32. Lessons Learned: Mario Novo, DPT and Amy Shah, MD

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. All right, what's up everyone? We are back with another lessons learned, two guests, three episodes, it's kind of a trend of ours lately. We've always been having some guests coming in with a lot of in-depth information on this time. It was Mario Novo, physical therapist talking about blood flow restriction, so in-depth, very in-depth episodes, but nonetheless, awesome, because we beat Peter Atia to it. That's our, that's a takeaway right there, we're on the forefront of medicine. Yeah, I don't really think he gives a shit, but it was fun, man, you know, I came into it I think having a good understanding of BFR and also have applied it to my own practice and also personally to my own training, as you know, but information packed, extremely dense, so I do apologize for those of you who listen and maybe didn't have a great understanding of it. I certainly think if there is one or two episodes that we've had that is worth maybe listening to it in another time or maybe even more than two times, it's this, you know, Mario kind of just the exemplary professor. So it was really awesome, and I even went back, I had to listen to it kind of to understand some of the biochemistry and kind of going back to undergrad, you know, dropping the Krebs cycle, something that you want to put so far back in your brain that we don't use on a day-to-day basis, but I think it's super understand. I mean, you and I both know that, understand that mechanisms of action is the first step when it comes to therapeutic application, but, you know, because they're still people, I think actually earlier today, I was having a discussion with some of the teams, I think listening professionals, and they were talking about how there's maybe a new study. I didn't get to ask which study they're referring to that maybe shows that BFR isn't great for preventing atrophy. I haven't been able to find that on PubMed, but I think it's, it's, it's really important to kind of understand the mechanisms behind why things are happening, and then you can start applying into more robust data, more clinical data. And lucky for us, we've got tremendous amount of level one data for the systematic reused meta-analyses. I'm going to mask control trials. You name it. Absolutely. Yeah. And, you know, and the reason I bring up Peter at T2 is because for the folks out there who listen to him, you know if he's talking about something, it's got to be on the forefront, right? Like, this is something that we know, just talk to Mario, who says in Japan and in East Asia, this is something, blood clover restriction that they're applying to in the regular gyms. Now, bring it over here. Go ahead. No, you know what? No, go ahead. Finish with that. I'll say that. Okay. All right. But bring it here to the States, at least, you know, and making an ICD-10 code and really using it for rehab, whether it's for injuries, or just also kind of just a science behind it. And I agree with you in the sense that I think our listeners, you know, if they listen to this, maybe get lost in the weeds, it might be a good opportunity to look at Mario Novo, kind of see his talks, go on YouTube, understand blood clover restriction, maybe like a general sense, and then kind of come back to these episodes because, yeah, there's a lot of biochemistry and, you know, from from my functional medicine mentor, he's the one who always tells me that, you know, it's all about biochemistry, right? Before you apply anything and understanding lifestyle medicine, especially. So for those of you nerds out there, and this was an awesome episode, kind of just going into the biochem endocrine, muscle physiology, vascular physiology, you name it. Yeah. No, I love that. What I'm just going to say is I don't even know if it's at the forefront of kind of thing. This isn't as cutting edge, like as we talked about, you know, he talked about Sato as applied it from like the 1960s, and, you know, Mario did a phenomenal job in episode of one talking, kind of going through the history of how we kind of originated, of course, in Japan, but then you had the separate Marvel timeline, he referenced, which anytime you can refer Marvel in episode, it's automatically win, and you're a DC guy. But, you know, he had talked about how it was also happening. I think it was SAMC that he was talking about, right, and some of the limb salvage programs that they were using it. And so I think in the exercise science literature, it's been talked about quite a bit. Of course, he said, again, for lack of a better word, quote, unquote, the bodybuilding world had perverted it, right? I mean, people are you have been using tourniquet type therapy for a long time, particularly for musculoskeletal medicine, you know, augmenting the muscle physiology, that kind of stuff. I think that the more scientific approach to it is kind of what we're talking about. So, yeah, exactly. And particularly with the newer electronic devices that are, you know, whether it's a figmometer in it that's automatically built in, or if you're using a Doppler, to kind of make sure that you're using the right percentage of your limb occlusion pressure, or arterially occlusion pressure, I think that's somewhat novel. You know, at this point, having looked at it for quite a while now, just because, you know me. And I recently held out of everything before I start using it, even if I'm going to invest in something, and then after I invested in it, not only tinkering it with my own training, and of course, my coach helps with that, but also thinking about how hard we're using in our patients. I would say read quite a bit about it, and I would say it's really about now fine-tuning the protocols. Like what is the best thing that's going to work, and how can we continue augmenting about it? You don't know. We'll link the Peter T episode. I think that, forget who the guy was, Jeremy Sombra. Jeremy L. Sombra. Yeah. Yeah. Lockler Sombra. Exactly. From Oklahoma or Mississippi? Jeremy Lonicky. Right. Ole Miss. Yeah. Ole Miss. Yeah. And he's talking about a lot of his work in his lab. They're actually looking at stuff that's, you know, beyond the basics of, hey, you apply it on the proximal part of the limb, like upper arm. You know that, distally, in the biceps, triceps, forearm, muscles, hand, intrinsic, you're getting benefits there. But what about the proximal to that, right? And so, that's, I think, still stuff we're figuring out. What has been your experience with it? Because I mean, I haven't tried this, but is it like that excruciating pain, like, what kind of protocol have you been doing with it? So yeah, in terms of application, so I have, I don't use, I've used a device that has this thermometer built in, and so it's, it's kind of set in a, in a, it, I'm not really exactly sure the size behind of how it detects which are, are true occlusion pressure is, which is kind of, you know, from what Maria talked about. It didn't really make sense to me this, so I have to kind of talk to the, the, the folks who made it again and exactly figure out what that system worked like. But basically, you know, setting it up percentage, you know, so whether it says 30%, 40%, 50% for the arms, that's kind of what the, the literature supports for upper extremities and for lower extremities anywhere from, you know, 40 to 80% with respect to the question about pain. Yeah, I think for the upper extremity getting at 50% is something that I can tolerate just fine. That's actually where I do most of my training for the lower extremity, when I first try to do it 80%, that was, it's out of this world type of pain. Coming back to, you know, Jeremy L's discussion that they talked about, you know, what I learned from that was interesting is at least according to what he suggested that the literature doesn't support that higher pressures are necessarily better. You know, if you're in that 30, you know, 40 to 60, 40 to 80 range, you might get the same benefits if you're looking to enhance, you know, muscle size, if hypertrophy is cool, maybe even strength. He did mention that if vascularity is something that you're looking for and for, for different reasons, people, people might be interested in that, then you need to be on that upwards of 80%. But yeah, I mean, the higher the pressure, the more discomfort you're going to experience. And I think I'm also an individual who has some, you know, I got some, some bigger legs on them, some thick, full back legs. So, so my pressure for the lurch, I'm going to be a little bit higher too. Okay. Solid. And then are you, you guys are using this a guy singer? I know Penn State's, of course, Matt here has been using as well. I've been gotten a chance to kind of, you know, talk to him, explore it or kind of shadow. But yeah, we do, we use the, we use the Delphi system, which is kind of the goal standard right now. Again, and what I loved about Mary talking about, he emphasized safety first, like not once, not twice, not twice, like over and over again in all the different ways, which is important, right? And in terms of we're applying the, a new application, new therapeutic, you need to consider the contraindications and the safety and what can go wrong, particularly when it's thing like this that I can't believe you mentioned that people are putting that on their neck and head. It's amazing. But yeah, we're using the Delphi system. I actually look into the obviously putting costs aside. I don't like the idea of a tethered system, right? Like you're walking around with something and you basically, it's an IV poll, you put the thing on an IV poll and you're walking around. Oh, I realize that. Okay, it's not like that. Yeah. Cause it's like a, you're attached to the cuff and it's basically like, and so it could interfere with the type of exercise you're doing, but Jenny Owens, the guy who, I guess he's the founder and the creator of it, he's, you know, he's, he's big on research and that's what's cool about it. So they put a, they partner with a lot of different professional teams and, and also medical systems to kind of use that. Gotcha. Now, is there anything in the science that kind of wowed you? I think for me, it was the fact that, you know, when you do regular weight lifting and bodybuilding, you kind of see that strength gain first, right? And then you get the hypertrophy after, as he mentions, but in blood flow, it's actually kind of the opposite where this might be something great for bodybuilders, where you get that hypertrophy right away, right? And as he tipicals, that cell swelling or the pump, get a, get a cool Arnold accent that I don't have. Yeah. And then you start to see the strength afterwards. And that's something you've gone through, right? You've been, you're like a large polo now, went from a small to a large, that's right. That's right. I can't remember that. Yeah. I actually have. And you know what's interesting? Yeah, I have seen my, the strength curve coming later. And now what's interesting about that though, as we'll talk about the second half of this, this episode here, you know, stress has a lot to do with how you feel in terms of strength and your muscles feel, too. So I think that the, I've had a different type of strep as well. So I was actually wondering if some of the PRs that I'm hitting in terms of on my squats and deadlifts, not PRs for all-time lifetime PRs, but I was in the last five, five to six years. If that has something to do with that, or is it the BFR hard to say, you know, it's really hard to say. But yeah, size is something that I did notice pretty quickly. And I think he had mentioned typically what's the conventional model of thinking when it comes to the strength curve, you know, initially, the initial gain that you're going to have is going to be in the first four to six weeks, is going to be the neurological adaptations for just wrenching, which is why people talk about, hey, muscle memory, oh, muscle memory comes back and one can argue with muscles, like, what does that even mean? But, you know, again, we keep reference that, yeah, episode, so we got a link in the show notes. That guy, Jeremy, he actually, they actually discussed about how that dogma might not be correct. He's someone who challenges that, that maybe the neurological adaptations don't come first. Maybe it's size that comes first, but I do think in my personal experience and end of one, I would certainly say that, yeah, the muscle size, I may definitely experience a hypertrophy first, and I'm getting stronger, but it's hard to say, I don't know if the strength is because of the BFR, like I said. Yeah. I got to finish that episode. I've been gone fully through it, but it's definitely, definitely something that's cool to learn from. Absolutely. At least from a different perspective, kind of, a Mario in the sense that they're doing different research. Cool, man. I mean, this is kind of a tough episode of breakdown, just because there's so much, and you know, I would hate to, for our listeners too in terms of going into the science, because they can better hear it from Mario, from a lot better scientific perspective. Is there anything else that you kind of want to touch on, or? No, I think here, particularly really well. The one thing I'll say is, you know, I think we spent a lot of time looking at its applications in rehab, you know, of course, going from the most debilitated individuals when we talked about Limp's salvage programs, amputees, and that he talked about the genesis in that region, and then, of course, going to the orthopedic literature, when it's spent a lot of time looking at it from the performance benefit, but I would do want to emphasize that we also have good evidence to kind of support that. We've had previous guests come on here and talk about that, hey, like, you know, for ACL to have, it works really well, and for which is rehab in general works really well. In the geriatric population, you know, because you can't load their bones and joints and it's not like that, but you still want to, you know, again, sarcopenia is something that everybody experiences after the age of like 40, you know, unless you were detrained earlier in your life. So you want to fight that as much as possible. So that's where we're seeing a lot of evidence going to, you're not seeing a lot of people in the exercise, exercise, exercise, fizz lab, put this on. However, just in June of this year, in the American Journal of Sports Medicine, which is like the parent journal for sports medicine. There was an article that was published, it was a systematic review looking at the benefits of BFR and athletes. And essentially, basically what they did was they filtered through about like 200 papers, or maybe like 230 something papers, I'll, I'll, I'll, we'll link it. And they kind of narrowed it down to about 10 different papers and they found that seven of the studies, seven of the nine studies found a significant increase in strength associated with the use of BFR training as compared with controls, 50% or four to eight noted significant increases in muscle size, which again, we've talked about over and over again, associated with BFR training and three out of the four reported significant improvements in sports specific measurements in the groups that use BFR training. One thing to note though is that there was significant variability in inclusive cuff pressures across studies. And I think a lot of that has to do with the, the various systems that use. I think in epis, towards end, episode two, when Mary was talking about the various app, apparatus that are out in the market, I don't know, is that the right term? I don't know. The plural is apparatus. Yeah. Yeah. But they're different systems, right? You've got the single chamber, you've got double chamber. So I wonder because I know like at least for, for the system that he recommended the H plus or like the smart tool system, like they, like 150 millimeters of mercury pressure with them corresponds to like 350 for the BFR thing, right? Just because the system is a little bit different. So I think that, that can probably make it a little bit more challenging too. But yeah, it's just something to note. But as always, like if you're working with a qualified professional who understands this, there's nothing like experimenting with yourself and figuring out if it's right for you. Yeah, I think that's key, right? I think the, the beauty of all this research and these, you know, the podcast and things that are coming out about blood flow resurgence, that the nuance will start to, you know, focus in a little bit more on different groups and populations. So that's going to be awesome. And I just love the plural apparatus of apparatuses. So pretty much, there's out there. It's preparing for your selling day. All right. Shall we move on to the next episode? Let's do it, men. All right. Here's a quick message from our sponsor, Comp Health. There are a lot of podcasts out there, murder mysteries, breaking news. There's even a podcast about garden notes. And instead, you're here learning how to be the best version of yourself, smart move. Do you know what else is a smart move? Working a locom tenant assignment with Comp Health. Now I know what you're thinking. If you are a physician, you already have a job. That's the best part. You can work flexible locom assignments on the side for extra income, or you can work locom full time too. And to top it all off, locom's almost always pays more on average, just head to financialresidency.com for slash Comp Health, and see what locom's can do for you financially. And now back to the show. OK. So this one was with Dr. Amy Shah, no relation. Awesome. Awesome episode. Like I said in the beginning of it, I mean, she's grown so much on Instagram just by providing so much education as a lifestyle medicine doctor. What were your, what you kind of take away from that one? Inspiration. Honestly, in a word. She's really cool. She's got an awesome journey. And I think that one that a lot of people can relate to, right, that the story that I'm not sure if we got the full version of it when she kind of talks about just that realization that she had when she was running around and she had just become maybe she had become partner in practice. And she didn't want to miss a meeting, but she didn't want to be a bad parent and she was running it. She got that car accident. You know what's funny about that is there's always that one big moment, the near death experience, right? That kind of makes you, I don't know how bad her car accident was. But something like what the hell am I doing, right? Right. You know, you, you heard that from a lot of people, you never want to be on the side of it. Sometimes you just need a wake up call and she, she just maximized that opportunity, which was cool. Yeah, absolutely. I think, you know, all of us can relate in that sense that I think most of us in this culture are just trying to make it, right? Like we're trying to be successful in more than one thing. We're trying to prove it to other people whether it's our kids or spouses or family or parents or friends and sometimes we get lost in that and not realize that, hey, we're actually in it for us, right? And we need to, we need to really individualize what that means for each individual, right? And not trying to people please, which we kind of talk about in that episode, especially coming from South Asian community, right? I mean, that is what we're almost taught to do at a young age is respect your elders and people please. So we definitely kind of go into that a little bit and her journey. But I just, I love how she took that and then started. So she has a nutrition background from Cornell and one of the most important things that I've learned was that, you know, she grew up in India, I think for like her first five years of life. So she was always around Arieveda and kind of this traditional Indian medicine. And then when she went to Cornell, graduated, she kind of threw away that Arievedic Western, or sorry, Eastern thinking. But then she started to realize that she went down this wellness lifestyle medicine that a lot of those things helped true, a lot of things that her parents or grandparents were saying kind of helped true and she found a way to incorporate wellness back into conventional medicine, right? And really formed that blend, really take the science of what we know now, right? She talks about, um, dysregulation of the endocrine system, uh, quote unquote, adrenal fatigue, the HPA access, and then we get into circadian fasting. Yeah. Yeah. Now on the note of the adrenal fatigue thing, I think this is an important topic, right? I mean, because again, maybe, I don't know, maybe seven to 10, 15 or maybe forever, honestly. It's just kind of a rollercoaster. Things come in, things get hot, things go away, things come in, things get hot, um, or pinch, whichever one you want to talk about. Um, adrenal fatigue is kind of back now, particularly when high stress, everybody's in high alert, right? We talked about, yeah, there recently about this, um, I think she, when I asked her and she kind of clarified, which I'm glad she did, this isn't really an accepted medical diagnosis, right? And it's not something that can be quantified, um, objectively, as opposed to adrenal insufficiency, which is something that we can, right? We actually have data. We can look at that. You have objective findings on physical exam, you can, you can document that. Yeah. Most of the time when people are talking about adrenal fatigue or their proponents of it, what they'll say is they'll claim, and like it's a, it's a mild form of adrenal insufficiency, right, caused by chronic stress. And, you know, the theory behind is that your adrenal glands, they're unable to keep up with the pace and the demands of the perpetual fight of like go, go, go, go, go, kind of what you just talked about and that our current blood tests, according to this theory, aren't sensitive enough to detect the small decline of adrenal function, but your body is in, in, in you are. And maybe there's some truth to that. I think Dr. Shaw did touch on that that sometimes our testing is an advanced enough to figure that out. And that's just getting better and it's evolving. But at the same time, I do think that we have to be careful. She didn't mention it on our show, but she did mention it elsewhere. Sometimes, you know, when people will say this, they, they will pray on individuals who are stressed out because the fact of the matter is everybody else, but now so maybe over the last 18, 24 months, people are even more so and they don't feel right. Right. So if people are a qualified health professional and you tell them you don't feel right and for the first time somebody actually listens to you and says, Hey, listen, I know your lab findings are all okay, but I know you're not right because you have adrenal fatigue. I mean, I do feel bad for not that, you know what I mean? Absolutely. Because it's not necessarily a physiology all the time that's given up on you, right? It's like, it's also a mental and emotional component that we got to realize, right? People are view exhaust all the options and you actually work. See, this is why like, it makes me so angry that like, functional medicine is not board certified, right? It's not 100% backed. Like, there's so many people out there doing it right, but there's so many out there doing it wrong. That's why it gets such a bad rep and it just pisses me off so much and that's a perfect example. Perfect example is that people pray on you and because they don't take insurance, you know, there's no ICD-10 code for adrenal fatigue, so I can charge you whatever I want and tell you whatever I want. You know, so that's a big point you made out. Yeah, no. And, you know, I think that another thing it's important to understand actually was just red a piece from precision nutrition about this. They talked about, like, and there was a, I think I might have seen on Instagram first, they were talking about, do you have stress pod, right? And basically it was a, it's an awesome infographic, I'll find it and we'll link it in the notes here. Basically, it's actually a quiz. I think it's a stress perceived quiz. You take the quiz and then gives you information. First it defines what stress pod is, right? You know, when everything is hurting, right? You have more GI issues, common GI issues that we don't have at all. Your brain fog, you keep getting sick. We talked about this yesterday with one of our other guests. You're struggling with your weight. Maybe you're not in the mood for intimacy and you know, your workouts feel impossible because you're fatigued like that. These are signs and these might not be, like, you know, these might be hard to figure out, right? You have to kind of really step back and look at the big picture of this infographic school by PN because it talks about the certain factors that increase your risk of quote unquote stress pod and then also gives you actionable tips that you can do, right? Of course, you eliminate some strategies on how you can eliminate. You've got to keep a journal so you can continue tracking it and you can add new stress relieving activities. Things that we've talked about over and over, but this is really, really cool. And again, there isn't one test. As you guys will see in this awesome infographic, I'm actually looking at it right now, but it's a big picture of things like everything else in this show is that we always talk about. Right. I got to take a look at that. I follow PN. I don't think I came across that. So we'll definitely link it. Yeah. I got to take a look at that too. Yeah. Yeah, go for it. No, no, I was going to say what's cool about it is you kind of, it's just like a quick quiz that you take and it kind of gives you your stress score, you know, where you might be and how you're tolerating stress or how you're responding to stress, I should say, tolerating as well. Press resiliency. Yeah. Absolutely. So let's move on to kind of circadian biology, circadian fasting, you know, something that I still need to read. Sasha found his book. It's all the list. Like I swear, I was like, I need to get more to scientific reading and it's all the list. I'm going to do it. I'm going to do it. Hopefully by the end of the year. What's funny about it is I have been listening to Dr. Andrew Huberman a lot. I told you lately, and he does refer to him over and over again, because Dr. Huberman talks about this a lot actually. You know, he gives a lot of the strategies Dr. Shaw had talked about. You know, she primarily uses, you know, circadian fasting is her thing. I think that's kind of where she mentioned that when she first was talking about a lot of other things like sleep and exercise and everybody was like, yeah, yeah, we all know that. But what about this thing? Talk about this fasting. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. Right. I know I told you this offline. It's a tool. It's a tool like anything. It can be a powerful tool if used in the right person at the right time and the right context. Or it can be detrimental. And so I think that's really, really important for people to understand. But I just taken a back step just for those people who don't really know what circadian biology is, it's just kind of essentially talking about circadian rhythms, right, which are your natural internal process that's regulating your sleep and wake cycle. And for most people, it's under 24 hour sleep and wake cycle, Dr. Matthew Walker will say that some people are beyond that, even a little bit more. And this can be very responsive, right? It can be any process within organism. And according to Dr. Sachenpond, it's worked every single cell in your body has its own. And it responds to the environment, the external environment, which is something that we talked about, you know, we'll mention in a second. And that's what it kind of is, basically. Yeah, yeah, I found it super cool. Her talk about light kind of brought flashbacks to Rudy Nassib's episode, right? Where we talked about light and depth, kind of give us future glimpse into also like hydration, right? Like we, we'll, you guys will hear this soon in a couple of weeks of Tracy Dews, but talking about how water, right, is in every single cell and how the mechanism's effects of just talking about Sachenpond is work. Like, we literally, what we call the ultradient right at that point where it's like so nuanced. But yeah, I mean, you're so right about how intermittent fasting is literally just a tool, right? And I think some people take it to say, oh, intermittent fasting works, right? They've seen in general population the research, the data, it works. Therefore, I have to do it no matter what, regardless of how stressed I am. And that's what it is, right? It's a stress. It's another stressor and to your body. So I know people who wake up at 4 a.m. go for a workout, try to do intermittent fasting on top of it. And my question is why? Like, you're already waking up so early, we already know our cortisol, you know, kind of peaks. You're also waking up earlier than sunrise, right? And for those of you guys that want to understand the hormone balance and cortisol and all that, we can kind of talk about in the episode, but it's just so important to get in tune with your body and not necessarily be so complex with it, right? But even just understanding that, hey, at night, I need to kind of dim the lights down, right? I should try to support my body in terms of getting great deep sleep. And in the morning, I should kind of do the same thing in terms of getting bright light into me, getting some sort of movement, waking up my body, supporting that. And then when you can get that night and day, wake, sleep cycle together, wow, it does wonders for the rest of your day and weeks of calm. Yeah, absolutely. And kind of just furthering that point a little bit, it's funny because Peter Taylor really said in Dr. Andrew Huberman last week also released his massive episode about intermittent fasting and the effects of it and how to incorporate that into practice. If that's something that's right for you, and what he kind of ultimately settled on, time should eating is a better term for it, right? Is kind of eating between the hours of 10 a.m. to maybe 6 p.m. Because again, you know, and I asked after shot is it is really difficult. Like again, back in the day, people were like, okay, just attach it to your anchor, it to your sleep cycle, and so skip breakfast, eat at noon, right? Okay, that's fine. But now we're learning we want to eat in the light hours, right? We're learning more and our thought process evolving. So now we're like, okay, eat an early dinner, which is I think kind of what Dr. Arnhett said too. Yeah, but then it's like according to the way that we most people work and just the regular social dynamics of it, like most people like to sit home and enjoy dinner with their family. We know that one of the pillars of lifestyle medicine, according to Dr. Beth Freides, and not just her, but what social connectivity is a big one, particularly with something that we've experienced this past year, right? If that's your only time that you're with your whole family and having dinner and you're really connecting with something, like now you're going to give that out because you're fasting. Actually, Peter T. has talked about this time and time again, that he, I think maybe, not fasting, maybe with keto, he stopped doing keto because he was tired of explaining to his children and not being able to share their appropriate meals with them and like that, you know, so something important to understand. But ultimately, one thing that I've learned from all these folks is really cool is that, you know, we really do have to appreciate what our circadian rhythms are and try to optimize and use all these tools, exercise, light and food as the ways that we can modulate those. Dr. Huberman talks about this over and over again and Dr. Matthew Walker even has a new podcast about sleeping. The last couple of series is talking about people's chronotypes, which essentially is like, you know, whether you're a night owl or a morning lark and how different people have different chronotypes and he talk gives us some strategies, I think, in the most recent one of how you can potentially shift your evening bedtime, maybe a little bit further and stuff like that. There's no ideal way to do it. I think most of the literature will support most of the evidence that we have to this day showing that night shift workers and being up late into the evening is going to be determined into your health, which is why the World Health Organization has determined night shift work as a potential carcinogen or a risk for cancer. And that's a better way to say it. But yeah. Yeah, definitely. I mean, chronotypes are big, right? And I mean, there's not a lot of us that write night owls, but there are genetically some of us who are and we're all kind of stuck by whatever employers tell us to write if we're not entrepreneurs and we don't work for our own, then you're stuck in that nine to five. And it kind of works a lot of people's advantage if you choose to, but then it also doesn't. So yeah, it's a good point. His book was great, you know, talking about that as well. Yeah. Yeah. What else here? No, I think I think no, at this point, we're probably going to be redundant because if people do listen to it, you know, that these folks, these guests who are so incredibly knowledgeable and so incredibly awesome to just come and educate us and just offer some value to you guys as well. Go check those episodes out and please follow these guys on Instagram, on social media, on their podcast, you know, when they do have one because there is a lot of value to gain and, you know, we're all kind of working together in this community to optimize and it's funny. You talk about how Dr. Shaw with her background of being a South Asian and Southeast Asian and then, you know, kind of neglecting that but coming in and now incorporating that and conventional medicine, it's just like, it's literally exactly what you and I are doing. 100% man, I'm so glad I kind of asked her about like future health professionals. Like, what is your advice, right? Because to be honest, we're one of the few that are trying to, you know, think about lifestyle and like what actually works and not necessarily just being quote unquote brainwashed by the medical education system, but also trying to be open and what's out there, right? And her advice was, listen, if you have a passion, you have something that you really want to see, go for it. Like, don't necessarily just be stifled because your mentor or your attending will tell you, hey, that doesn't work or you can't do that. Go out, look at the data, see for yourself, you know, keep tracking, keep reading. There's so much out there that we're starting to learn that we once thought was wrong. So it's just, I think, you know, luckily lifestyle medicine and wellness is more and more on the come up. So that's always good to see. But this is exactly why we're doing it, right? And if it's funny, my wife told me, well, future wife kind of wife, I guess, it's a way to come up. Told me like, you know, she's like, you guys are medicine redefined, but it's not necessarily just redefining health, right? You guys are redefining the approach to health, right? With collaboration, she's like, never was there ever a time where doctors have the opportunity now or healthcare practitioners have the time to collaborate, right? And she's like, you guys are redefining that off this platform. And I was like, you know, like, you're absolutely right. I mean, this is why we do it. It's so that we can get different perspectives and go in with three-headed monster, four-headed monster, and approach these issues and kind of give it out there to the other healthcare professionals or the patients. That's what we need, man. I was telling my attending today that, you know, yeah, currently in the United States, I mean, we have 43% obesity rate and it's only climbing. If not, it's just not getting better. And so it's going to require everybody, every single one of us across different disciplines to get together and to combat chronic disease and obesity and all the things that are burning the healthcare system today. It's just not sustainable the way it is right now. So we're all doing it. And hopefully you guys are doing it with us. And, you know, if you guys are doing cool things, which I'm sure you are, then, you know, more power to you. And if you are able to share this episode with somebody who you think will benefit from it, then that would be something that I think would be, you know, we can ask that you're doing your part. We really appreciate that. And then, of course, as always, welcome any feedback and your recommendations you guys have. We're always ears. You can email us at medredefinededgeemo.com. And it's all a government. Yeah. And I'll add Spotify has this cool new feature where we can ask questions I think they can take polls. So we'll kind of, I'll try to test out some of those things. Maybe ask some questions for the listeners. Yeah, I was on anchor. So we'll test those out. I think we can do like question and we can give some answers based off whatever questions like viewers might have or something. So we might be able to incorporate that in some of the lessons learned. So we'll see. All right. All right. Next time, Daniel. All right. See. I just want to reiterate that all to much and I are super, super grateful for all the listeners out there that show up every single week and learn from us, but also help us grow from you guys subscribing to rating, reviewing and sharing these episodes. It's the reason why we do what we do. And like I said at the end of the episode, I mean, we really are trying to redefine medicine. So we really do appreciate that. If you have found this to be helpful, please go ahead, subscribe, share. And again, time for that quick 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 relationship is formed and anything discussed in this podcast does not represent the views of our listeners. We recommend that you see the guidance of your personal physician regarding any specific health related issues. And until next time, let us know if you have any questions. You can email us at medredefinedatgmail.com or find both of us on Instagram. Stay blessed.