Sports Medicine Specialist, Marci Goolsby, M.D.

0:00 Hi, it's Doctor Robert Seikard with a new episode of Doctor Podcast. And today I'm really pleased to have as our guest Doctor Marcy Goolsby. Dr. Goolsby is, as you can see behind us here, the Medical Director of the Women's Sports Medicine Center at the Hospital for Special Surgery in New York City. Hospital for Special Surgery or HSS, as it's known as the top orthopedics hospital in the entire United States. Doctor Goolsbee is also the assistant professor of family medicine at the Wild Cornell Medical College, also New York City, also one of the top medical schools in the country.

0:37 And she's also the president of the American Medical Society for Sports Medicine, a very prestigious organization. Thanks very much for coming today, Marcy. Really. Yeah. I really appreciate you taking the time, so I understand that you did your original training and residency and and family medicine. How did you become interested in in sports medicine after that? Yeah, So I went into residency sort of thinking I wanted to do sports medicine, try to keep an open mind. I knew I wanted to train in primary care.

1:10 I like the idea of kind of knowing pretty global, comprehensive medical training. So that's why I chose to do family medicine. But kind of always had in the back of my mind that I wanted to do sports medicine. I was fortunate to have been exposed to. In college, I was a basketball player. Really. San Diego, Yeah. And so. But going forward, I wanted to make sure that it wasn't something I was interested in, just because it's what I knew, you know, what I had been exposed to. So I could try to keep an open mind as I was going through training.

1:42 But I just kept coming back to both family medicine and sports medicine, something that just kept drawing me in. So love the idea of working with active patients who are motivated or not active patients and trying to get them motivated to move. And just love that, that positive approach to medicine. So that's what attracted me to it. That's great. And then you became more interested in women's sports medicine and are an expert in that, actually. How did that occur? Well, I'm a woman, OK? That's that's a good start.

2:15 Yeah. You know, for me, being an athlete was such a huge part of who I am and how I got here and and in the path that I took. So I just love the idea of getting to work with female athletes and active women. Now, my practice is not strictly seeing females. I see a lot of males as well, right. But I do specialize in a couple of things that are a little bit more common in women, such as stress fractures for example. So, so that's that's kind of how that came to be. Right. And I understand you were also the team physician for the WNBA's Liberty team and also at some point the US women's basketball team.

2:59 Can you tell us how you got interested in that and what your role was there? Yeah, so I was. I was really fortunate to have some amazing mentors along the way. And and that's how I got connected to Lisa Callahan. She and Joe Hannifin were the two physicians who started the Women's Sports Medicine Center at HSS many moons ago. And they were looking to expand their group and they were covering the New York Liberty. And for me that was like the great circle of life, like coming back to the sport that was so important to me and gave me so much.

3:29 So it was sort of an offer I could not refuse was getting the opportunity. No. But I still have dreams that like they're short of player and like I need to suit up or like I have extra years to call. So the the dream comes back. But yeah, that would be a disaster if it got down to that far down the bench to me. But yeah, it's it's been an awesome experience and I was. I've just been honored to be involved in women's basketball and and got to work with the team a little bit before they went to the Tokyo, Tokyo Olympics as well.

4:03 So that was my brief moment with the US women's team. But what an amazing group of people. Yeah, incredible athletes. Yeah, incredible athletes, incredible people and just really fortunate that I got to have the experience to be in their lives. Great. You also mentioned that you were involved in the biathlon. Yeah. Can you tell us what that is? I don't think that's that popular here in the USA, but very popular in Europe. And tell us what your role? Was with that so the biathlon is a very fascinating and and great sport.

4:33 So biathlon is cross country skiing and shooting. So most people are familiar with it from the Winter Olympics, if you watch the. Winter Olympics I'm amazed by. It yeah, it's it's a fascinating sports, especially from a sports medicine perspective because you know, they're having to just give it their all with the skiing and as you know like exhausting and cross country skiing and going up and down hills. And there's a lot of interesting factors like what the snow is like what, you know, what the weather is it hard, is it soft as a pack that determines what skis they use.

5:03 And then they come into the range and they have to basically hold their breath five times and be still to shoot a target, which is just, yeah, it's incredible. Special rifle that they carry while they're skiing. Right. Yep. They wear it on their back like a backpack and and there's different, you know, there's fast ones and there's Sprint ones and there's longer distant ones. There's some relays with just women and some with mixed with men and women. So there's a bunch of different types of races that they compete in and and it's their seasons basically in Europe and sometimes Asia in the winter and so they're gone all winter and and it's actually an incredibly popular sport in Europe.

5:45 It's always on the TV there. The crowds are huge at some of these events. Yeah. It's it's, I think it's the maybe I have this wrong but it used to be at least the number one spectator sport in winter in Europe was. Yeah. And certain countries in particular have a long history. Yeah. Yeah. Well, that's amazing. And what was your role in in the? I was one of the team physicians. So what I would typically do is go and spend a week or two every winter go to at least a couple events over there. I was fortunate to have a colleague that I that I did that I covered with and then so we would take turns doing going over there to see them and spend some time with them.

6:25 A lot of it was managing colds and sort of illness prevention. So when COVID came along, I'd had some good practice and some of the things that that we all learned. And yeah, it's it got to go to the Olympics, which was incredible with them. What a cool experience. So very fortunate. That's great. Now you mentioned earlier stress fractures. I know you specialize in the non surgical treatment of of stress fractures and also overuse injuries. Could you tell us what a about what a stress fracture is?

7:01 I've actually had a few from running, so I kind of know what it is, but some people don't know what that is. Can you explain that and how you treat them? Yeah, well, to make it a little bit more complicated, I tend to use the word bone stress injury. That's a little bit more of an umbrella term to include stress fractures and something called stress reactions. So kind of a spectrum of of issues that can happen. So it's basically like the repetitive load to the bone that sort of exceeds what its capacity is.

7:28 There's not enough recovery time, There's just a change in activity. So usually that's associated with it. Running's a very common thing. We see a lot in the military as well, but you can get it in other sports. But running's a common one and sometimes it's just, you know, a change in training volume. There is a lot of factors, kind of intrinsic and extrinsic factors. So things like their bone health, which I'll talk about a little bit more. But other things like did they change their shoes, did they add in speed work?

8:03 But a lot of it's like training, just their bio mechanics, like how they move and where their strengths and weaknesses and tightnesses are. So it's when that that repetitive stress sort of exceeds the capacity of the bone, there gets to be some inflammation in the bone and that's where we'll see edema or inflammation on an MRI, for example, but no fracture. So that's called a stress reaction. And then if it gets to a certain point and there's actually a crack in the bone, then we call it a stress fracture.

8:30 So it's actually like a microscopic or tiny. Yeah, it starts with little microscopic cracks and then they kind of coalesce into a fracture. Right. And it's very painful it. Can be, yeah. And then you can't run or do whatever activity you were doing, right? So how do you treat that non surgically? Well, I think the most important thing for stress factors is figuring out why it happened. So trying to address any of those risk factors. So, you know, my patients know I just pellet them with about a million questions and get exhausted by the amount of questions that I asked them, you know, about their training and like, what kind of changes and what shoes are you wearing and are those new shoes and how old are those shoes?

9:12 But a lot of things, like have you ever been told you had low vitamin D? Are you a vegetarian or vegan? When did you do that? Why did you do that? History of eating disorder, menstrual history, history of stress fractures or other fractures like traumatic fractures and even some zebra things like have you ever had a kidney stone looking for hypercalceuria? So some other things that that might be related to impacting their bone health and increasing the risk of stress fractures. A lot of it's activity modifications.

9:44 So if it hurts, don't do it kind of thing. And so it depends. It's different for each bone. A metatarsal or a foot stress fracture is going to be different than a femoral neck or a hip. So it kind of depends, some people need crutches or a boot, some people it's just don't run it. It depends a lot. We really rely on the pain with activity in the stress fracture treatment. We're still doing some research on other things, right. So right now it's mostly you know, clinical management and and and modification of activities and weight bearing and then you know there's some things that are out there, but the evidence is still pretty sparse for whether they're valuable to do medications and some devices as well like shockwave and stimulators.

10:33 And some of those things with electrical pulses. Does that work or it doesn't? Work. Maybe. Maybe. Yeah, maybe. I you know there's some for. Some people, not others. Yeah, the unfortunately, there's a lot of research that we still need to do to really prove its value. But there are some potential things that I'll use on occasion in certain situations. Somebody who's not healing well is usually the most common thing. Somebody who's just got delayed healing, I might try some of those things. Right now you mentioned equipment they use, for example runners.

11:10 What's the story with How often do you really need to change your shoes If you're running, If the shoes look good and. Make sure whether it's the shoe company telling you no. Usually it can be variable, cuz it may depend a little bit on the runner themselves or like a big runner and they have are they gonna wear out their shoes more? But 350, 500 miles? 250 Depends on who you ask. Somewhere between 2:50 to 500 miles I see. I usually tell people if they're not running that much, but it's been over a year, it's probably worth getting a shoe because it they break down a little bit even without so the.

11:45 Cushioning kind of decreases and and therefore they're more shock waves to. The yeah and you don't, you won't see it, right. It's the mid sole, so it's the part of the shoe you don't see. So if you start to see visible wear on the bottom, then you know you're well past where you should get new shoes. Yeah, shoes. What other types of overuse injuries are there commonly other than the stress fractures? Tendonitis issues shin splints which is sort of a tendonitis issue as well. Plantar fasciitis, Achilles tendonitis, hip tendonitis like side hip tendonitis, those kinds of things.

12:19 IT bands which is again kind of like a tendonitis there. Patellofemoral pain is another one that we see. So just the kneecap tracking, those are those are the most common ones that we see and runners now overuse injuries. Of course we talk about racket sports and overhead sports and those injuries are are different when it comes to overuse, but tendonitis is probably the biggest one that we see, or tendinopathy. Right. And another thing that you're an expert in and and talk a lot about is the female athlete triad.

12:51 Can you tell us about that? Yeah. So there's different terminology. There's the female athlete triad. There's also a male athlete triad there. The equivalent relative energy deficiency in sport or red S is kind of describing more the the imbalance essentially between the intake and the outtake. So that's what it comes down to. It's the nutritional intake versus the exercise energy expenditure. That's that balance that that gets off. And it's not just because they're running more, it's because usually they're just not keeping up.

13:26 It's not balanced. Sometimes the nutrition part is more like an eating disorder or what we call disordered eating kind of that grey zone where they might be restricting a little bit or they might be cutting out certain food groups and they're just not getting the fuel that they need for what they're asking their body to do. Are they restricting to kind of lose weight? So. They can. Run faster or. It's variable and and the and the evidence shows that losing weight maybe in the very beginning you might notice the difference but ultimately it doesn't make you run faster.

13:58 So trying to break that myth too that's out there in the culture of thinner is better for runners is an is an important message. But when that energy gets into that imbalance, essentially the the hormone system, the volume gets turned down South, You know, that acts as that whole system kind of the volume gets turned down and it leads in the end to a decrease in the sex hormones and that can have an impact on the bones. Which hormones is it's? Like estrogen. Estrogen, yeah. What about testosterone?

14:31 And testosterone and males as well, Yeah. And and in males we see that more with that. So in women, the tool in our toolbox is monitoring their periods. So the menstrual cycle is something that we can monitor in women. So if they're losing their period, their periods are lightning, they're spacing out. That's a sign usually that there's an imbalance. We don't have that in men. And for for males, the physical sign symptoms, they usually need to be in a deeper energy deficiency for us to see that.

15:03 So it can be a little bit more subtle and difficult to pick up. The treatment is prevention, like creating the right culture and getting the right messages and making sure that people are appropriately fueling for their sport. And I use my sports nutritionist and sports psychologist a lot. It's really a team. So when patients come to you, if you detect that there's this imbalance of nutrition and you would refer them to your colleagues. Who? Yep. Usually we work together, and a lot of it is just education, like making sure people understand, like you're not getting your period as an athlete.

15:37 It might be common, but it's not normal. And the implications of that on on various systems. But the bones are kind of usually the one that's front and center, 'cause they're at increased risk of getting stress fractures and early osteoporosis. Oh, wow. So that that's a big problem. Yeah. Especially in women. So is it because they're not taking in the right kind of nutrition or or just not enough? Calories. It's a little bit of both. So you know there's going to be foods that are more energy dense than others.

16:03 So if they're not getting enough fats and proteins, for example, that's a common thing that we see, like they're getting a lot of vegetables and maybe some carbs, but they're just not. They may not be getting as energy dense as they need. And getting that fat in particular is really important for endurance athletes. And we think like carb loading, right, which carbs are important too. But having a good balance and making sure that there's they're getting that healthy fat is really important. So it's it's both.

16:33 It's both vegan and and still, yeah. Absolutely. You can be a vegan, you can be vegetarian and and do it. I think one thing is, are they doing it for the right reason? Sometimes some of those diets can be what I call a gateway diet, kind of like a gateway drug. So sometimes it's the beginning of that control and restriction and it's really an an eating disorder variant for for that person. And of course plenty of people are vegetarian and vegan and it's not has nothing to do with an eating disorder and you can do it.

17:03 It's just a little bit harder, right. It takes a little bit more of a concerted effort and and for sure in those patients I'm quick to send them to sports nutrition to just to make sure that they're getting what they need because it's just a little bit harder, especially in the higher mileage runners. Right. You know, Carl Lewis is one of the greatest track stars of all time. Got I think 8 gold medals and and tracked. He became a vegan somewhere along the way and claims that the reason he was such a good runner is because he changed his diet to vegan.

17:37 So it is possible to perform, but some people just don't know exactly what to eat and. What not to eat to? Get the right mix. It's also what they might be cutting out. Like when people go gluten free, for example, it's like, is it really the gluten that was the problem or is it what was what you were eating that had gluten in it, You know? So I I don't know Carl Lewis's experience, but did you just become a healthier eater in general because of the changes that he made? Yeah, what's the story with gluten, by the way?

18:09 I don't know. All of a sudden, it's the worst thing in the world. I mean, 10 years ago, I never heard of gluten. Yeah, I mean, absolutely. Like there are real, you know, there's celiac disease, right? There's true gluten intolerance and then there are people that I think are just gluten sensitive.

18:27 You know, like anything there's, you know, it's kind of a thing right now. But I I do, I mean it's not baloney. It's not baloney. I mean there's there's some validity to it. So yeah, And some people truly need to be gluten free. And it's fantastic that there's just so many more options out there for people that are gluten free or dairy and need to eat dairy free. Yeah, easier to get stuff. There's a store next to me near where I live, where it's an entire grocery store, Giant store. It's all gluten free, gluten free and organic.

19:02 The entire store. You can't. You can't. It's very interesting. Now you treat a lot of runners and triathloners and and people who participate in those sports. In the past there were rumors or people were told that it's not good to run because it damages your ankles and your knees and your hips and you'll get arthritis at a younger age. But in recent years I I've seen studies that actually show the the opposite. What's the truth about that about running and doing vigorous sports like that? Running.

19:41 Is great for you. It's great and and there's a lot of, especially here in New York because you you just can put on your shoes and go you know, it's so convenient, it's so nice. I think that, you know, what I always tell people is just whatever sport and exercise you enjoy doing is what you should do. Now just like anything there can be extremes, right? So, you know, excessive running can have implications, especially like we were talking about, if there's not good balance, if there's not good recovery time and strength training for injury prevention and other things you do, but the.

20:14 And the majority of people there is not, it's not going to lead to breaking down your joints. Now there are some patients that have specific issues where they might swell when they run because they have an ongoing kind of cartilage thing and they're wearing things down. That's a different situation. But the the sort of just typical patient is running bad for the joints, absolutely not. In fact, there's some recent evidence to say that that that's healthy for the joint kind of that impacted rebound that's good for the cartilage.

20:44 Right. I mean, I'm an ophthalmologist, but my practice, I also see patients that have all sorts of orthopaedic and and physical problems. My impression is the more people who were inactive and not running get more operations on their knees and hips and other parts of their bodies than than my patients who were very active runners, even to a very senior age. Movement is super important for arthritis, not only for prevention, you know, in terms of weight, but there's beyond the weight, there's there's value to the exercise for the joints in the long run.

21:18 And then when you do have arthritis, exercise is super important and valuable treatment. So you know if if there's something that specifically hurts, we just try to figure out either a temporary way to do something different or if they need to switch activities. But exercise is super important and a lot of times the things that I'm doing are trying to manage their symptoms so that they can go do the things that they want to do from an exercise perspective because we know ultimately that's the most valuable thing.

21:51 I mean, my patients who have the the worst arthritis, but not that symptomatic, they're always exercises, they're always active people. So being sedentary is terrible for the joints, right? Yeah. And people know it like they don't like sit. Arthritis likes to move. It does not like to sit still. Right. So if you're out there, if you're thinking of running, it's actually good for you. Don't listen to the people who tell you it damages your joints and things like that. Go out there and run, of course, everything in moderation.

22:23 We spoke a little bit about nutrition, and I know you're an expert in in vitamin D and calcium metabolism, especially in women. Can you tell us about that? Yeah, I mean, I've, I've done some research in that in that realm. You know, vitamin D is something that we know some about and I think there's still a lot we don't know about. It's a hormone. It's involved in a lot of systems in the body. More recently it's it's it's bones we know, right? It's if it's low you need, you need it to be good and we know that.

22:58 I think there's a lot we don't know still about variations in different ethnicities. For example, we don't know I think all of the what we're going to know about injury prevention. So we did a study and looking at vitamin D deficiency just from a prevalence perspective like which kind of patients and what their vitamin D was. And we were surprised even though our numbers with stress injuries was really high, it was really a ligament injuries that was the highest in our tendon. So there were a lot of other things, Patella, femoral pain, tendon issues, ligament issues.

23:31 A lot of those patients had low vitamin D as well. Now obviously, as you know, that doesn't necessarily, you know, prove cause and effect, but it was interesting that what we found, because we were sort of surprised by that. Like, maybe there's more of a role of vitamin D and its importance in being at a good level for other injury prevention beyond the bones, the ligaments in the muscles and tendons and such. Right. Do women need to take extra vitamin D and calcium or? No, not necessarily. I mean in in this part of the world, right, there's much more vitamin D deficiency and insufficiency than in South for example, where they get more sun.

24:07 So it's it's not that more is better it's the necessary amount is better. So in injuries I have a pretty low threshold for ordering a vitamin D test, for example and A and a lot of people I'm seeing in just their regular physicals are are getting a vitamin D checked and then if there's low we need to supplement right? So. When should women and men get bone scans to see if they have osteoporosis or a softening of their bones? Well there's sort of the standard like across the board you know recommendations for in the later years like post menopausal women and and men.

24:47 But for in my patient population it's and there's a study that is looking at the female athlete triad and return to play in consensus And in that paper we we sort of created guidelines for who should get a bone density test and has to do with the type of injury. If you see a certain stress injury like a high risk stress injury like a femoral neck and the hip that's that buys them a bone density test just because it's it's such a difficult stress fracture to get. And typically we do see a high correlation with other risk factors like the female athlete triad and we know that those usually have a lower bone density associated with them based on previous research.

25:28 So that's somebody I'll get one even with one injury but even like multiple fractures like long bone fractures and then those other factors too. So eating disorder, history of eating disorder, prolonged amenorrhea, so more than six months of not getting a period. Those people should get a bone density test as well. And then there's a bunch of other medical conditions and medications, you know, where you would need to monitor that too. Some of the breast cancer treatments and steroids and things like that.

25:57 If people are on those long term, some seizure medicines as well does. Exercise like running, triathloning, whatever, help with osteoporosis. It does. Exercise is exercises medicine, right? You've heard that phrase a lot and and for osteoporosis and bone health, exercise is the only thing that is a valuable treatment to do basically from birth to death. So it has value your whole life, especially in kids, it's the most important in kids. So multi directional weight bearing impact exercise, it's when they're going through puberty and kind of those early years is the most critical time because that's when they're going to build their like Max genetic potential sometime between 18 to 25 we sort of hit our peak And then and that stays with you for the rest of your life when you do it as a kid and a teenager.

26:48 Whereas later on you can kind of like it's sort of more of A use it or lose it situation. But if you don't get to that Max genetic potential and that's why it's so important to pick up things like eating disorders and the Triad and amenorrhea, because the longer that goes on, the less likely you're going to, you're going to be able to recover the bones. So if you take a hit during that really critical time, you know it can have long term implications for the rest of their life, so. Very interesting because that's not emphasized that.

27:17 I mean, we, we hear talk about, yeah, kids should exercise and all, but it's it's not really stressed that much that what you do during those critical years under 20 are going to influence what the rest of your life is like. Yeah. And I think it's really important for for younger females because we're seeing a lot of sport drop out in in women compared to the men. And so keeping girls in sports and activities and some of it is just the culture of like you're either on the year round travel team or there's nothing.

27:50 And so we we've got some work to do in how we do our sports in our in our younger population. Education is is really critical. What? What are the musculoskeletal differences between men and women, and with regard to injuries and and so on? That's the how long do we have? Few weeks. I mean, I think there's there's more similarities than differences, you know, sort of the movement patterns are different. What happens to both girls and boys during puberty? The changes that are going on are really important.

28:31 ACL injury prevention is a very important thing for the females in particular, but men too. So females are more prone to ACL injuries. Oh yeah. Why? Why is that? Well, there's a lot of theories, but they think it has more to do with kind of the neuromuscular and biomechanical issues difference between the two. So that injury prevention stuff, it's been proven, very well proven that it's helpful in preventing ACL's. But we're having a lot of trouble implementing it. Some of it's just I think getting the message out and implementation, but just changing that that that culture to injury prevention is is really important.

29:10 So there's a lot of efforts. Are pediatricians informing parents about this? The the critical importance of this I I. Hope so, but I think it, yeah. I think it needs to be messaged to the coaches in the sport leagues and we have a lot of programs set up at HSS trying to implement some of those injury prevention programs. We have a new app that they're that they've just came out with, so trying to keep people engaged in that ACL injury prevention. ACL by the way, is is in in the knee, right it's.

29:41 When people blow out their knee, that's. Right. There's a ligament there that keeps your knee stable. Yeah. Yeah. So that's a common injury for more for women. Yeah. So that's I. Forgot your original question, the difference between men and women, right. Yeah. Yeah. So that's one. That's one that you know is is very important. It's just a lot of that has to do with landing techniques. So that's one key difference biomechanically between females and males and trying to rework and and retrain the landing techniques for females versus males.

30:15 As so do pro female basketball players have more ACL injuries than than male. They do, but not as much. There's not as much of a difference. I think some of that is you know just training the level of that they're at but some people have they already torn their ACL and perhaps even got sort of weeded out from if they didn't recover well from it but but they still are seeing it. We don't have as much we don't have a lot of robust data yet for the WNBA players which is the NBA but some and a lot of it is related to that.

30:51 But just that's that's probably one of the biggest biomechanical differences is just how the landing techniques in the movement patterns more knee valgus and females wider hip versus compared to the knee. So Patella femoral is another one that's very common Patella, Patella femoral instability. So Patella dislocations is much more common in in females versus males and that that can be a. Very dramatic kneecap, Where? The kneecap dislocates, yeah. So that's that's another difference. And oh, there's a lot of things.

31:25 I mean, there's a, it depends on the injury you're talking about, I see, between the differences. Which sport as well? And I've heard recently that in the old days I think they used to repair all ACL surgically, but is there some new data that shows that people who have that may not need surgery and there are ways to rehabilitate? Necessarily new data, and it's ACL reconstruction, so typic typically usually. So they'll use a donor tendon or a tendon from somewhere else on their body to do the reconstruction to put a new one.

31:59 So can't sew it back together very well, but the there are definitely some patients who who are what we call Coopers who seem to recover well. They don't remain LAX or loose, depends on what they want to do. So if they're doing straight ahead, not cutting sports, they tend to tolerate not having the ACL. But if you're playing soccer, it's pretty difficult to to do without. Having ACL reconstructing a lot of sideways movement. But yeah, there's actually, there's a number of people out there who who are living without an intact ACL and doing fine.

32:37 Really. Yeah. It's just it's individualized. Very different. So there's recent studies. I'm sure you're aware that vigorous, regular exercise is is not only beneficial for your musculoskeletal system, but there's evidence that it's it's good for your heart, reduces heart disease, reduces Alzheimer's, reduces diabetes and also mental health. Also valuable. For yeah, sleep, depression, mood disorders in general. I mean, there's really nothing else out there in medicine that is just across the board, right?

33:16 Has implications. Cancer. Is another area right. These studies are are real and people should know about cancer as well. Cancer is, is. There's been a lot of impressive data coming out of cancer, primary prevention but secondary prevention as well. So the importance of exercise during recovery from cancer and how it mitigates a lot of the side effects and then even preventing the cancer from coming back. Right. Yeah. I've read these studies. They're fascinating. But I don't believe anyone's come up with a theory for why exercise helps.

33:48 All these different things, all these chronic diseases that we tend to get. What what's your feeling or opinion? It's. Probably multiple simultaneous things going on metabolically. It's not just about like keeping their weight healthy. There's something obviously valuable and depends on the system. Depends on the issue. Right, still I think a mystery. But there there's no doubt that it helps these things and prevents these things similar. You know, there's an obesity and a diabetes epidemic, especially in older people.

34:24 And again, exercise is helpful for that and reducing the complications that occur from that. How do we get that message across to people? There seems to be an emphasis now on using Ozempic and Moon Jaaro and Mugovi drugs to control those things once they happen, when exercise. Might be a a better way to deal with this. Yeah, I mean it should be part of the conversation. You know, there's there's been a lot of the American College of Sports Medicine and their Exercises Medicine campaign, really trying to get primary care providers and healthcare providers in general to make sure that that's a part of the regular conversation.

35:04 There's exercise prescriptions, there's exercise recommendations and it doesn't have to be anything fancy, it doesn't have to be expensive. Any movement is good movement and doesn't have to take a lot of time. You know, we were talking earlier before we started about some of the literature that's come out about High Intensity Interval Training. So even short bursts of exercise can be incredibly valuable. So, you know, a lot of it's going to whatever fits with you is kind of what I tell people, whatever is going to work for you is is the right exercise to do.

35:36 And yeah, it's keeps people from falling. So we talked about the osteoporosis as you get older, the strength training is so important, it can not only improve the bone density, but it also can help with fall prevention, right? And it's pretty hard to break your hip if you don't fall. So working on balance and strength training you know is really important. And and as you mentioned in elderly not and it's not just directly related to the weight that's been proven as well. It's not just exercise helps you lose weight.

36:08 You know one of the values perhaps of those medications though is that if people do lose weight then they might feel better about exercising. But I ideally they're they're being done in conjunction. Right. I think one of the issues is our job as physicians, we're not doing a great job of it in getting the message across the patients. Like I'm an eye doctor, but I tell my patients, especially ones who have diabetes or I see are overweight. I talked to them actually about exercise and they kind of look at me strange.

36:40 Wait, you're my eye doctor. Why are you talking to me about so? Because it'll help your right, it'll help your diabetes. It'll reduce the risk of you getting heart problems and brain problems. And I think all doctors, no matter what their specialty is, should discuss that with patients because it not only helps your particular specialty but everything else about that patient. So I I think it's important for you and for me to spread that to our colleagues and and let them know there's not enough emphasis of that.

37:14 Well, it's been great talking with you. I learned a lot today and I'm I'm sure the audience has as well. I'd like to thank you very much for taking the time to to chat with us today. Thank you so much for having me. It's. Been a pleasure. Thank you very much. Appreciate. It.