again, much better with the 100 grams of protein, which to many was surprising, right? As ultimately I alluded to, the thought was you can only have maybe 30 to 40 grams in a sitting. And the rest, we would assume those 60 grams would get oxidized. Maybe about 4 percent, I believe, of the amino acids and that 100 grams were actually oxidized or wasted. So not much at all. Do you want to talk about kind of, yeah, go ahead. Yeah, no. So ultimately what they concluded from this were that, hey, there's a dose response to the protein amino acid, you know, and there's really no upper end limit of absorption and muscle protein synthesis. And I think that there are a couple of key things that stood out to me immediately as I saw it. Because that's what I'll do. I could have granted the figures and then I'll go back and I'll look at the methods and go from there. And they're actually, by the way, for the record, you know, for paper that's this nerdy and this in depth, the figures are phenomenal. So I encourage you to watch it just because I think that a great job putting those together as somebody who is trying to publish on a routine basis that's very hard to do to make them pretty. So I think that's super helpful. And that's kind of what their key takeaway was. And so a lot of people, I actually first saw this in flight and on social media somewhere on Instagram. They were like, oh, great. Look, this new study says that you can really have up to 100 grams and really have no, so try to get as much as possible or try to get just focus on your daily protein intake and don't, you know, go too crazy about in one sitting. I think it's a good message, but there's a little bit of nuance to this and it doesn't really support the author's conclusion, at least what their methods show. And the key point, one of the key points that you made in terms of the type of protein they use, right? And so people who've been in the bodybuilding fitness room for a long time know the difference between way and casing, that's the very basic. You can take it further beyond that, right? And you have, you know, different types of way proteins that are right, concentrate to isolates and you have hydrocellates and all that kind of stuff as well. And the idea was like, okay, this is going to have 30 minutes of absorption and two hours of version. And while we're talking about absorption and then this antibiotic window, so to speak, I also encourage people to go back and listen to what Dr. Sean Arndt had to say way back when. Absolutely. Or something. Yeah, before I think it probably was and so we'll link that. And so with that, I think it's important to understand that, you know, milk is about 80% casing protein and cases that slow absorb protein. So in the bodybuilding world, they'll recommend this is something you should be taken before bedtime. So you stay quote unquote, anabolic throughout the night. And so yes, you had this, there's a nice little graph that shows absorption over 12 hours, which is constantly uptake for the, for the milk protein over the, in the hundred gram group, excuse me. But it might be absorption spread out over 12 hours rather than just within the first to hour. So I'd be curious. You know, my first thought was what does a hundred gram of way look like just way, right? Do you end up oxidizing a lot more? We don't know the answer to that question, right? We don't know if there is the upper end limit of just way, way. So it's more of a protein distribution and Peter Tia had a really good piece of what we were talking about offline about this that explains this. It's more protein distributed over 12 hours, rather than a spike and having a true test of upper end limit of muscle protein synthesis. And so that's, that's not what they showed. That being said though, like there are some important key takeaways from me and some recommendations that I would make for people, which this study didn't change. This study just confirmed. So I'm curious if you have anything else to add before I make that. No, I was actually going to talk about my takeaways too. I think you know, Peter Tia talks about how there have been some way studies, obviously not, not up to the hundred grams, maybe 40 and 70 grams, Brad Schoenfeld and Alan Ergon. I've kind of done these studies, but I believe with the way have showed, hey, there's probably like a 30, 40 gram maximum there because of, like you said, the quick absorption and quickly in those two hours really just go into the muscle, but. And that can be modulated too, right? So a couple of things. I talked about if you're taking drugs, your upper end limit is way higher than it is for somebody. The other thing is trained individuals, right? So trained individuals and untrained individuals can really, really matter. So you know, the more you train the more efficient your pro, your muscles are for, for exhibiting that process of muscle protein synthesis, the better you'll be able to, and then there's individual variability as well, right? So typically the general rule is recommendations are anywhere from 30 to 50, but there's no hard cutoff, right? And so I would say, you know, in the context of life, how does this really matter? I think that's ultimately what the bottom line is, do we, do we stop or do we just try to eat it in one big bowl list? And they also picked 100 because they were like, that's, that's probably what a reasonable sitting somebody can eat it in my first time was like, I can do more than a hundred grams of protein. Yeah. But let me. So lots of things. Yeah. Go ahead. I was going to say, let me give my recommendations because you're more an expert on this than I am. So I'd love to hear kind of your feedback and what, how you would change things. And so this is, I see it in three different levels, right, depending on your level of comfort and knowledge on the subject, you already mentioned bodybuilders. I think this study for them is like amazing, right, because it really provides more nuance. And now they can actually go into their workouts, go into their actual timings. I mean, this is all they're doing 24, seven. So they can really now have time certain, certain things, right? So this paper to them is like of the utmost importance, I feel. Level two is probably like us, right, people who are fitness junkies, understand most of this stuff. But at the same time, or not like counting every single second of every single day. But for me, how it's changed is post workout. I'm definitely getting at least 50 grams of way, let's say, but also of solid food, right? Because absorption now, I'm thinking more about absorption rather than just thinking about, oh, let me just get liquid protein in me. So how can I maybe after workout get 70 grams of protein? So for me, that's like four eggs, a protein bar, and like a Greek yogurt. And having that mix of solid foods plus way, I'm now really hitting that peak, but also maybe saturating it for, let's say, six, seven, eight hours. Now I'm also thinking, wait, maybe I should add casing to at night, you know, we know where we wake up first thing, you're kind of in a catabolic state. That's why I recommend heavy protein at that time. But would that at least help me build more muscle overnight? Right now I've been taking way at night time, but is it worth it making that switch? And the third category, you know, a lot of the general population, which is just, just get your protein in it, right? Like don't worry about as much of the numbers and, well, not the numbers, but the timing of things. At least obviously break it down throughout the day because I think that's the easiest doing it during breakfast, having protein, pre or post workout, and then having some protein during dinner. I think getting those numbers off would be the biggest thing for most people listening to this. I think that's solid advice. I love that. I think about, it's so funny back in 2009, when I took Microsoft Physiology class and Sean arts class, and he, at the time, was talking about chocolate milk for post workout for athletes. It's like chocolate milk, can't be it, can't be it. And I was like, that's so silly, it's so simple, but it's so silly. And here we are in 2024, talking about how milk, which is a combination, is this study is giving us, it's so good, right? And so it's so funny, because chocolate milk, what's obviously, you know, in the post workout window, particularly you want to add more carbohydrates as well. So we typically would recommend a ratio somewhere, depending on what your goals are and what your body type is, and also your workout, how hard you train anywhere from a two to one to a four to one ratio, maybe a one to one ratio, depending on your physique goals. And what that means is carbohydrates to protein ratio. So chocolate milk obviously adds more carbohydrate, right? And so in the post workout, a really peri workout window, when you have a high response of these catabolic hormones, and then your absolute afterwards going to have a high insulin response, you want to use the insulin genic substances to, you know, push that protein into the actual muscle tissue, and then it can maximize muscle protein synthesis. So this is something we've known such a long time, and so, you know, I'm curious what Arn has to say about this, but yeah, it still holds true, right? And again, yeah, I think that I would kind of go backwards, and I think if somebody came to me and asked me, hey, what do you think about that? I would say, okay, rule number one is, let's just, let's just get our protein in for the day. So what are that targeted? For me, it's about 200 to 215 grams per day, like that's rule number one, what's important to me? So really, I like to spread that in four increments of 50, if I can, but that doesn't always work great, depending on work, and training, and sleep, and that kind of stuff. And so I don't get too excited about that. I've already, with my story of talking about how a combination of proteins are likely best, because even if you have one or two times where you end up getting a little bit more and you get a little bit less, if you have a little bit casing throughout the day, you're going to have absorption spread out, right? And then you also highlight something else really cool about, you know, liquid protein versus taking it with foods. And so again, we know that foods are going to slow it down and then depending on the type of food that you get, like if you have a fatty meal or more fats, that's going to slow it under the absorption. If you have more fibrous meals, it's going to slow it under the absorption as well. So those are other ways to modulate that. Do I think people should be thinking about that stuff? Absolutely no. Right? Absolutely not. I think when we get to that high level athlete, then these are the conversations that we have. We're talking about chocolate milk post workout, right? You don't want to be having two scoops of peanut butter post workout and then like a glass of milk. Like I'm not really sure that's the optimal thing. That being said though, again, refer back to the episode with Dr. Art where we talked about being more of a garage door and not a window, right? So that's also something to think about. And so there's a lot of a lot of a lot of details that we can dive into, but they've they matter for very few people. So this is if some people might see this and start majoring in the minor type situation and that might be it. And I don't I hope that's not what that is. I hope this is just like cool for the nerd like us and we're like, oh, this is fascinating and we can just the figures, but I hope people don't share their practices and as long as they're getting the daily protein intake, which is probably the most important thing. And then if you've already met that, then you can spread that out. Then I would say, you know, if you have those two things dialed in, then you're already in the top five percent probably at that point. And then we can get talk about the sexy stuff afterwards. Yeah, it's funny. After reading this paper, I think post workout, I've been averaging at least like 70, 75 grams pro tea right after that. That first being a post workout meal. Yeah. Chocolate milkman. That's quick. Nothing beats it. That's quick. Bon Vita, bro. Well, we we're we're coming up in 45 minutes, so I don't want to take up too much time, but I do want to share this for any of my trainees listening, particularly as physiatry colleagues or even for you, because I think this is something I recently heard on a podcast and I thought it was fascinating. And this is a paper published in 2020, and I forget who the first author was, but I think the title was something of and we'll find and we'll link both of these. It was a visual audit at a positive is associated with pain, but not osteoarthritis, which I thought was super cool, right? Because we both of us treat patients in acute pain and chronic pain and we know that knee osteoarthritis is the leading cause of disability worldwide at this point, right, particularly even more so than back pain, I think depending on stats that you look at. And so I thought that was really interesting and you know, this is not the first study that came across because I think when we think about osteoarthritis, particularly knee osteoarthritis, we know that for every extra pound that you carry, it's anywhere depending on how you're moving anywhere from four extra pounds underneath to seven extra pounds and we're going to talk to Dr. Arvian Davis about this in the very near future in terms of how we transmit four extra pounds and how extra load will often tell patients, I'll often tell patients, okay, like especially carrying adipose, it's like carrying a backpack that puts extra loads onto your joints, that's going to be problematic. Well, that's the theory that we've always had and we've told people, hey, if you lose weight, you have less load, therefore you're going to feel better, you're going to have less pain. And this kind of laughs in the face of that, okay, maybe it doesn't laugh, this is a little bit of pressure work, but this kind of tries to dispel that notion as well by saying that actually a visceral adipose in terms of how it functions as an endocrine organ may be more related rather than the external load, am I making sense so far? Yeah, yeah. So what was cool about that is like this was an observational study for roughly three people and they use the database of like most, which is like the multi center osteoarthritis something study and they essentially what they did is they got baseline dexascans to quantify like what their, you know, body masses and then they got also baseline measurements of x-rays and other imaging to look at the knee and grade, you know, radiographically grade osteoarthritis and they would check them at 30 months, 60 months and then also have pain skills during that time. And the average BMI was not high, right? So this is an elderly population, middle age to elderly population as well. I think 50 to like 65 or 70 if you get the exact numbers, but the average BMI is really 30.5 in the study and what was interesting was that they found that total and visceral fat content but not subcutaneous fat content was positively correlated with worsening knee pain and widespread musculoskeletal pain and the amount of visceral fat that we had was also associated with number of painful joints and that was a positive correlation throughout. This is despite like the same loading force as what you're saying, right? So essentially you'd have the same weight, but the one with visceral adiposity is going to get more joint pain rather than somebody with the same weight with just subcure muscle. Right. Gotcha. Yeah. Right. So that suggests maybe that's not a load bearing issue. It's not a mechanical issue necessarily onto the joints. Right. Now again, observational study, right? So this is correlation, right? We're not talking about causes necessarily. And so that that's one suggestion. And so again, that theoretical mechanisms is not a new concept. This has been studied for the last 20 years actually because there were other studies about this as well. Right. So, you know, the inflammatory cytokines, you have a high level of CRP, right? CRP is inflammatory markers that we know can contribute to that. So these are acute phase reactants. We've talked about that in multiple different domains with, you know, Bill Cromwell, you know, about heart and that kind of stuff as well. And so also with musculoskeletal stuff, right? So you have those things that are going to be high. So high amounts of adipokines also release, which can contribute to pain as well. And interestingly, there's something that I had never heard about an adipokine called this fatten name, a very appropriate. It's been associated with several musculoskeletal pains as well. So this, this is something that, you know, they had linked to a paper in the, you know, journal clinical medicine. So it's a pretty rigorous journal talking about how this fatten adipokine is associated with osteoarthritis and osteoporosis. And they have shared risk factors. And so again, only released by visceral fat as far as I'm aware. And so some of these unique, you know, cytokines that they end up releasing can be pathologic in that sense and how they cause pain and also increase pain sensitivity. So not just contributing to pain, but also pain sensitivity. So in those chronic pain instances, when people have quote, quote, quote, fiber myalgia, right, not just missing a diagnosis or these centralized pain syndrome. So go back to Patrick Feynman. I'm just throwing out names left and right. We listened to that episode. So, you know, we think about, okay, well, why are these people have such an amplified pain response? Well, okay, well, maybe that's something to think about. So very interesting, not practicing in any sense whatsoever, but something that I have been thinking a lot about, right? So one of the things that we like to think about, we would like to say that nutrition plays a significant role in X, Y, and Z and everything. Goes back to our bias, right? of being like health conscious individuals. But we don't have as far as I'm aware, we don't have any good data that show that you're weight and your, your, your nutritional quality and quantity affects your interpretation of pain, right? We have observational studies. We have court, it's really hard to control for. And it's something that I was looking to do. In fact, that I wanted to work with somebody that we know who's been a guest on here. I won't share that in case it does happen to implement a specific type of nutritional eating pattern to see if that affects people's chronic pain perception and whatnot. It's just hard to to conduct because people who are in debilitating pain, you know, they don't necessarily want to do that for that reason. And we know that behavior change is very hard. And there are other layers to it that we have to try to peel through. And so I thought this was very, very cool. Something that I need to be more mindful of. I'm not really sure how I'm going to implement this into practice other than just encouraging people to be more healthy. But something to think about, again, for that one percent of people who are super interested in where we can get DexA, we can get MRIs to check the visceral you know, quantity and quantify subcum versus visceral adipose. Some of them think about. Yeah, no exactly what I was going to say. Dexascans people. And having I think patients understand this paper the way you explained it and then taking ownership and being like, okay, yeah, I do want to know my visceral fat and I do want to reduce that and having that number to track and make those lifestyle changes, you know, definitely I think this is moving the right direction. So, you know, it's a very, very cool study. The other reason I want to just highlight this and then that excited me about this is this is like one of the first times I came on my radar from my specialty or our specialty in musculoskeletal via visceral adipose contributes to that, right? We know pretty clearly at this point in people who are, you know, more tuned with their health at visceral adipose, how it functions and endocrine hormone for diabetes is so it's pretty strongly correlated with diabetes, if not causative, as well as heart disease. We've talked about this multiple guests in the past. So not many people will question that at this point, but this is interesting to say that it's also going to be musculoskeletal issues, which is something you and I do on a daily basis. So maybe we should pin this and talk about it with our patients in the near future. Are you especially when you're doing your telehealth practice? 100% maybe that'll help. Yeah, loving it. Thanks for sharing. Cool. Alright, I think that wraps up this progress note 15. If you guys have any questions, we'll link everything all the episodes, all the articles, whatever we find that we've talked about as much as we mentioned in the show notes. So be sure to click on that. Alright, we'll see you next time. And there you have it folks. Thank you so much for tuning in to another episode of Medicine Redefined. If anything that we talked about in today's episode really peaks your curiosity and you want to delve further into it, be sure to check out the show notes. We have hyperlinked all of the resources, all the podcasts that we mentioned as well as the research articles. If you enjoy this episode, please consider sharing it with a loved one, share it with your friends and family. And also, please leave a rating and review. It goes a long way to helping our algorithm out. I want to thank our team, Herita Yapuri for social media, Ethan Jew for video, Zaynablegmani for research, and Sarah Khan for our upcoming newsletter. That's right. We have a newsletter that is about to roll out. So please be sure to go to Medicine Redefined.com so you can input your name and your email so you can stay up to date with that. And as always, our disclaimer, everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient, laser, informed, and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal position regarding any specific health related issues. Take care.