58. Lessons Learned: Nicole Harkin & Alex Hajduczok

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 health care. Alright, what's up everyone? Back for another Lessons Learned Cardiology Series, Cardiovascular Series, going over these three episodes with two guests, Dr. Nicole Harkin and Dr. Alex Hadshuk. So let's start with the first episode, which was Nicole Harkin, so we talked about essentially Cardiovascular disease as a concept and also understanding it from a standpoint of the physiology, so I should say the pathophysiology as well as consumer tests that we should be looking at to assess risk for cardiovascular disease. And I know you would have been a cardiologist if you had a second profession, but I think right now that'd be a little tough. But tell us your thoughts. I really enjoyed it, I think it was really informative, I think partly because it kind of aligned with my biases from the research that I had done. And you know, I had some time to reflect since I had that discussion and actually went back and listened to it. As I had mentioned over the last couple of years, I've gotten more and more invested in this space, both for personal reasons, but also from an academic standpoint. I've probably, I think she's actually the fourth or fifth cardiologist and maybe the third lipidologist that I have a conversation and two have been kind of, okay, well, you know, APOB and these things are maybe advanced markers and we don't have the sciences and quite developed it. And other person said, oh no, I mean, this is very much so and there's a lot of nuance to it. And then with her, I think she kind of echoed that sentiment that there is nuance to it and there's a place for it. And then with some of the guidelines at least across the pond seem to agree with that sentiment as well. So that part obviously I enjoyed, but I think it really just kind of comes back to really what lens we're looking at the problem from, right? And I think that that's the case with anything when we do this whole like health issue. You know, she's looking at it from preventative standpoint and medicine largely isn't that all, which is our beef with a lot of it, of course. And I think that's why, you know, I always have to appreciate that as a still a novice in the field of medicine is when I'm having the discussion with these folks who have been doing it for 30, 40 years and they're definitely wiser than I am that we haven't been trained to prevent disease, prevent illness and prevent all these major adverse cardiovascular events that we talked a lot about. Yeah. For sure. You know, I'll add on to that. So I come from the standpoint of like I hated cardiology, like in med school, like I just never understood it. It was way too complex. I always thought about cardiology as just the heart and obviously, you know, this episode kind of opens your eyes to, wait, there's also a basketballer attached to that, right? Like blood flow. And I think the cool thing about cardiology for people who like really truly want to understand it, it's almost like, you know, I'm trying to get into F1 as of late, right? It's because there's huge boo about it, but it's also because there's been so in depth, there's so many different ways that you can look at it. And that's exactly what cardiology is. It's the how, right? It's the pathophysiology. It's the when, which is a huge discussion when we talk about preventive cardiology, the what, right? And we're doing what the heart, we're doing what blood vessel, we're doing what plaque, the who, you know, or their different populations, what's the genetics, and the why? Like why does this all matter in the end? And that's because obviously cardiovascular disease is the number one killer. So I think taking all those into consideration, it really makes sense, especially as us physicians when we look at our patients. And obviously from a rehab lens, I mean, which patient doesn't come through with cardiovascular disease. I mean, I'm always seeing high blood pressure, CAD, heart failure, you know, et cetera. So I think from that lens, for people who, I really urge people to go back and listen to this because it's going to change your perspective in terms of how cardiology probably should be looked at. And what it will probably probably be looked at in the near future. And for me, who on, I'll be all admitted, I haven't seen a physician a while ever since moving to Hershey. So I should probably get on that. But one of the things I need to test is APOB, right? And I was just listening to a Peter Tia podcast, like taking notes, and he talks about how APOB should just be like the one thing that everybody should frequently get. And his ceiling would be at a 60. So he's very aggressive when it comes to treating, you know, and he wants people to be let in the, in the fifth percentile or below. And he's thinking everybody in their 20s should be getting this test is how early you should start and actually when you should probably be treating. Now, I mean, you know, that's going to differ from provider to provider, obviously. But as we know, Peter Tia is one, somebody who really, really digs deep has a research team and loves talking about this stuff. But I think that's, that's kind of the perspective I came off, came with from the first episode. Yeah. And I think that's one that she mentioned several times that it's somewhat controversial. And to me, I'm not exactly, I mean, yes, the arguments have been made with some of them. We bought it right caused or not clearly being defined and whatnot, you know, how to target it. To this day, the standard lipid panel, right, checks LDL. What some people will say, we talked briefly about this non-HDL cholesterol tracks APOB pretty closely. And I mentioned some of the cardiologists who had talked to who were not really naysayers or dismissed the, the profound benefit of actually checking APOB. And their argument was, well, you can just really get non-HDL and that's a poor man's APOB. And to me, I don't really know why we need to get a poor man's APOB. If one, we can just get the APOB and two, like insurance will pay for it or I will pay for it. It's fine. That's a different discussion. The bigger point with that argument, though, is men. We also talked about how in a perfectly healthy person without any of the metabolic syndrome markers, which we touched on that a study came out a couple of years ago that like 88% Americans have that, maybe non-HDL is a good marker. And there's about a point nine correlation. But again, the key phrase there is perfectly healthy person, non, like no metabolic syndrome markers, right? And that, how often do we see that? You just mentioned people come in with actual heart disease and I would say if it's not that, it's risk factors, right? I think during the episode you talked about how almost every single person's had a stat. And that's either for, you know, like impaired treatment for, you know, cholesterol issues, lipid treatment, whatever it might be, which are risk factors for cardiovascular disease, or it's protective, right, for heart disease or stroke or whatnot. So I mean, I would say at least anecdotally greater than 95% of patients that I see both on the inpatient and outpatient setting are, you know, have some form, you know, either predisposition or actual heart disease for that. So why we wouldn't check something that's going to give us the best data and allow us to make the informed, most informed decisions, I think that's a little bit over my head. There were a couple of other things that we talked about as well, right? Well, actually, I'll pause there. No, I was going to say, go ahead, because I think my final thought was going to be this episode will give people the power, hopefully, to approach their doctors and get the test necessary or at least inquire, right, about these tests and have a great discussion. Yeah. And I think, so it was a two part series, right? And I asked this important question about how to actually approach our physician or providers or cardiologist and actually have the conversation about, hey, what are some of the important risk stratification markers, right? Whether it's LDL, LDL particle number, particle size, it's another one that we talked about some of the advanced lipid panels, it would be LP Little Lay, how critical that is as well, how the European guidelines recommended that every single person should have a check at least once in their lifetime. You're about a peterotia. He also suggests that this might be the most atherogenic particle. And I think he's not the only one who'll argue that. And the thing that there was a study that I remember coming across right before we talked about it, that up to 50% of urethic stenosis are, or LDL is responsible for up to 50% of urethic stenosis. So, and then we also have, you know, dvTs and thrombosis in that nature as well. So I think that there are a lot of different markers that people should be aware of for themselves. The caveat is going back to what are we going to do with the test, right? We talked about APOB is something that you can't target, just like we can target LDL. So I think that's, that's a no brainer, LDL particle number and particle size to my understanding, maybe a little more challenging in terms of using as, you know, targeted therapy towards those, but they're still important because coming back to that metabolic syndrome, you know, point, if somebody has that, the discordance tends to be higher between LDL particle number and LDLC costration, which is usually, you know, taken in a lipid panel. And in those individuals, the risk tracks closely to the particle number. So that's, that's something that every provider who's actually checking this, whether it's a PCP us in, in the rehab setting, needs to be covered up. And what does discord, it's actually mean for the people out there that say, huh, what is that? Yeah. That's a good question. Yeah. So, so, you know, if, if your LDLC is high, right, traditional LDL, and your LDL particle number is also high, that's concordance, right, if they're both high, not good, if they're both low, good, but if LDLC is high and LDL P is low, that's actually better than if LDL P is high and LDLC isn't, right? And so individuals who have some metabolic syndrome, particularly high triglycerides, they're going to have them going in opposite directions, which is basically what discordance is. And when you, they do go in opposite directions, LDL P is a number that you're more concerned about. And so that is really, really important to understand. So I think that, you know, fortunately, we don't do a lot of this. I'm not going to do a lot of this in sports medicine, but looking at person taking a step back and that 50,000 foot overview and looking at their lifestyle factors, I very well might order this test, and I think that this is the conversation that we're going to start having. And then, it's not a blanket statement. I'm not going to order it probably for every single person. But I think that, you know, when we're looking in front of, you know, if it is an individual with a hard BMI, you know, waste circumference ratio, like you talked about, or any of those other metabolic syndrome markers, then maybe one might be more valuable than the other. Yeah, for sure. Yeah. And I just think it was an awesome episode, Dr. Harkin, just, she knows the data, she knows her stuff, like she's not just talking as if, you know, from, from out of thin air. I mean, this is stuff that she's looked up at the research as any cardiologist would. Well, I should say that as hopefully most cardiologists should, but yeah, it's just a great episode overall. So how about what you want to transition to that second episode now, kind of talking about the interventions? Yeah, but before we do that, I think I do want to mention briefly that even though we spend a lot of time looking at objective markers for risk stratification, something that really should be emphasized is just history, history, history. Every medical student knows this, how important that is. And she talked about even before somebody comes to her, the intake process of how in depth she's going into personal medical history and family history, how important that is. I don't know. It's hard to say which one would be more important, but I think that's just as critical. So knowing your own medical history and your family history and really digging it back, I think that's also very, very important. So I don't want people to be like, okay, I want to go get the test done, but you haven't done research on your research. You have no idea, like if your mom has this or your dad has this, if there isn't even a premature history and your grandpa died before the HF50. So I would urge people to do that because that's much easier to do and you don't need a physician to do that. And that might give you a lot more information and you don't have to fight anybody to get that done. So that would be the little bit of advice, not medical advice, just advice. That's very true. We're talking about genetics there. And now the second episode I guess is talking about how to influence your epigenetics, so to speak, which is huge, and Dr. Harkin is a preventative cardiologist. That's her main practice now. And so she really delves into the lifestyle, medicine aspects, looking at those pillars, looking at the history, like you said, and trying to put better intervention out there for patients to stabilize, and not, you know, reversals great if it could happen. And we talked about this, but stabilization I think is what most people care about, right? Because we want to look at adverse events. And what we're trying to do is prevent another myocardial infarction from happening or preventing a stroke from happening, right? But if the plaque stabilizes and that's the result of it, then also we don't really care about the plaque receding so much. So I think that's like an important thing, right? Because when we talk about longevity and health span and lifestyle medicine, a lot of people are in this mindset of reverse, reverse, reverse, right? And I think that's just the society we live in. We want to gain more muscle and reverse the fat. We want to reverse aging. We want to reverse, you know, et cetera, et cetera. So I think that right there is just kind of an important fact that people need to take note of. Yeah. And, you know, that's really interesting that you bring that up. And I think you kind of alluded to this during the discussion with her as well. And I think I'm wondering why this is. I think partly it's because information is so readily accessible through social media, through Google, through everything like that. And people can read about procedures like, for instance, I had a patient come in and, you know, if she had bilateral carpal tunnel syndrome and I'm not a surgeon, but I recommended that it was point that she had a discussion with a surgeon to kind of get that addressed. And she started asking me in-depth questions about the surgery kept telling her, listen, I know this is how it's done, but it's not what I do. And she mentioned how she looked it up and this is what the post-operative course is supposed to be like and all that kind of stuff. And it's interesting because you could probably see a lot of these things on YouTube now. You can actually watch the procedures. And that might be the case when it comes to nutrition, of course, with cardiovascular research and all that stuff as well. And so people are maybe hyper focused on this aspect they're talking about, can I reverse my plaque? It's cool and all, but does it really matter if you feel like crap, like if you get short of breath while walking upstairs, like, you know, is your heart functioning well? I don't know. Maybe you reverse your plaque. And so I think she talked about this. She's like looking at quality of life is really, really important. And I wonder if 50 years ago before, did we have, you know, before we had all these things that are so readily accessible to us, if people didn't care about that. That's true. That's right. So maybe the outcome that we're looking at. Yeah, yeah, yeah, exactly. Yeah, yeah, absolutely for sure. Cool. So let's talk about some of the lifestyle interventions then. What are the ones that kind of got you excited that you learned something new about? Yeah, I think it was no surprise to me that she started to tackle with the nutrition thing. I think we took the lifestyle medicine approach and nutrition is the most polarizing. And again, I've been thinking about, if I had to pick one, right, that I would want to start like implementing. Of course, I know the right answer is it's really about what, you know, meeting the patient where they're at. Like, hey, if they're open to having the nutrition conversation versus exercise versus sleep or whatever intervention. Is this for cardiovascular disease? Why? To start one. For good question. For the lens. Yes, for cardiovascular disease specifically, right? I wonder if exercise might be an easier place to start. I know we talked a lot about plant-based diets, about how they are for lack of a better word, cardiovascular protective, if not definitely beneficial for long term heart health. But man, I think the more I do this, the more I have conversations with people, it's hard. It's very, very hard to do. I'm in the same boat, man. I would start with exercise because it's not everyone knows it's helpful for you. In some way, shape or form, it's going to be beneficial, right? But to get people to buy in to eating more plants or eating less processed food, the results just aren't immediate, right? And I think, again, we're talking about a society where if everything's at your fingertips, we're just gravitating towards quick remedies and keeping up with a diet that's helpful is tough, right? And that's why I guess I'm a fan of these objective markers because in a way, you can gamify it for patients and be like, all right, your EPUBs here, like let's try to target it next time to a lower end that the only ways you can do this are by X, Y and C, well, not only ways, but here are some ways that you can do that. And so I guess it gives patients a little bit more motivation. But in the end, man, I mean, nutrition is just, oh, man, that's tough. That's a tough thing definitely to talk to with patients, especially in the healthcare system we're in, right? I mean, if you have an hour and a half, awesome, you can probably start with that, which is what Dr. Hartkin probably does at times, right, because she has that time to do with her patients. Yeah. Yeah. Yeah. I think, you know, and we talked about exercise from an aerobic versus an aerobic perspective, right? Or strengthening versus cardiovascular exercise, but really about movement. And you and I have talked about just getting up, getting steps in and just walking how important that is. I actually came across the study. I was looking at an examiner earlier today and there was a study published in a sports med journal in February of this year, looking at the acute effects of interrupting prolonged sitting time and adults with after, you know, post-prondile and what that did to the post-prondile group. Oh, my God. Yeah. The glucose response. Thank you very much. And, you know, they compared essentially sitting for, you know, after you eat to just standing, sitting to just light intensity walking and a significant benefit, right, in terms of decreased glucose response. Of course, the question becomes, well, how high does your glucose get after? But I'm willing to bet it's not harmful in any sense, right? So I think that that's another important thing to keep in mind. It's just, you know, what's your need, right? Non-exercise activity thermogenesis throughout the day. How much are you moving? You know, there's the next guest that we're talking about, Alex referenced a study in BMJ. I think it was published last year. It was like meta-analysis, looking at just step count and overall cardiovascular health. And all calls mortality decreases, I think, anywhere from 10,000 to 16,000 steps a day, like down like 17 or 18% for all calls mortality. So it's just really about getting activity in through the day, you know? And so when I think about incorporating these interventions into lifestyle, rather than saying, okay, let's, I do like ECs and caskies, let's get more plants in a day, it's simple messes like that, but also let's move for two minutes after you eat something like that, you know? I feel like that's easier to buy in food to hard, man. There are so many emotions and psychological factors that are associated with what we put in our mouth. That's a little bit more challenging. And you know, just a dovetail on the movement aspect, I mean, this will have a huge fan of Kelly Starrett and what he puts out his content because he's always just talking about easy ways to incorporate movement, right, from a mobility standpoint, from just an exercise standpoint. And you know, for those of you guys that are new to this podcast, I mean, we've had him as a guest. He's probably in the episodes like somewhere in the 30s, I think. But you know, his, even he just put out an Instagram post, I think today, just talking about like his, you know, how he's sitting, just doing work on the ground and how he'll be like a 90 90. Yeah. He'll be in a 90 90 and then on his knees and then he'll be up on his toes and just moving his, you know, just different movement patterns. And like, even that just, sure, it might not consider as exercise or steps, but if it makes you feel better, it's going to have a chain reaction to at least make you, maybe feel better about yourself and then maybe go on that walk, maybe believe some pain, right? So it just starts from somewhere. Yeah, something that I remember Dean Somerset talking about a long time, maybe over a decade ago is rather than sitting on the couch, just sitting on the ground. If you're sitting on the ground or you're watching a movie, like you on the couch, you sit there in the same position for three hours and then be comfortable. But if you're sitting on the ground, like you are going to want to change positions multiple times because your bumps are hurting that ground pressure. So that I make it a point to do that as much as possible. Absolutely. Same. Crossbow, foam roll or like just use my, what do you call it, the, another, the, the high price. And just do something at night as if I'm watching TV or something, yeah, for sure. All right. So anything else from that part two, I mean, we touched on sleep. We did exercise nutrition. For me personally, I asked her about sauna because I just remember hearing like a bunch of podcasts being like, hey, the future of cardiovascular disease, like some of the therapy might actually be the sauna. And I don't know if you got to chance to listen to Rhonda Patrick's episode. I think it just came out maybe today or yesterday. She does a deep dive in terms of the sauna and like, I'm going home about it now. I mean, there's just a lot of good data that that shows a lot of benefits through sauna, especially if you do it at least four days a week from blood pressure to just the heat shock proteins and helping with longevity and just decreasing mortality, all cause mortality. So. Yeah. And I think at least that what I'm aware of most of the data though, something to keep in mind is what's coming from again, from the finished countries and from the European countries, right? And the second part is that it's really looking at dry sauna, which it's harder to to come by in terms of gyms than the infrared sauna and most people will end up extrapolating that information and say for infrared sauna, it needs to be much higher, like the 170, 180 degrees Fahrenheit, whereas dry sauna needs to be a lot lower. So again, with these research studies, when you're actually analyzing them, is the intervention a one to one? I don't know, but I do agree much like anything else, there is a ramp up period. You can't just jump into five days a week, 20 to 20 minutes a day because I think the doses, what do they recommend? You want to do 20 minutes, again, dry sauna, right? 20 minutes of a couple of times a week probably to get the benefit of your talking about the episode. But for what I can recall from previous listening, yeah, I think it's about 20 minutes at least. It's kind of where you get benefits. And I think there's a spectrum too. So like there's different physiological things that will have your body at 10, 20, 30, 40, you know, 60 and onwards, but yeah, I've been finished the episode yet. So, you know, well, the other thing about it, I think Peter T again did an AMA episode with Bob Kaplan back on the day looking at heat and cold therapy. And part of the conclusion they came to with that, it's a good mimetic for exercise. And maybe some of the benefits that are conveyed or because of that reason, because just getting your heart rate up to 140 degrees for sustained 15 minutes, it's going to give you a lot of good benefits. Yes. You're almost getting in that zone two range without really doing any, like, you know, not really short of breath, but yeah, absolutely. Sparing the joints. Yep. Yep. So yeah, for me, it's part of my morning routine, Elise Anna via my gym as a dry sauna, which has been nice. So, yeah. Cool. Nice. Awesome. What else? Anything else from that second episode? No, I just encourage people to definitely go back and listen to both of them. I think that Nicole does a, or it's just a Dr. Harkin, I apologize. She does a phenomenal job at really just highlighting and kind of giving us where the evidence is for, again, both the diagnostics portion in the first part of the discussion and then also at the intervention, you know, aspect and really giving us perspective and looking at the big picture. So I encourage you guys to go listen to that and you'll be much smarter for it. Absolutely. For sure. All right. Cool. He's my co-presidents from last year, Dr. Alex Hatichuk, who's made a, made a name for himself as a champion of whoop. He is someone who has done a lot of studies with wearables and kind of their relationships with not only in patients and just looking at different markers of cardiovascular disease, but also with resident wildness. So you know, I knew a little bit about this from beforehand, but for you, meeting him for the first time, would you kind of take away? Yeah, man. He's brilliant. It's so funny because he was really keeping up in the very get-go. Just telling us how remote monitoring, you know, at the backstory of how it really started in the lab for him, taking that time between, well, time during medical school, again, his PhD and then ultimately deciding that he wanted to get more clinical training. And that, how that developed and then his own personal training and looking at, you know, his recovery and sleep and the interplay with residency training and how he was able to apply that to really turn it into for the better and create this wellness initiative essentially. And I'm excited to see what the data from that shows. Now, I didn't know this, so I know that, so you were a part of this study, but you're not going to be an actual end in the study because your internal medicine is like correct. So I was a prelim resident, so I had a different rotation schedule because I didn't have to do ICU, my engineer, whereas they did. So they brought us on just to get more kind of data, but we'll be used like separately in terms of rotation schedules and kind of just the end-to-the-end points. Maybe like a separate analysis, yeah. Yeah, yeah, that's very cool, man. I think that's, it's important and, you know, so maybe you're not allowed to disclose this, but I imagine other than HRV, there are a lot of other markers. We kind of, you know, reference that you got, he looked at some subjective scores, Bernat scores, and that kind of stuff as well. Yeah, exactly. Yep, so we would do some screens, so we do like a PHQ9, we do the grit score, and you know, we do those essentially every two weeks, and then every, I think month or two, we do like a bigger survey with almost all of it. And then, yeah, they would be tracking our HRV for the most part. Yeah, I don't think like sleep or anything of that, the journal, things like that were included. It was just usually used in HRV and just seeing the trends with rotation. Tell me this, knowing that you're being monitored like that, be honest now, reflecting back, did you change any of your practices? No, I mean, I feel like a lot of the other residents, they felt like, oh, man, I have to wear this wound, like I have to wear something, like it was, excuse me, it was difficult for some people to consistently wear it, because they're not as a fitness junkie as I am, or you know, they're not so like geeky as we are in terms of tracking data and things like that. So for me, I thought it was awesome. But no, I kind of kept the same lifestyle I was living, still going to gym as I normally would. Yeah, there wasn't, there wasn't really much change. Yeah, I think there's something, I'm curious again to see what the data shows, but I'm wondering what the Hawthorne effects can account for, you know, where as people know they're being observed, particularly those who, everything that you just mentioned isn't a part of their routine. Right? Going to the gym, getting good quality sleep or getting just adequate quantity sleep. I see you or no, I see you doing things of that nature. I wonder if, and hopefully we'll be able to chat with somebody who was a part of it, actually, part of the data that's finally analyzed and see what they thought, you know, from that. But I'm excited to see what it shows. And then more importantly, what we're going to be able to do with that, I think that he said, you know, some of his hope is that program directors would better take this information and really evaluate whether the structure, you know, at Hershey, you guys have that, but I imagine a lot of institutions have it. I mean, our ICU rotations were for four weeks as well. Probably a lot of variability into what kind of ICU you're doing, but you know, you really have to question, do all these rotations need to be structured a certain way or is there a better way? I mean, really that's what it's all about. Totally. I mean, I think when it comes to like the bigger institutions, right, I mean, there's like 20 per class in the internal medicine residency at Penn State Hershey and rotation schedules can be a tough day when you're trying to figure out 20, 60 per year, essentially and trying to fit it like a puzzle that's almost impossible. Someone's going to get the short end of the stick, right, and that might result in them burning out in a way that might not be helpful to them or to the program and they can have that, you know, chain reaction to other residents now picking up the workload, et cetera. So it's how do we create a fair system, right? And he brings up the point system, maybe like I see his higher points, clinics lower points, and based off that, you don't go over a certain number of points in a quarter. And like something for us as a preland resident is that we would do more medicine rotations to cover the categorical residents when they were on clinic. And so that would result in us burning out a little bit more during, you know, those months where we had to cover. So I think it hopefully, yeah, there's some good data that shows that program directors take this into account and can come up almost, you know, with a, with a standardized system for a lot of programs to use as a template. Yeah, so I think that we're touching on the wellness aspect and for those who are going to be in the medical field, I think that this is going to be directly beneficial to you for anybody listening who this is not going to be because they're not going to be a resident or fellow anytime soon, largely what we're talking about recovery. I mean, that's his interest. He's a champion for whooping. We spent a lot of time talking about HRV. So we've mentioned HRV several times, but just to recap, it's basically the beat-to-beat variability within your heart, right? So the RR interval that he talked about, which is kind of like this little squiggly, boop, boop, boop, online that you'd see on TV and ER or Grayson Adam, whatever you watch. And, you know, the more variable it is, it's actually a better thing because it's a signal that your heart is adaptable and it can be accommodating for any type of change that can come. And if it's actually consistent, as much as we talk about being consistent and being a good thing, if your heart is very, very consistent, beat-to-beat variability, that's not a good thing. So that's a bit counterintuitive. But more and more data that we're seeing nowadays suggests that higher HRV heart variability is a marker for healthier heart or more resilient, autonomic tone, is that a good way to say? I think so, right? That balance between the parasympathetic and sympathetic and allowing your body to distinguish between the two and allow them both to activate whenever needed. Yeah, and I think the important thing here to recognize is that most of the new wearable technology that's coming out is using HRV as a metric. I mean, this is probably the most standardized metric now that we're seeing in wearables to look at progression, right? The whole point of wearing wearables is to see, are you getting healthier or are you progressing better? And so, you know, Woop uses a recovery score, a strain, respiration rate, all these different kind of things put it together. And at the end of the month, you get a report and essentially you're looking at your HRV and seeing what are the things that are helping with your HRV. Now, essentially, Aura Brang, I'm sure, is kind of the same thing where you have a journal, you're looking at sleep, you're looking at your daily activity, and the output is also looking at your HRV and, hey, is it getting better, is it getting worse? What do I need to change on the day-to-day, but also on the month, the month, the year-to-year? For that report, you're only getting the specific variables that are influencing for the better or worse if you do the journal, right? Yes. If you do the journal, you're just getting whatever output you are from the journal, and then it'll run regressions, so it'll tell you, like for me, blue blockers, 10% increase in my recovery, and I am likely to wear blue blockers when I do not drink alcohol, for example. And then alcohol minus 25%, likely to do this, I will not take a magnesium supplement. So you kind of, it's nice because you learn what goes in conjunction and how you can change also just like habit stacking, in a way. Right. It's accurate. Right. Yeah. Nice. Yeah, I like that a lot. What about, we mentioned, I think one of the big barriers for this is cost, right? Again, we talked a lot about your fan of it. I mean, I am too, from exactly what I've learned and all the people who speak highly of it. And I think that just as much as I mentioned about the sticky nature of a ring for nighttime, I think during the day, I'd much rather wear a watch than a ring, just how I am, especially in the gym and whatnot. But again, there's a cost factor, right? There's this deep price tag, depending on version you're getting and newer versions are even more expensive with a monthly subscription. So if somebody can't afford that or isn't buying into it, what would you suggest for markers for recovery? How'd you go about it? So I think we talked about this. So what is obviously like subjective readiness, right? Waking up and, you know, it's funny, ever since you mentioned that in that episode, I wake up. So before I look at my HRV recovery, I look at my head and I'm saying, okay, right now, would I be able to kind of like bench press pretty heavy or squat pretty heavy, just like based on how I feel? And most often when I'm like, yeah, you know what, like I think my, I think I can do that right now. My HRV will probably be higher or when I'm like, you know, I'm pretty dead, it's probably not going to happen. HRV will be lower. So I think there is, you know, probably really good correlation in terms of just feeling how you're ready and really being in tune with your body. Now, obviously that takes time to be in tune with your body. You've been working out for a long time now. So we've kind of gotten used to that. But really being honest with yourself and saying, hey, how do I feel today? Do I feel ready to go crush it, be a little more intense or not, right? And then I think the other thing is just heart rate. Looking at your heart rate, I mean, that's correlated with your HRV. So when you wake up in the morning, when you take your heart rate, if it's higher, you know, if you get a trend at least for a week, you kind of know where your baseline is. If you're on the higher end of that, you're probably not as recovered. If you're on the lower end, you know, lower heart rate, you probably are better rested. So I think that's also, you know, that's a great surrogate, I would say. Yeah, I agree. I was actually reviewing a podcast slash YouTube episode of Dan Pope, one of our earlier guests. He reviewed a journal club article or just an article, I think I forget what it was, but it was recently published looking at the effects of sleep and stress on the risk of injury and like collegiate athletes. I found it really interesting. And I think most people, if you're interested in that kind of stuff in sports and academics and this kind of, you know, these types of issues and interplay, then I highly recommend watching the entire thing. It's about 30 minutes. But if not, you can fast forward to the 27 minute mark where he gives his insight into how he practices in clinical or his clinical practice. And when he gets clients and patients to come in, and he talks about the rating of score, right? himself, you know, he gives himself, I think it's from a zero to 10 or a zero to five. How, how do I, a zero to 10, I think he says, and he says, most days, he's at a six. And you know, if he's at a seven or eight, then he cannot wait to get on the gym. If he's at a four or five, then he knows that he needs to dial something down, whether it's volume, whether it's, you know, intensity, whether it's just maybe just doing some mobility work. There are some other markers that you can look at too. You've already mentioned heart rate, but just knowing what you're simply, what your hydration status has been throughout the day, I mean, simple as that, right? Throughout the week, like for me, I'm fasting right now. And so, you know, I'm very mindful of that when I am training during the day, I'm also eating a little bit less. So my overall caloric intake for, you know, per long period of time for over a month time is a little bit less. I'm also cognizant of that. I mean, this is not going to be the time to just hit PRs in the, in the gym, right? I'm sleep deprived. So just knowing that what's been building up over the past few days, right? Like if you know that, hey, you are in the middle of a big move across the country or just really buying a house in this crazy market and in your moving, maybe this is the time to try to really, you know, go to the gym and try to PR all the time. And that's really how bad things happen. And so in the absence of HRV, which is just one marker, I think, these are other things that you can really know and they're pretty easy to track. I think just kind of takes some time to kind of really look for a fuck back and think about it. Absolutely. And I will add on, you know, we are talking about costier and I think healthy is your greatest investment in life, right? Like without it, you can't really, you can't do anything else either live or you're dead. And so like I urge people, like really look at your expenses, like whoop is $30 a month, right? It is a steep price. But if there are subscriptions that you think you're probably not like worth like looking at, like whatever, if they're magazines and stuff, like I highly recommend people to like look at Aura Ring, look at Woob, like do the research, but also just trial it out, see how you like it. I mean, you can always cancel these things. But for the most part, I've only seen people get benefit from them, at least if they're really looking to improve their health. So I will put that in there too. Yep. Do you, do you have to buy, is there an upfront thing to buy the device or no? Just a month ago. Yeah. Give me them now for sure, but if you cancel it, you have to send it back. Don't think so. But you won't get like any of the data. You probably keep like the woo, but you won't get like the, because it's all basal the app, right? So yeah. Oh, right. Yeah. Right. Right. Then it's just a black man with no interface. I guess it's stylish. Yeah. Yeah. It's somewhat cool. So part of the club, you act like it's right. I want it. Go for it. No, no, I did want to let people know we are not paid by whoop. However, if whoop is listening and they do want a sponsor, then we're in. We're in. We're in. I was going to ask, man, some, if you get, if you're down for some bonus content, so obviously you mentioned your fasting for people. I don't know. It's Ramadan. So if you're okay with talking about what is your like workout regimen look like right now? So obviously there's no food or water right from sunrise to sunset. You break your fast at night or before sunrise or after sunset is when you're eating. What are you doing in between? How are you checking your hydration status? What are you doing for your workouts? How have you kind of modulated those things? Yeah. It's a good question, man. I think. Oh, I'll try to keep it concise. I will say that one of our previous guest, Dr. Diel Khan actually did a post on this not too long ago about what recommendations he makes for the month of Ramadan when people are fasting. And I think that Dr. John Verdi wrote something about this because he would train a lot of folks, you know, professional athletes as well, who were fasting at the elite, elite level. But anyways, what do I do in terms of tracking my hydration status is just somewhat gross. But yeah, just looking at the color of my urine, let me throw out the day. I mean, and I'm very cognizant of breaking my fast with a couple of glasses of water and getting plenty of water in the morning. I'm at the state where in the beginning of the month, it's always harder, right? But as days goes on, it's a little bit easier. So you don't need as much food. And again, we have intermittent fasting has been a part of our life. So I think we can go extended periods of time without it anyway. So it's really not that that really affects you as much. In terms of training, right now, there are a lot of other stressors in my life. And I'm a new dad. And so I really try to get training whenever I can. What I've been trying to do lately is to do it in the evenings towards the end of my fast and then right after I can eat, right? And that way, it's, quote unquote, ideal because in the post workout I'm eating, I've also done this in the past where I've, in the morning after I'm done eating and I start my fast and I work out like 30 minutes after it because I usually have like a cup of coffee from my day of start. So I've done that in the past. I've tried every single variation. Today, interestingly, I took a little bit of nap, a little bit of nap, I took a short nap and and I woke up and I went to the gym. So it was like around 11 and I felt amazing after 10 minutes and like felt stronger than I have in the last two months. So I mean, that was interesting too. I mean, sometimes just a, you know, catching up a little bit of sleep will do wonders for you. I would say, honestly, it's whenever it's easier for somebody to get it in, I've also in the past done like after breaking my fast. But then I find that it's pretty late at night when I'm working out and I don't like work, like I don't like to go hard before close to bed. My sleep quality suffers after that. So really, it's whenever you can get it in. Again, the important thing is, you know, even today, I didn't try to PR, that's, this is not the time to do it because when you are dehydrated, when you are, you know, in a cleric deficit for extended period time, the likelihood of injury is going to skyrocket and probably not to do that. But that doesn't mean that you just completely sit on a couch. In fact, most Muslims who do fast find at the end of the month, they're end up getting wait because they're eating late at night and early in the morning and they're really not doing anything. And they're like, oh, well, you know, I'm fasting. So I'm not going to do anything and then they're like, I don't know how I gain five pounds. Yeah. Yeah. That's right. I don't have any of the element packets in the morning. I don't know if you ran out, but I ran out. So I need some more. Yeah. We're going to need some more of those huge fan, huge fan of the Raspberry Man. Oh, God. Let me some of that. I think I've had that one yet. It's probably still stuck there. I've been going through the PS the pack. But I can only do it. I love it. Like, I can only imagine even when I'm fasting and I do it, oh my God. It's unbelievable how much it actually just helps you push past kind of the brain fog and get it through it. Like, can we imagine like doing that in the morning, you know, before your fast begins just keeping a little extra hydrated. So cool. For sure. That's a good point. Yep. Some elements for type of better work to put into your diet. Yeah. Awesome. Anything else? No, man. It's been great. Uh, guys, three amazing guests. Highly recommend you guys, which I get out three episodes. Yeah. Three episodes, two guests, but it felt like content was three guests worth a while. So, um, go back and check that out and it'll definitely be worth your time. So, um, definitely enjoy that. And if you have any feedback or any, uh, both positive and negative, please shoot us an email. I met Redefined at gmail.com and, um, you know, be sure to subscribe, review, rate, and share. And we're all like on all socials. So we're on YouTube. We got clips on YouTube, TikTok, LinkedIn, Twitter, Facebook, Instagram. So check out all those, too. All right. All right. Thanks so much for taking the time to listen to the lessons that me and Ultima have learned. Again, we highly suggest you listen to the past three episodes with Dr. Harkin and Dr. Hadgechek. These three episodes are by far going to be some of the best episodes you will hear about the cardiovascular system and will give you actionable tips so that you can live the best life possible. And again, we are on social media. So we are trending on TikTok. We're on YouTube. We're on LinkedIn, Facebook, and of course, Instagram. So if you want to check out short video clips of our guests, talking about different topics, be sure to check any of those platforms out. And if you've been here already, you guys know the medical disclaimer. Everything in this podcast is for educational purposes only. It is not constitute the price of medicine. We are not providing medical advice. No physician, patient relationship is formed and anything discussed in this podcast is not representative views of our employers. I would recommend that you seek the guidance of your personal position regarding any specific health related issues. Until next time.