Listen, I think we could have a conference only on this, actually. It's so unexplored and so important. So if you have any questions, we'll stay for a few minutes. I know there are other sessions. So I guess the big question is, and I've had to separate how I treat patients from pure orthopedic to all of this. How do you manage it in your clinic? Is it within your orthopedic slot, or you break out of their time, or you say, I've got this great team of people that I'll hook you up with? So I'll go first. I would say that in terms of all that we talked about today, I definitely am not cutting edge yet. But one thing that has changed in my practice is that I am a lot more aggressive about getting bone density tests, especially in my younger fracture patients. I counsel them. And then I do a lot of shoulder surgery. And if patients have bad bone quality at the time of cuff repair, I talk to them about that, and I recommend a bone density test. So that has changed for me. Right. Go ahead. I also do that. No, I do exactly the same thing. But again, I don't have time, but I do try to have a very low threshold to send them to our metabolic bone people. And certainly, if I have any suspicion, I order the dexamyself, because I agree with what has been said. You can't rely on the primary care doctors to do that. They just don't do it. Right. I have pretty phenomenal non-operative partners. So I always go, I got a great team behind me, and let me refer you. Right. Well, I think it's worth us understanding these, understanding that the answer, and that was the whole point of wanting, when I thought about you as speakers, to bring you together. I think we underserve our patients if we just say, it's not a surgery, find someone, and we need to connect the dots. And I think that's, it's hard. I get it. It's hard. And so the way I've done it is not only building a team, but I have separated office visits, and we have completely non-operative, cash-based, I'm going to talk about this. And then we have completely orthopedic. And we just keep them separate, because this is a huge need. And what happens is when we stay in our only surgical lane, they go out and find alternate practitioners that may or may not be medically trained, because there's a lot of just certifications running around. So I feel like we're the experts. We're the keepers of mobility. So that's my whole soapbox. Thanks for tolerating it. What's your question? »» Hi. Thank you so much, Karina. I'm almost at the end of my speaker. Can you hear me? »» Okay. Can you hear me? There you go. »» There you go. »» Thanks. Thank you for all the talks. I do have a question regarding intermittent fasting, fasting, and protein intake, specifically in the women athletes. So I find a lot of varying literature as far as wanting to do intermittent fasting or fasting for 36 hours to really get the autophagy and the senescent cells cleared out. And then also in regards to like the athlete needing to have enough protein, but maybe making it more plant-based, which actually isn't as easily absorbed by your body as some animal proteins. So kind of finding that balance and how it relates specifically to the women athletes that we treat. Because I feel like a lot of these studies have been done in men. And some of the fasting cohorts that they've been studying, I feel like it doesn't fully capture the hormone cycles and the cortisol spikes that women go through that men might not. »» I was wondering your take on that. »» I think that's a great point. I can touch base on that quickly. First of all, you want to think about metabolism. And what's the point of people doing fasting or not fasting? What do they want to do? Most of my population certainly wants to maintain an ideal body weight and then most of them want to perform to their utmost ability. So I always describe metabolism as this big monster that you have to feed during the day and it can really act against you or it can act with you. And so metabolism wants to be fed. And so when you wake up in the morning, if you're not feeding metabolism and then you go through the day with this intermittent fasting and then you get to the afternoon and the dinnertime, then it's going to store all this stuff because the metabolism monster says, well, I'm going to hold on to all of this stuff and start producing fat because I don't know when you're going to feed me again. So I think especially for women getting to the age of 40 and performance and metabolism, you really want to wake up and I even say kind of your first even eye opening, like keep it in the bathroom where you do pour a little like protein. It doesn't even have to be a shake, but there's stuff that dissolves into water and you pour protein and have a glass of protein when you wake up. And so that starts your metabolism so it knows it doesn't have to store fat. And so I'm a big fan specifically of getting a fair amount of protein before 2 p.m. So you can have something first when you wake up and then have a good breakfast, a good lunch and then really kind of only a snack for dinner. So if you're talking about intermittent fasting, then if you're talking about between like 6 p.m. and 5 a.m., maybe that's something that's okay, but definitely not intermittent fasting starting in the morning to the afternoon. That's actually the worst thing to do. So I think protein is key, especially in the morning and up until 2 p.m. And I think don't do any fasting between that 5 a.m. and 2 p.m. time. And I'll just add to what Dr. Sutton has said. For training athletes, intermittent fasting is very difficult because you have to fuel this, right? But there's a difference between a training elite athlete and a mere mortal person, right? For us, intermittent fasting, it has all the benefits we talked about, but still throughout that time period you choose, you have to get enough protein because otherwise you'll metabolize your protein, right? Especially if you're lifting heavy weights, which is the way we should. So I recommend to my patients one gram of protein per lean body mass. Not your actual body mass, but what your ideal is. Separate it into five because you can only digest so much, right, at a time. Spread across the day so that we don't have these huge spikes in glucose, which then give us all the metabolic problems. So for recreational people, that's how I manage them. For elite athletes, it's a very different story and to starve an elite athlete who needs all that, I don't find in the communities that I take care of that that is a good recommendation and that sounds like what you just said. Yeah. Yeah. Thank you so much. Yes? Thank you for the talks. They were awesome. I have a question in regards to something you said very briefly. For these aging athletes, should we be more of a preventative and prescribe them a therapist that gives them a prehab or recommend a trainer for them as well? Just a question. I mean, you've kind of touched upon my whole patient population where if somebody walked into my office, they're pretty much leaving with a wonderful relationship with a physical therapist, potentially a strength and conditioning coach and potentially a regular coach for whatever event they want to have. Because the problem is each athlete is so different. When you're even talking about metabolism, bone density, I have athletes that are amazing runners. They've always been so, but now they can't run a marathon without getting stress fractures. So I've recommended them to have a marathon coach, even though they think they know everything they need to know about running, they can't keep themselves from being injured. So I think it's tough because the population is usually a Division I athlete or somebody that's played most of their life and they're like, I know exactly what I'm doing. But for me, as soon as a lot of these athletes hit 40, glute strength goes down, core strength goes down, and they don't realize it. So when they usually leave my office, I will have a local physical therapist who I will work with most of them in my area and they're amazing. I'll even go to their offices and see what they do. They usually partner with some sort of strength and conditioning coach, which is really important. And then for my elite triathletes, marathon runners, I do have coaches that'll either do virtual and kind of not too expensive training, but just some way that they're not getting stress fractures and not getting injured every single time they're working out. So I find it to be a huge, huge benefit and it keeps them from coming to my office. So I thank you all for staying. We've run behind and I know there are other meetings. But if you have other questions, those of us who can stay will. Thank you so much for coming. Thank you.

orthopedics

bone density tests

shoulder surgery

protein intake

aging athletes