← The Curbsiders Internal Medicine Podcast
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- [00:00]
A
It's 2026 and we're about to have our three year anniversary of our patreon@patreon.com curbsiders. So to celebrate, we're offering the first 1000 members who sign up free house officer privileges for one month. That lets you get access to 70 plus bonus episodes where Paul and I recap High yield Pearls, answer listener questions and give our picks of the week. It's a lot of fun, so check us out at Patreon. Or you can click the link in the episode description to sign up. Paul, why should you never take sides in an argument at the dinner table?
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B
It's gonna be something about like a main course or something. I don't know, Matt. Why?
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A
Trick question, Paul. It's the perfect time to take sides because no one's paying attention. So bring some Tupperware. Ooh, it's pretty bad.
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B
Yeah. All right. So, Matt, how many Tai Chi masters does it take to change a light bulb?
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A
Oh, topical. I don't know, Paul.
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B
None. The light is within. Now, I don't know what that means, but I have to assume if you practice Tai chi, it is hilarious.
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A
We talk a lot about Tai Chi on this episode. So very topical.
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B
The Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. For the more, the views and statements expressed on this podcast, solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework
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C
and let us know when we're wrong.
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A
Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician, probably the primary care physician, Dr. Paul Nelson Williams. Hey, Paul.
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B
Yeah, probably. Hey, Matt. How are you, Paul?
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A
I'm doing well. We had a wonderful guest, a very enthusiastic guest, talking about healthy aging. This is one of our geriatrics episodes that we're bringing to you with the Penn Geriatrics folks. And Paul, our guest was Dr. Elizabeth Ekstrom. Before we tell you about her and introduce our co host, Paul, what is it that we do on the Curbsiders and why are we still doing this?
- [02:23]
B
We're doing it because we love this and our listeners. And what do we do, Matt? I'll tell you. We are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. As you mentioned, we have a heck of an expert interview for our listeners tonight, but we are also joined by a co host and one of the writers and producers of this episode, Dr. Ashley Randolph. Dr. Randolph, how are you?
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D
I'm good.
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B
Great. Glad to hear it. Matt, would you like to hear about our guest?
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A
I would, but before we get to that I would just like to thank Dr. Rachel Miller, Dr. Leah Witt, the Geriatrics Fellowship folks who have been helping us with this this episode and our Geriatrics focused episodes are brought to us by a grant through the Penn Geriatrics folks. So very thankful to them for that and really excited for people to hear this episode. So let's hear about our guest.
- [03:17]
B
We had a great conversation tonight with Dr. Elizabeth Ekstrom, MDMPH, MACP. She is a Professor and Chief of Geriatrics in the Division of General and General Medicine and Geriatrics at Oregon Health and Science University. Her research focuses on promoting a healthy lifestyle in older adults with an emphasis on Tai Chi which we will talk all about. She has been part of the investigator team for multiple randomized trials that show Tai Chi reduces falls and improves cognition in older adults. Again, we talk about this as well. Her newest book, the Gift of Aging, shares research based strategies and motivating stories of elders to help all of us age with joy, purpose and engagement. And she really does teach with a lot of joy and enthusiasm. You guys are going to enjoy her energy very much. She taught us a lot of practical ways to talk to patients about just continuing to move, how to eat healthy, how to do the things that can actually maintain healthy aging and promote longevity in a way that is actually meaningful to the patients themselves. It was a really fun conversation that covered a wide variety of topics. So without further ado, let's get to it.
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A
Reminder that this and most episodes are available for CME credit for all health professionals through VCU healthurbsiders.vcuhealth.org Elizabeth, thank you so much for joining us and dealing with us through technical difficulties. We're really excited to talk about this topic, but first the audience wants to know what are you enjoying outside of medicine these days? Any hobbies or interests?
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C
Yeah, well, it's wintertime so one of the things I absolutely love to do is ski and my husband and I are just absolutely passionate about skate skiing right now. We just took a trip to Utah and did a bunch of skate skiing, so that's been awfully fun. And then in the summertime I've taken up the new sport of wing foiling, which I happen to live in Hood River, Oregon, the world capital of wind sports. And most of the people in the rest of the world have never even heard of wing foiling. But Google it sometime and take a look and see what it is, and you'll be amazed. And I'm not very good yet, so I'm, you know, don't look, don't look.
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A
For me, this isn't like the same kind of foil they put on the bottom of a surfboard when they pull people into giant waves, is it?
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C
It is, actually, yeah. As a matter of fact. It's like having an airplane wing beneath your board. So it's pretty awesome, and it's a very magical feeling that you really can't get any other way. So I would welcome anyone to come on out to Hood river and give it a try with me.
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A
I think I've seen something like this. It was in a lake, though, so the only waves are by boats, but these are just like. I don't know if they're motorized. And there were these people just zooming around the lake. It was like a cluster of teenagers going around the lake on these things.
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C
Yeah. So you can get motorized ones that you just have the board and you stand on the board and then it goes up on the foil. But the way we do it, when there's wind and water and all the good stuff we've got here in the Pacific Northwest, you have this wing. So there's this, you know, kind of giant fabric wing that spreads out and you hold onto that and you use that to steer yourself in the wind and ride the swells on the river and stuff like that. So it's pretty fun.
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A
That sounds so cool. And I am not cool, but, Paul, this is something that. This sounds fun. I think I could actually get into this.
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C
Yeah.
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B
This has a very WADO hobby feel to it, actually. So I would not be surprised if one day you're out there. Wind foiling,
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A
skate skiing sounds cool, too. I think I could see myself being a cross country skier at some point because it's kind of, you know, I'm kind of an endurance athlete type person. That could be really a thing for me.
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C
Yeah, well, classic cross country is super fun, too. Skating adds a whole nother layer because you're basically on a groomed track, but you've got a toothpick ski that weighs less than a pound each, and you're using skate motions. So the. The kind of intensity of the exercise is tenfold. Or more. It's really crazy, intense activity, but it's again, so incredibly much fun.
- [07:27]
A
See, you're selling it even more to me because
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B
masochism involved in it. I'm like, Matt is going to love this and I've also got a chance. And you're just flogging yourself at the same time. It's perfect. And every 10ft or so someone punches you right in the throat. Matt would be on board in a heartbeat.
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A
All right, Paul, anything else you want to ask? Because we are going to get to an actual case.
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C
Sure, I'll ask.
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B
My usual. Elizabeth, we always like to hear if there is any advice or feedback that you have either received or that you like to give that you found especially helpful or find especially helpful.
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C
Yeah. Well, being a geriatrician, I'm all about having people find joy and purpose and meaning in their life until a very old age. And you want to start as young as you can with all of these healthy aging things we're going to talk about tonight. But you also just want to ensure that you're living your best day. I mean, you never know what could happen to any of us any day. And every day is what matters. And healthy aging is all about living each day to the best of our possibilities. So that's my mantra and that's what I tell my patients and tell everybody I see. Live your best day.
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A
I don't think anyone can argue with this message. I feel like there's so much controversy in the world right now, but I feel like this is just like a message that I'm sure there's some contrarian out there that's going to want to argue with you about this, but it just seems like such good advice.
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C
Yeah, well, you know, so many of us in medicine have had this delayed gratification for so many years. Right. We went through medical school and residency and fellowship and, you know, you're just working so much and you feel like every day is kind of tough. But I just tell everybody, all of my learners, I say just stop and enjoy it. Look at your opportunities today and these amazing patients you get to meet and these amazing teachers you get to learn from and live your best day and get outside and do something active.
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A
All right. Ashley is listening very intently and she's ready to do that by reading a case from Cashlack.
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D
Ms. R is a 65 year old female who comes to your office for her first Medicare annual wellness visit. She has a past medical history of hypothyroidism, hypertension and prediabetes she has recently retired and is interested in learning more about how to keep busy, both physically and mentally.
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A
All right, so this is a major life transition. What is your experience? Or like, where do you think we should be starting with people? Because this does actually come up. I was actually talking to somebody about this kind of thing today, somebody that had retired and actually a couple people that retired even earlier than this. And we're really struggling with like, what am I going to do with the next, like 40, 50 years.
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C
Yeah, well, that brings up a great question, because the question, do I retire or not? Is the first step you need to take. And I have to say, there's a lot of literature out there telling us not to retire. If you have a terrible job that gives you back pain and no satisfaction and you're just grinding away every day, and there's something that you could be doing in retirement that would get you to be more active and lose some weight and have more purpose, great, retire. But if you've got a job that you enjoy and that gives you purpose and that allows you to have communion with other people and get out into the world and do things, and retirement might be the worst possible thing you can do. And just for a few statistics about retirement, short term memory declines about 40% after we retire. Within five years after retirement, we tend to have about a 5 to 16% worsened mobility. We have more chronic conditions, mental health problems. There's a 40% increased risk of heart attack and stroke in the first year after retirement. I mean, all of these things for all of these reasons. It's actually ranked number 10 on the list of 43 most stressful life events. So retirement can be very stressful and one of the kind of magic places in the world. Or there's five of them actually, the blue zones. I haven't checked all of your podcasts to see if you've had somebody talk talking about the Blue zones before, but there are five places in the world where people are known to age best and that have the highest percentage of centenarians across the world. So like Sardinia, Italy is one of them. And Ikaria, Greece and Nicoya Province, Costa Rica, one in Japan, and then the fifth one is in the Seventh Day Adventists in Loma Linda, California. But these places have this amazing, amazing amount of people who live to be over 100. And the word retirement does not exist in their languages. They are in their 80s and 90s, they're still out pruning olive trees, they're going fishing for their family, they're doing, you Know, taking care of grandchildren and great grandchildren and great, great grandchildren. And there's just no such thing as retirement. So, you know, that's kind of the first question to ask. If you've got people that you're seeing in your clinic and they're thinking about retirement, you is this the right thing to do? And it's our entire mentality in the US Is, oh, we gotta make it to retirement, and then life is gonna be great. And that's just not true. So, you know, when you're counseling your patients, always stop and think, you know, is retirement the best choice, or are there things you could do? I mean, could you cut back but still keep the best parts of your job or maybe move into a different role that's a little bit less stressful but still allows you to have purpose? So, you know, that's the first thing I always say is, you know, why do you think you want to retire? Is this really the right thing to do? Especially as young as 65? I mean, if you think about it, a lot of us have 30 to 40 more years of life after age 65. I mean, essentially, that's the same as, like, going from finishing high school to age 65. You've got that entire span of time that you're still going to live. And do you, you know, how often can you go on a great trip or learn to cook Persian food, or you do all sorts of different things that are going to keep you interested through retirement. Is that really going to last for 30 to 40 years? It's not. Matt's like, oh, my goodness. I guess I'm not retiring anytime soon.
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A
I'm just thinking, I mean, that's a lot of life, Paul. I mean, I'm just.
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B
I'm not worried about it. The chances of me living that long are real slim. So, like, I still. Still should probably retire.
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C
Don't count on it, my friend.
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A
But this is really a paradox. I know what you're saying. I mean, that is. I think most people think about, oh, I just. I want to retire. You know, they think retirement will be this magical time where they'll have more money and they'll have all this time to do all the things they wanted to do. And then a lot of my patients who are about to retire, they kind of do. Some of them do know this. They're like, you know, I had a friend who retired, then he started having all these health problems. And, you know, they start to get worried about that. So I wonder how much of it is actually just that these problems were building up and now they have time to actually go engage with the healthcare system. So you're finding these things, but, I mean, you don't find a heart attack or a stroke. So do we have, like, mechanisms for this? Is it just like when you lose a sense of purpose in life that you just. It's bad for your cardiovascular risk?
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C
Absolutely. So, you know, if people are active on the job and they retire, their activity level might go down. I mean, you know, we always say, oh, yeah, I'll retire and then I'll just be biking 100 miles a day and all this great stuff. But there are plenty of people who don't do that, right. They retire and they wind up being quite sedentary and you could totally improve your diet and do all the healthy things after you retire. But a lot of people don't. They lose their social connections. They might have a lot more alone time. And we know that social isolation is terrible for your health. Right. It's just bad as smoking 15 cigarettes a day. I'm sure you've had that on some of your podcasts. And so there's just. There are so many factors that play into the whole retirement time, and the loss of purpose is enormous. That is a huge factor in our health, both mentally and physically. So, yeah, I mean, I would ask anyone to think twice about deciding to retire and especially deciding to retire at 65 or earlier. You know, maybe, maybe 70, maybe 75. Just, you know, find things that are going to keep you engaged and keep you active and keep you, you know, keep you getting up in the morning and going to work. Doing something is incredibly important.
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A
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B
so for Ms. R, who has made the catastrophic decision to
- [20:03]
C
retire, she already did.
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B
And now the ship has sailed. Pandora's box is open and she's coming to us and just sort of asking for general advice in terms of sort of staying busy and staying physically and mentally active. Do you have general advice or even specific advice to give? I guess. Where do you point patients like this in terms of how they should be spending their time to make sure that things remain meaningful and they remain healthy?
- [20:26]
C
Yeah. So this is where we dive into the healthy aging. Right. So if you've retired and now you've got all this time on your hands, you don't know what to do with it. I say your next job is exercise. And, you know, get out there and really get started on a super healthy exercise program. It will take a major chunk of your day if you really do it. And then, of course, healthy diet, doing more cooking on your own, eating out less, like learning how to cook super healthy foods on the Mediterranean diet and doing more of a plant based diet, taking care of the social connections, making sure you're seeing family members, grandkids, anyone that might be close enough to you. Hopefully you're not living totally isolated, 1,000 miles from any of your family. And then, you know, I really spend a lot of time working with people on finding a good volunteer opportunity. And it can be easier said than done. I mean, you know, if you're still pretty healthy and active, you can volunteer to, you know, teach, you know, little leagues, baseball or soccer, you know, soccer coaching or, you know, things where you're really getting outside. If you don't have as much physical strength anymore, you can, you know, go to the library and read to kids at the library. You can, you know, I tell people to volunteer at the Oregon Historic Historical Society. They've got a great program there where people can go in and if they're at all a history buff or just want to learn more about history, they can do that or volunteer to be an attendee at the symphony or whatever and just kind of get out and do something that has purpose. If you did have a pretty high power job, that you have a lot of skills at an executive level, join a board. There are so many charity organizations that need board members and then. And that has a lot of purpose. And you can really keep yourself busy doing those kinds of things. Go to a community center or a senior center, take classes, learn something new, do art, do their tai chi classes, go to their community lunches, all of those kinds of things. And many of these places you could say, well, but I'm stuck at home. I don't drive anymore. I've got health concerns. There are lots of ways to have transportation included when you do some of these volunteer opportunities or when you go for exercise classes. So in our community, many of our community centers also provide free transportation to come in to the center and take a class or do some exercise, things like that. But most people don't know about this, and it takes some time to kind of figure out what's possible for you. So I spend a lot of time talking with people about what they could do and what's gonna work for them. I always try to tap into what they've enjoyed in the past and try to get them restarted on something that is along those line, things that they've already enjoyed and are familiar with.
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A
Do you have some handout or resource? I know you've written books. What do you think? Is there a source that you point people to or a handout that you give them when they're thinking of retiring that kind of talks about this kind of stuff? Because I feel like we can talk to patients in the room and it makes sense to us, but then they forget so much of it very quickly.
- [23:47]
C
Yeah, yeah. Well, that's why I wrote a book. I've got it right here, Gift of Aging. And it does talk through some of this and give some ideas. But I also, you know, I use our community centers as good resources because a lot of them have, you know, this whole list of events that are happening and classes you can take, and they're, you know, they're in the community and they're wonderful. I mean, I go to the community centers and give talks myself, and so I know what they're like and I know what they have available to them. And so I use them a lot as resources. But all communities have some resources. Like we've got an Asian American community Center. That's amazing. And if people have that background, I can refer them there and they come back to me with these giant grins on their faces. So it is kind of finding what's in your own community and just doing a little bit of outreach that the Alzheimer association has some good classes, good resources. I refer people there, just whatever's going to make sense for them. It's very individualized. And I mean, there's no one stop shopping for finding the right resources in your own community. But we have a great behavioral health team, and oftentimes they can point me in a good direction if somebody needs volunteer opportunities. So I use my behavioral Health specialist to help me out with some of these questions. And even if people are at a point where they need to maybe not live independently anymore, they need to move to assisted living or something like that, a lot of those places have resources as well. So I'll be like, go have lunch at this place. They'll give you a free lunch and find out what other resources they're offering. They'll take bus rides to the symphony and all of these various things that can get people engaged. And. And Portland's a great place. So I think we have a lot of resources like that, but I think looking around, you'll find some in your community as well.
- [25:57]
A
I have a family member, and I don't want to name the person specifically because they're a private person, but I've been impressed at how much since retirement. It takes a lot of effort to fill the time, but they've. They've had this, like, developed this whole new schedule and life and routine and everything, and it's working well. And I think it's a lot of these things that you're saying, and I didn't realize how smart this person. I knew this person was smart, but now I'm like, even smarter than I thought. They're doing a lot of these things, I think just intuitively, I don't know, maybe they read your book and now I'm gonna have to ask them. But anyway, so that's great. Well, Ashley, how about reading the next part of the case?
- [26:40]
D
In further discussion with Ms. R, you learn that she lives alone and reports that outside of work, she previously spent most of her time relaxing and watching television. Her diet includes some fruits and vegetables such as cucumbers, grapes, and bananas. Though she notes that preparing healthy meals for one person is challenging. She has come across information online about strength training and protein supplements and is unsure what information she should believe.
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A
So tell us. Yeah. What would you start? Where would you start with her?
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C
Yeah. Well, the hardest part is that she worked, but now she lives alone, and all she's ever done is relaxed and watched tv. So how are you gonna transform this delightful woman into somebody who's out exercising regularly, eating a super healthy diet, spending time with friends, maybe reconnecting with friends that she's lost touch with, or making new friends at the community center or a local pool or a, you know, arts built, you know, building or something. And it's. It's tough if. If your main, you know, if your life has been dedicated to your work. Do we. What work did she do, Ashley?
- [27:45]
D
Do we know Warehouse work.
- [27:48]
C
Warehouse work. Okay. So she was on her feet a lot, and she. But she, you know, it was not something that was kind of stimulating her brain that much. I mean, I guess if you're in a warehouse, you got to remember where about 10,000 different things are, right? But it's, you know, really kind of of talking with her and thinking through what's going to make the next 30 years really productive and valuable for her. It's going to take some time because she doesn't have any hobbies that she's identified for us yet, and she doesn't have skills and exercise. She doesn't have skills and diet. She doesn't have, you know, she's living alone. So she's at very high risk for social isolation now. So I would just start by saying, you know, what. What's most important to you? Like, what matters most to you and what's been important in your life so far? And what could we do to try to ensure that the things that you care about and are passionate about are things that you can continue to do moving forward? And a lot of times when I ask that question, people will say, well, I've got some grandkids, and I always hope those grandkids are local so that they can actually spend time with them, but we can focus on family a lot. And then the healthy aging can be a motivator for being able to spend more time with your grandkids. Like if you're starting to have some mobility issues or maybe have some weight issues or chronic conditions that are a problem, but you still want to be able to play with your grandkids, or you still want to be able to take them out for dinner or whatever. That can be a fantastic motivator to get started with healthy aging. And I usually start with diet and exercise. You're going to get the biggest bang for your buck that way. So then, okay, what do you think about. Well, we can start with exercise. And honestly, exercise is so important. Matt sounds like you're a good exerciser. I love that. Paul, I don't know if you're going to confess just how great you are about your exercise routine.
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B
Nope.
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A
Paul runs a lot. Paul's a runner.
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C
He's a good runner. Excellent. Running's fabulous. But I'm going to spend time with her, really trying to think about what she enjoys doing. Does she like to walk? We talk about healthy aging. How many doctors around you tell people, just get out and walk. If you walk two miles a day, you're going to be great. Not okay, that is not enough for healthy aging. So you definitely want to do some aerobic exercise, brisk walking, riding a bike, something like that for 30 to 60 minutes every single day. This terrible requirements that have been set forward by the US Are so under. They're so underrepresentative of what we should really be doing. But then the strength training. So she's already mentioned that she might be interested in strength training, or maybe she just read about it and she's really not interested. I hope she is. But strength training is just critical to successful aging. I mean, if you can do 30 to 60 minutes of strength training two to three days per week, you are going to maintain your mobility so much better. You're going to reduce your falls. You're even going to reduce dementia. It has such a. Such good cognitive benefits. So the strength training routine is absolutely vital. And then stretching and balance. So you already know I'm a big Tai chi fan and have done a lot of randomized control trials of tai chi, and we found that it reduces your risk of falling by probably 60%. I mean, that is huge, right? Going to physical therapy or doing other types of exercise only reduces your risk of falling maybe 20%. So it's the tai chi that really makes a difference. Okay, I'm going to turn it around and ask you all a question. How much fall risk reduction do you get from walking? Somebody shout out an answer.
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A
Paul.
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B
5%, 6%? It's going to be like an increase in falls because people are walking around without stability, they're going to hit the ground more often. I feel like you're trying to fool us.
- [32:00]
D
I'm going to go with 10%.
- [32:01]
C
It's zero percent. Walking does not reduce your risk for falling. So it's great for. I tell people that walking is great for your heart and lungs. It's bad for your back, it's bad for your hips, it's bad for your knees, and it does not reduce your risk for falling. So if somebody's already concerned about falling or having some difficulty with their mobility, getting started on Tai chi is just absolutely critical. And that should be ideally a class two to three days per week for an hour. A lot of community centers do it. We've actually done our randomized trials and then gotten funding through CDC to be able to disseminate that across the US and there are many states across the US that actually their community centers teach our Tai chi program, which is called Tai Chi for Better Balance. So older adults can find that program in my community. It costs them between one and five dollars per class. So it's very inexpensive and affordable. Yeah, exact. Exactly. Right. And so people can get, people can do their Tai Chi classes a couple days a week and just make a world of difference. And a lot of people who start doing Tai Chi classes then find their community as well. Right, because you're going to class every week and you're meeting people who are like minded. And I've had people who started in their 70s, they're still doing it in their 90s. They've now got these friends that they've had for 20 years. So doing Tai chi helps you develop a community. And I've got patients now who started in their 70s and they're still doing Tai Chi in their 90s. And now they've got these friends that they've had for 20 plus years that do Tai chi together and then they'll have lunch together. And it just, you know, they motivate each other to keep going to the class so they don't wind up dropping out and becoming, you know, having worsened mobility, all of those kinds of things. So it's incredibly important to have this, you know, really great exercise program and that when you're first retired and now all of a sudden you have all this time but you haven't been exercising regularly. Getting started on a great exercise program can be kind of life changing, but it can also take up a lot of your time while you're learning it. And there was a patient in our practice who came in and he said, I want the optimal exercise program. So we gave him this program that basically takes two hours a day because it's 60 minutes of aerobic exercise, and then three days a week, 60 minutes of strength training, and three days a week, 60 minutes Of Tai Chi. And so then we got a message back back from him that he wanted to change doctors because it was absolutely ridiculous that we asked him to exercise for two hours a day. So there's push and pull here. You want to start with something that they think is feasible. But I do try to help people understand the value of really being able to have a good exercise routine.
- [34:55]
A
Yeah, Matt, and I think the U.S. the guidelines for Americans, the exercise guidelines that say 150 minutes of moderate intensity a week.
- [35:02]
B
Week.
- [35:03]
A
I almost wonder, because we know that it's like exercise, if you think of it as like a medicine, and the higher the dose, generally you keep reaping benefits. And it's the rare person that can exercise so much that they actually are harmed from it. But I wonder if it was just like they're like, well, people are not. People are going to have trouble just hitting 150 minutes. So let's just put a low number. I know. I guess there's observational studies that show that, like, 150 minutes or more, those cohorts do better.
- [35:32]
B
They do.
- [35:33]
A
I agree with you. It's a pretty low ball.
- [35:35]
C
It's not optimal. So, you know, you do plateau. There is a plateau where you do enough exercise and then you really don't need to do more. That plateau is, on average, approximately eight miles per day. So if you run eight miles every single day, you've probably reached your plateau. Now, of course, I have people do strength training and other things, but really, eight miles, that's at least two hours for somebody in their 70s and 80s. Right. So that plateau is pretty high. You can do a lot.
- [36:08]
A
Yeah.
- [36:09]
B
Can I ask, since it's come up and we're emphasizing it so much, and I feel stupid, but this is kind of my role in the show. How do you explain what tai chi is to your patients? I get the sense that it's purple soul movements. I've read about 7,000 studies that it's great for back pain and preventing falls. And. And if someone's like, so what is Tai chi? I'd be like, oh, you like. You move around and I think you stand on one leg sometimes. I don't know. So you do this with your hands?
- [36:31]
A
Yes.
- [36:31]
B
Thank you, Matt. I think you have to wear a robe. I'm not entirely clear on that, but. So could you explain if I'm explaining to a patient what Tai chi is, if they have interest, just so I can kind of propel them forward, because I'm not sure I would do a good job if I was asked.
- [36:43]
C
Yeah, absolutely. So I just start by saying it's a gentle martial arts form. And, you know, if you ever saw the movie Karate Kid, that is Tai chi. So, you know, it's something that you can do at any time.
- [36:56]
B
You just nailed your audience.
- [36:59]
C
You know, you don't have to wait till you're older. You can. You know, kids can do it, too. So it doesn't. But it's a gentle movement. And basically what you're doing is you're putting yourself in a situation where you almost fall. So you're stepping outside of your. Your rotational comfort movement, and you're taking these steps, one side and the other forward and back. You're taking these steps, and it's increasing your rotational safety and increasing your core strength, so that if you start to almost fall you have a better ability to right yourself. Okay, so that's part of it. It's that kind of truncal stability that you're really honing in improving. The second piece of it is that it's dual learning. So you are making physical movements by moving your body in the Tai Chi movements, but you're also doing mental movements because you have to memorize the moves. So anytime you dual task with physical and cognitive exercise, you're getting double benefit. So that's why it's so good for cognition. And one of our studies that looked at people who had kind of mild cognitive impairment who did Tai Chi, they gained three points on their MOCA scores. And on average that's like six years of cognitive health. So these are people over 70, these are people who are a little bit older, already have some cognitive changes. And you're basically giving them back six years of cognitive health by having them do Tai Chi that's enhanced with kind of cognitive training and making sure that people are really engaged in that cognitive part of it as well. So it's an amazing thing. And you're right, you started to name some of the benefits from it. And it reduces arthritis pain in your knees. It's actually at least equivalent, if not better to PT for knee pain. It reduces pain of fibromyalgia, reduces blood pressure, reduces cholesterol, increases 6 minute walk distance for people with heart failure. I mean, and it's just the list. It decreases depression, it improves sleeps. One of our trials showed that it makes you sleep 17 minutes sooner and 42 minutes longer. It just has these kind of remarkable. If it were a pill, the entire world would be on it. Right? But it's Tai Chi. And then what I do is I go to YouTube right in the room with the patient and I pull up my Tai Chi for better balance with Suman Barkis, because he was our master trainer. And I show them the YouTube video and it's 12 minutes. It's not enough for them to do for the rest of their lives, but it gives them a start. And I say, you can try this at home and before you go to the class, because if you try it at home and you start to learn some of these moves a little bit, you won't feel quite so self conscious when you get to the class that I'm going to ask you to go to next. So we start with YouTube. I show them a few of the things in the room. I might even have them try a few of the things in the room if their mobility is already Kind of poor. I'll have them do a seated one instead of a standing one and then gradually move to standing. Or if their mobility isn't terrible, but it's not great, I'll have them put a chair in front of them and have one arm on the chair and the other arm is doing the Tai Chi moves and then switching so that they have the stability of the chair. In our first trial, our first Tai chi trial, this 89 year old guy comes in and he walks down the hall to get randomized for our trial. And he is using a walk and he has an oxygen tank, right? And he's 89. And as he's walking down the hallway, I was like, oh my goodness, why didn't we have exclusion criteria for walkers and oxygen? But we didn't. So then I'm like, oh, please get randomized to sit and stretch. Please get randomized to sit and stretch. Well, of course he gets randomized to Tai Chi. So I went to his first Tai Chi class and I said, sir, you cannot break your hip in this class. We don't want our study to have a bad outcome with a hip fracture. And so his instructor was great. So she had found a roll of duct tape and she took the walker and she duct taped the walker to the floor. And then she duct taped the oxygen up the walker so he could hang onto that walker, which was totally stabilized. And his oxygen was. He was not going to trip over the oxygen because. Because it's out of the way, but just coming to his nose. So six month trial. the end of the trial, guess what?
- [41:43]
A
He didn't need the walker anymore.
- [41:46]
C
No more walker. Walker was gone. He didn't have to use the walker. Guess what else?
- [41:52]
A
Did he come off the oxygen too?
- [41:53]
B
I don't know how he.
- [41:54]
C
No more oxygen. Yep, he was able to come off the oxygen as well. So that's just like one of my stories that is so amazing about the value. And he was 89, so it is pretty incredible what Tai Chi can do for you. You.
- [42:08]
A
I was going to ask about Tai Chi. I think of like meditation and breath work as almost like parasympathetic training. Is there a component of that to Tai Chi as well?
- [42:18]
C
Oh, absolutely.
- [42:19]
A
Yep, there is.
- [42:19]
C
Yeah. It's very meditative and it's very slow. You know, a lot of people who are more fit are like, oh, it's too slow, I can't do this. And I'm like, yes, you can. It's so valuable. This is good for you. You know, you've been Working for the
- [42:32]
A
last year, it sounds like people like me need to slow down.
- [42:35]
C
Yeah, you're finally retired, so you're. You can slow down and do your tai chi. And then three months later they come in and they're like, oh, thank goodness I started tai chi.
- [42:44]
A
Yeah, but I just mean people that need to slow down. People are like, it's too slow. They're probably the people that need it most. They need to slow down. They need to take. They're probably amped up all day and need to slow it down. I'm projecting, Paul.
- [42:59]
B
I'm just picturing you, like teeth gritting, like, I'm gonna be the best tai cheater. You're just like, you're just in competition with everyone else in the room.
- [43:05]
C
Well, that's why it has such great benefits for sleep and depression. You know, it just gets people into this very meditative space.
- [43:16]
A
Full disclosure, what I'm about to say is a sponsored promotion for locumstory.com but don't worry, there's no sales pitch here. Just a friendly heads up about something you might be locum tenens. It offers physicians a higher paying, more flexible way to work. Work Locums lets you take control of your schedule with part time or full time work or even assignments on the side of your day job. It also gives you a chance to try out new practice settings, travel to new destinations, all while still doing what you love. So if this isn't a sales pitch, why does it sound an awful lot like we're selling locums? Well, here's the catch. Locumstory.com is literally just a free, unbiased resource dedicated to educating physicians about locomotives. Locums. That's it. There are no salespeople, no commitments, just free information. Think of it as your go to guide for everything you'd ever want to know about locums. How it works, how to get started, and how real doctors are making it work for them. So whether you're simply curious or seriously considering a change, pop by locumstory.com to see if it's something that makes sense for you. That's locumstory.com. Okay, so we talked about how strength training is important two or three times a week, that we want them walking eight miles a day, we want them doing cardio more than the 150 minutes that are prescribed per week. And so 30 minutes a day, at least of some sort of activity. And the other thing we had asked about was diet. And as we're talking about diet, I would like to hit on protein a little bit too. So how do you tell somebody like Ms. R, like what to prioritize? You mentioned Mediterranean, but what's like your general spiel on diet?
- [45:04]
C
Yeah, great. So Mediterranean diet is the diet that has, you know, withstood the test of time since the 1950s, is kind of the healthiest diet in the world. No other diet has been proven better than it, you know, like some people will try to do Mediterranean plus with, you know, green teas and all sorts of extra stuff. Stuff it's not better, at least not enough better to make it worth it. So the healthy fruits, vegetables, I tell people to get five colors every day. You want to lean towards the low glycemic index things which are not grapes and bananas, they're berries and apricots. And the vegetables, you want to lean towards beans and legumes and all sorts of greens and colorful things. Squashes and peppers, all of those tomatoes, all of that great stuff. Bright, bright foods and colors. And so that's the mainstay of your diet. And you really want to work with your patients to kind of move away from the white potatoes and move away from the grapes and bananas. Avoiding white carbs is kind of a nice mantra. White pasta, white bread, white potatoes, those kinds of things. So you want to have really colorful fruits and vegetables and that's what your diet hinges on. And then protein is, is absolutely the most important. Next thing I talk about, and I recommend people try to get 70% of their protein from plant based sources. So lentils, beans, all of the nuts and seeds and things that you can get protein from are so important. And we should be eating those in our diet every single day, probably every single meal. For plant based sources of protein, whole grains, quinoa, farro, all of those different things are so incredibly important. And then for the, for the animal based things, low fat dairy, low fat, like a low fat Greek yogurt, high protein Greek yogurt is excellent. Low fat cottage cheese is excellent. Egg whites are great. If you want to have breakfast with three egg whites and just one egg yolk, you're going to have a much healthier breakfast that way. No red meat. There's no red meat on the Mediterranean diet. But lots of fish, salmon, the kind of cold water fishes are fantastic for the Mediterranean diet. Not too much chicken. Actually, that's fairly minimal. I mean, there are people who kind of cross over into the DASH diet. And the DASH diet does have quite a bit of evidence for it, especially for lowering blood pressure. The key for DASH is That it tends to be lower sodium, but it does allow more chicken breast and maybe a little bit more dairy, which is probably okay. And it definitely helps get you more protein. I always encourage people to get 1 gram of protein per kilo of weight. So you know, if you weigh 130 pounds, that's 60 kilos. You want to get at least 60 grams of protein per day. That's easier said than done. You know, you can have like half a cup of, you know, chickpeas or some kind of lentils or beans is somewhere around like 13 to 15. So that's a pretty good sized serving. But that it's a, that's a pretty good portion. If you do eat meat or eat fish, I should say you're not eating meat of course, but, but you know, if you eat fish, a full can of tuna is usually 30 grams. So that's a pretty good chunk of protein right there. But if you're really working to get the 70% from plant based sources, you're going to want to focus on getting some nuts or having peanut butter toast in the morning with a super high grain whole grain bread that has quite a bit of protein in it. Protein supplements aren't terrible. I mean, if that's what you want to do, that's okay. I think, I think you don't have to. If you're willing to get protein in your diet. All of the things I just mentioned absolutely taste delicious. Why would I eat whey protein instead of all of those things I've mentioned? But you certainly can add protein supplements. I mean you can make a smoothie in the morning with low fat Greek yogurt and some low fat milk and some fresh peaches and blueberries and maybe just a touch of honey because you're trying to stay away from sugar. But that's a wonderful high protein breakfast that's so easy to make. And I think Ms. R can probably learn to make smoothies that are going to be pretty healthy for her. So if people want to supplement their protein, I'm not against it by any means, but they can get pretty expensive and they are more processed. I mean we haven't talked about ultra processed foods at all and I don't know that we need to because everybody knows they're so bad. But if you're using protein bars or even some of the protein supplements, they can be more processed. So I don't have people try to do that a lot. But if they want to supplement a little bit, that's fine.
- [49:55]
A
And tofu, tempeh, soy, any Issues.
- [49:58]
C
Yeah, those are great. It's sometimes harder to get people to use those. I mean, my problem with soy and tempeh and all of those kinds of things is that I like to eat them with soy sauce, like in a stir fry. And then you're just getting a wicked amount of salt, which is not good for you either. So, you know, if you're using some low sodium soy sauce and you don't put very much of it on, and you do a great stir fry with beautiful vegetables and pea pods and carrots and squashes and mushrooms and all of those great things, and then you add in some delicious tofu. That's a great choice. Tempeh is supposed to be really nice for vegans just because it has so much B12 and some other great vitamins to it. There are a lot of people who find that a little unpalatable. So it's hard to cook it well to make it taste really great. But I eat it once in a while and try to find good recipes for it.
- [50:55]
A
I know our keto listeners are going to be upset that we're not eating full egg yolks and that we're not eating as much meat.
- [51:05]
C
But, yeah, red meat, no more than once or twice a month.
- [51:09]
B
I'm just imagining Matt, the authors of the new USDA guidelines, just crying tears made of whole milk after they hear this episode.
- [51:14]
A
Just because.
- [51:16]
C
Exactly. Yeah. I. I mean, so some of those new guidelines, I mean, if you want to drink whole milk instead of 2%, you just have to drink less because you're getting more fat and more calories. Right. And you're getting less protein. I mean, it's replacing protein with fat. It's also replacing carbohydrates with fat. So, you know, so sugars, I mean, milk actually has a fair bit of sugar in it. So if you eat the full fat milk, you've got a little more fat and a little less sugar. But it does come down to you gotta watch your calories too. And, you know, for every 10 years we get older, we have to eat about 500 less calories. So if you can eat 3,000 when you're 40, you can only eat 2,000 when you're 60. Right. I mean, it probably doesn't start quite that young. If you can eat 3,000 at 60, you can only eat 2,000 at 80. Right. But you do have to monitor the caloric intake as well. And a lot of those things are very high calorie.
- [52:12]
A
Okay, so to the audience, I don't wanna. We're not Meaning this to be controversial. This is healthy aging. Uh, let's not. Let's not fight about. We were. Paul and I were texting with a colleague about this the other day. How. Just people get so angry if, like, if they are. It's almost like a religious fervor or like a. Almost like a political, like arch rivals. Like, when you're talking about a diet, like, if you're like, you like Mediterranean, they like keto or something else, and they. They take it, like, personally that you. That you subscribe to a different dietary pattern. Okay, so Mrs. R. So we've got her on a Mediterranean diet. She's eating. We're going to steer her towards some better fruits and vegetables, some fish, lots of beans, lentils, nuts and seeds, tofu, tempeh, if she can stomach them. And I think. And then we have her doing her strength training, and she. She's on the way to. And she's also going to get involved socially, which we really stress how important that is, and trying to find some way to fill her time. So she still has a sense of purpose. Of course, she's doing tai chi, so I think she's on a good path for her retirement. Ashley, am I missing anything else, or do you want to go to the next case? Was there anything we missed here that you can think of?
- [53:37]
D
No. I mean, I guess the only thing would be if someone had chronic pain or mobility limitations, would your recommendations for physical activity change.
- [53:44]
A
Good question.
- [53:46]
C
Yeah, great question, Ashley. So I think you certainly have to think about what their condition is and what's going to be manageable for them. I mean, if somebody's been in a. And I mean, I had this exact case. I had a patient who was in her early 80s, and she had been in a wheelchair for 15 years. When she came to see me, and I said, why are you in a wheelchair? And she said, because of my arthritis. And I was like, well, arthritis shouldn't put you in a wheelchair. Let's get you up. And so I started her on some chair tai chi, and I got her some PT, and within about three months, she could walk 800ft. Now, that's not very much, but it's better than being in a wheelchair all the time. And her pain level had gone from an average of like 6 to 7 down to an average of 3 or 4. So, you know, and if somebody doesn't have too much pain now but are willing to start an exercise program, I tell them, you might have a little bit of pain. You know, you're using some muscles for the first time that you haven't used in a very long time. So, you know, you might have a little bit of muscle soreness. But we do want to do. We want to start slow, we want to go slow, but we want to, you know, we want to have you gradually increase so that, you know, you can get to a place where you're much more fit. And so I start where people are, you know, when, if they're stuck in the wheelchair, it's chair tai chi and it's just starting doing some standing, doing sit to stand exercises. That is a great exercise and it's free. You don't have to pay anybody anything to do sit to stand exercises, right? If you can just do 30 a day to get started. And so start where you are. And if you can only walk five minutes, I say, well, then walk five minutes six times a day to get your 30 minutes total. And you, you know, if motion is lotion, that's another mantra I'm sure you've heard a million times. But if somebody's a little bit older, their pain is from arthritis or they've got some neuropathic pain, they've got some sensory deficits, those kinds of things. If you can get them to move more often, even if it's a slow pace, even if it's not very much to start, it's going to transform their lives and they're going to have so much less problems with pain. Of course, I give them all the pain strategies. I have them take some Tylenol arthritis, which tends to work better than extra strength Tylenol. I have them use a heating pad anytime they're sitting. I have them use diclofenac gel for their knee arthritis. I mean, I try to do all of these non pharmacologic and mildly pharmacologic strategies to help reduce their pain. I mean, you can tell I'm a cheerleader, right? I really do try to convince them that the way they are going to have life less pain is by being more active and that it's really important that they increase their activity level to get rid of their pain. I was like, I mean, I say if I sat in this chair, if I don't even sit here in a chair for 45 minutes, I mean, I'm on a ball, I'm on a movement ball. So I'm dynamic even as I'm sitting right here. If I sat still in a chair for 45 minutes, I would be stiff. So I don't know how anybody can sit for six hours a day. In a chair. Right. But you do have to get to where they are. You can't go over the top and say you have to get to eight miles a day. You have to start with, can you walk five miles? Okay, let's do that three or four or five times a day and get started there. Yeah. But I do a lot of work with pain management. I send people to physical therapy, of course. Cause that can be really helpful. And if they are homebound and they qualify for home home health pt, that's great. So there are lots of ways to get them started and get them some resources. But in the northwest and in a lot of states, actually, the community centers do have various exercise classes that you can go to and get started with something that's going to be possible for you to do.
- [57:48]
A
There's almost no conditions where people should just stop moving and just sit perfectly still all day. We talked about this, how there's guidelines for people actively going through chemo that say you should keep doing aerobic and even resistance training, that you'll tolerate the chemotherapy better. And I think we, as physicians, we're not really taught to talk to people about exercise and fitness training. It's something we're starting to do more on the show. So I think the message just hasn't got the patients. And a lot of us kind of just assume, oh, you have heart failure, you have arthritis, you're going to stop being active now. And we just accept it. And I think patients accept it too. But it definitely has to change because like you said, people have 30 or 40 years left, whether they're 60s and they have something happen to them, they got to keep going.
- [58:41]
C
Yep. Yeah, I thoroughly agree with that. And there should never be a time in your life when you're sedentary. Like, you know, I have people who, I'm like, you gotta get up and move every 10 minutes because your back is sore and your knees are sore and your shoulders are sore. And if you sit for 10 minutes, you're going to stiffen up. So I want you up and moving every 10 minutes. And like you're. They say you're crazy. I'm like, just try it. And then they come back a month later and they're like, oh my goodness, I feel so much better.
- [59:07]
A
You might be crazy, but it's the right kind of crazy. That's my assessment. All right, Ashley, let's get to our next case.
- [59:15]
D
Okay, Ms. E. She's a 79 year old female with a past medical history, history of type 2 diabetes, hypertension, and Colon cancer. She comes to your office for routine follow up of her chronic conditions. She denies any acute complaints, but shares that her family has expressed concern about her mobility. She reports worsening balance in several near falls over the past few months. Mrs. E questions the level of concern, stating that at her age she believes these changes are simply a normal part of aging.
- [59:44]
C
Show her the 84 year old who just finished a marathon or the, you know, the hundred year old woman who, who's like deadlifting 100 pounds is a great video that's also from Portland, Oregon, but there. Yeah, so she doesn't have the right role models. Kind of showing her how active you can be, but. I'm sorry, Matt, I interrupted you. You want to get started?
- [60:07]
A
I was going to say you have maybe even throw in osteoporosis for this person because I think that's another one that's common in this demographic. And, and I've seen patients that are afraid to do any kind of movement thinking that they're gonna break a bone. You know, if I can break a bone with, you know, from coughing and sneezing, how can I possibly do any exercise? So let's just throw that in there with this one as well.
- [60:32]
C
Yeah, and that's such a huge consideration because what is the best way to prevent and reverse osteoporosis? Exercise. Right. And it has to be core strengthening. I mean, you can't just walk, just walking. You're going to think I hate walking, but I love walking. But, but you know, just walking does not reduce your risk for osteoporosis. It's not enough of a jarring activity. So I tell people like, do can you jump rope? Like, did you use to jump rope when you were a kid? Could you do that again? Or you know, are you healthy enough that you could run up and down some stairs to get some jarring activity? Could you do jumping jacks? Or, you know, all of those kinds of things are so valuable for jarring exercises for osteoporosis and then of course, strength training as well. So doing that core strengthening, doing those weights, doing the hip abduction, adduction, strengthening exercises, using the stretchy bands, doing things. I have this long list of exercises that I can give people who have osteoporosis and that can get them started and give them more confidence. And your goal really is to give them more confidence because once they've got the confidence, they're willing to try more things. And that's how you're going to get them into a whole different state around the Fear they have, and the concern about falling and the concern about fracture. But really, in reality, that's what they have to do. And I have another great story of a guy I met a long time ago. He was in his early 80s. He was on 22 pills, three hypertension pills, three diabetes pills, two cholesterol pills, two sleeping pills, pills BPH. I mean, he had done everything right. And he was feeling miserable. He was so unhappy. And I was like, what do you do for diet and exercise? And he's like, I'm willing to try anything. So we got him started, and he had to start with one block, and now he's up to, like, three miles, and he's now almost 100 years old. I mean, I've had this guy in my practice for over 15 years, and he's on two medications, and, like, one of them is thyroid, so we're not going to get him off of that. But he literally. He dropped weight. He got off of all of these pills. He sleeps great. He feels great. His son was like, dad, you can stop doing this stuff. You're almost 100. So he comes in and he says, can I stop doing this stuff now? And I was like, no, the reason you're still alive right now is because you're doing this stuff.
- [63:10]
A
His son's trying to be helpful, but, you know.
- [63:13]
C
Yeah, exactly. So when somebody's got all of these chronic conditions, you know, I talk to them, I say, you know, your diet isn't very healthy. You're not exercising optimally. If you are willing to make some changes, we can probably get you off of some of these pills you're taking. You'll have less pain, you'll feel better, you'll be to. Able. Able to get down on the floor to play with your grandkids again. You know, just give them things that are. That are motivating for them. I mean, I have. I have so many old people, right? And a lot of them are like, oh, I just take too many pills. I want to get off these pills. I'm like, well, I know how to get you off the pills. And so we just, you know, we just kind of approach it from what their goals are. I mean, it really goes back to the what matters question, like, what's most important to you in your life? And. And what could we do to get you doing that again, Paul?
- [64:08]
A
I think I'm just gonna have patients listen to this episode when they tell me, just because you're radiating, like, positivity, and I feel like it's been like, yeah, this is an expert that I talk to and I think you should listen to what she's saying cause you're not listening to me. Let's. Ashley, let's read the last part of the case here.
- [64:31]
D
After counseling Mrs. E. That her concerns may not be solely due to normal aging, she discloses concerns about her memory. She notes that she can recall events from many years ago, but frequently forgets items on her shopping list. She asks whether there is a medication that could help improve her memory.
- [64:48]
A
Yeah, and then of course there's this whole supplement market for, you know, anti aging and memory supplements. How do you tackle this one?
- [64:58]
C
Yeah, I mean there are zero supplements that are, that truly help with anti aging and that truly help reduce dementia or prevent dementia. So zero, zero. So you know, if you want to get health benefits, exercise and eat your healthy diet, I mean the things that have some anti inflammatory properties probably have some value because inflammation is a big part of heart disease, a big part of dementia, a big part of stroke. It's a big part of things. So some turmeric, lots of garlic. I mean just load your meals with garlic and you will be healthy until you're 100 years old. So those kinds of things, things are great and they're fine. And I, if people want to do that, I say but, but then I'm like, okay, here's the benefit you're going to get me. You can't see my arm down by the floor. Here's the benefit you're going to get from the turmeric and here's the benefit you're going to get from the exercise. So I try to put it into context of how much benefit they're going to get from each. There's certainly, you know, people who believe things like resveratrol are going to be helpful. They probably, it probably is way down at that floor in its overall value. But if people are motivated to try to do things that are extra healthy, I just steer them back to the diet and exercise. And I'm like, if you're already doing great with diet and exercise, there's still more you can do. You can always make improvements and then they're really adding on. If you're doing a perfect job with diet and exercise, adding supplements is going to do zero benefit for you, for you.
- [66:51]
B
Can I ask because so much we've talked about fresh foods and fruits that are brightly colored and sort of maximizing these certain things for folks who have trouble even getting out of the house and shopping or reliant on community based delivery food Source like Meals on Wheels are being the big one, where is a wonderful service, God bless what they do, but often tend to be sort of laden with sodium and not ideal for patients. So I guess my larger question is for people who have financial insecurity or have challenges sort of shopping or kind of making their own foods, are there any community based resources broadly that we can look for? I recognize there's going to be sort of hyperlocal stuff that you're not going to be able to speak to, but where should we start in terms of counseling patients who may struggle with finding healthy food options if that is such a foundation of aging healthily and aging well?
- [67:34]
C
Yeah, great question. So first of all, Meals on Wheels can be great. I feel kind of lucky in Portland, but they have diabetic diets and they have vegetarian diets and they actually don't put too much salt on their food. And it is fresh and it is colorful. So. And Meals on Wheels is great because they also have a social isolation mitigation goal. So they really spend time with people and might even like enroll them in an art class or something. So they're kind of taking on two things, the eating and the social isolation side of things. And if somebody qualifies for Meals on Wheels, that is fantastic. If they don't. So I'll tell you about a little project I did with a couple of was a, let me think. It was a medical student and a pre med student in Portland, Oregon. We did an overlay of the communities in Portland that are the lowest income. And we overlaid that with the communities that have the oldest population, the Highest percentage over 65, and the lowest economic status. Then I sent these two out to shop in those neighborhoods and, you know, like the place you'd expect there to be a food desert, right? And so I said, okay, go shop there. See what you can find on the Mediterranean diet. I mean, they went in, they found a bag of lentils for $0.89. They found bok choy for like $0.69 a pound. They found, you know, squash on sale for 29 cents a pound. They, they went into these very lowest end. And you know, maybe it doesn't look as perfect as if you went into, you know, new seasons or so. Well, it's local. It went into some, you know, big chain Trader Joe's, I guess. But it's still totally healthy food and it's fresh and it's, you know, it's very inexpensive. So we made up all these recipes that were $8 or less for four people. And, you know, to show people the hard part is they've never cooked these things before. You know, there are plenty of people who have never cooked lentils in their life. You can get 8 me out of a dollar's worth of lentils, right? And just add some onion and garlic, and maybe if you've got some greens or tomatoes or squash or something you can add in, it's great. So the other thing I spend a lot of time doing with my patients is talking about recipes and kind of sharing how they can buy these things that can be very inexpensive. The Mediterranean diet was not a diet of wealthy people. It was considered the poor man diet. This developed in Sicily and Naples, the poorest parts of Italy. And it's, you know, you grow things. So the other. And now you're going to say, I'm really crazy. But the other thing I talk about is having a garden. And, you know, even if somebody lives in an apartment, I'll say, you know, do you have a balcony or a window that you could grow some tomatoes in or that, you know, you can grow some things in and, you know, start to have some fresh produce on your own? And at first, everybody looks at me like, you've got to be kidding. I haven't. I'm 84, and I. I've never done this before. But then I'll be like, okay, well, let's, you know, get a bag of potting soil and put your tomato in there. And they come back and they're like, wow, my tomato's growing. So, you know, that's. It also adds purpose. You know, the Okinawan blue zone. The Okinawan blue zone is the people there. A lot of their purpose is around gardening, and they have these beautiful gardens. So there's so much. Much you can work with patients on, and it's just a matter of taking the time. But honestly, if you spent your entire visit talking about tai chi and diet and getting them to find new things at the grocery store that are going to be super healthy, then you don't have to talk about their diabetes or their heart failure or their arthritis. My patients will be like, wait a minute, I've got all these medical problems, and you haven't talked about a single one of them today. And I'm like, if you do the diet and exercise stuff, those problems are going to go away or they're going to be so much easier to manage. So if you can refocus your visits around these healthy behaviors, you're going to be able to gradually take people off of medications and they're going to have less heart failure exacerbations. I mean, somebody who kept getting hospitalized for heart failure because they ate pizza all the time was willing to try lentils and yams, and turns out they didn't go back to the hospital for a year. You know, it really can make a huge difference. And once they see that difference, they're willing to keep making changes.
- [72:14]
A
Well, I want to ask questions because I think we've given Mrs. E a lot to think about. She can do some exercise, she can eat healthy even for a low cost. There's ways to do that. We can get her some recipes. But, Ashley, any last questions or any other things you wanted to dig into? Into?
- [72:36]
D
I mean, the only thing would just be circling back to the 5Ms. I know on other episodes we've talked about the 5M. So I'm just curious what your approach would be using that in older adults when it has to do with healthy aging.
- [72:47]
C
Yeah, well, I mean, you've heard me say what matters a million times tonight, right? That's the one that you can really use to guide your care in thinking about healthy aging and thinking about lifestyle changes and behavior change. And it's really finding, understanding what matters most to them. And if they want to play with grandkids or they want to be able to go out for a walk with friends, that can help you direct. And then, of course, I mean, we've really talked about every single M, haven't we? We've talked about mobility with the Tai chi. We've talked about mentation. So Tai chi helps improve mentation, but actually so does Mediterranean diet. It's kind of the best way to reduce your risk of developing Taiwan dementia or to slow progression of dementia and allow more quality of life if you already have dementia. Medications we've talked about, because you're trying to reduce those medications via your healthy lifestyle changes. And then the multiple chronic conditions, of course, we're really working to control those better and not have those be the focus of your life. So all of this is completely underpinning the 5Ms. And trying to, to allow people to gain autonomy, gain independence, gain what matters, you know, gain. Gain mobility. All of those things are, are wrapped up into this and, and healthy aging is the right answer. And I'd, I'd say there's, you know, it's important to think about from the perspective of the entire community because you could call me a Pollyanna and say that I'm just, you know, working with people who have the ability to eat all this expensive stuff and go to these classes which literally sometimes only cost a dollar. But in reality, we want to make sure that our entire community has the ability to do healthy aging and to age well. And one of the just crimes in the US is that our average lifespan is about 79. But what do you think our average health span is? Okay, turning it back to all of you, average health span in the US 62. Paul.
- [74:53]
B
Oh, I'm gosh, I'm gonna go 63. I'm sorry to do a team ad if we're playing Price is Right style.
- [75:01]
A
Ashley.
- [75:02]
D
Oh man, the pressure. I'll go with 67.
- [75:07]
C
So you are all really close. It's right now it's 64. It was 63. It just went up a year.
- [75:14]
B
So, you know, it's the best day of my life.
- [75:16]
C
64. I mean, that's nothing, right? You haven't even really retired yet and you've still got these 40 years to manage. So if our goal is to really ensure that healthspan equals lifespan and that we're allowing people to have these healthy, active, engaging older years, we really have to work from a community perspective and make sure that people are able to get access to all of these things that can be helpful to them.
- [75:42]
A
Let's get some take home points that you want the listeners to, to really remember from this. I mean, you just gave some great that probably could have served as a take home point, but anything else you want them to remember?
- [75:54]
C
Yeah, you know, have fun. Nobody just wants to go lift weights at the gym three hours a day. So you've got to find things that are going to be fun. If you hate cooking, find a grandkid who doesn't know how to cook yet and teach them how to cook. That'll make it more fun for you to too. And just try to have joy in every day and give joy to others. So finding a walking partner and helping them walk with you, going to the gym and doing a tai chi class and taking some friends with you to the tai chi class, the things that you do for others are what are going to bring the most joy for you. And healthy aging, it's a community endeavor and it does require a lot of social interaction and you got to make it fun. But it's a really valuable thing to do.
- [76:44]
A
Paul and I are going to try out some wing foiling. Paul, I think we should do that.
- [76:47]
C
Come on out. I'll take you out.
- [76:49]
A
Yeah. All right. And would you like to plug anything? I would recommend you plug your book,
- [76:56]
C
the Gift of Aging. It's Got a lot of fun stories in it. We've even got a story of 106-year-old in it. But it kind of talks through all of these things I've described tonight or around just all of the lifestyle things we can do to age well and keep active and keep ourselves in the best possible health for all those extra years we're given.
- [77:17]
A
What age is a good age to give that book to somebody? I'm in my early 40s. Should I be reading that now?
- [77:23]
C
Absolutely, yeah. Because the sooner you start, I mean, one of the big pluses of the blue zones is that they start at age zero. Right. They have these healthy behaviors and things like strength training from our first patient. Strength training seems to have just enormous benefits for women when you do it from age 35 to 55. So, you know, you can start early with all of this stuff and just build, so you build the habits and then when you get old, the habits are built and you can, you know, keep doing things. And I mean, if you, if you're in your 40s and you're not running now, you're not going to run a marathon at eight, but if you start now and, you know, start building up, you're going to be super healthy and you're going to be that active grandpa who loves to play with his grandkids. And it's just such a much better way to age.
- [78:16]
A
Yeah. Love it.
- [78:22]
B
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [78:28]
D
Yummy.
- [78:31]
B
That is exactly the energy I want everyone to bring. Are you still hungry for more? Join our Patreon and get all of our episodes ad free, plus twice monthly bonus episodes at patreon.com curbsiders you can find our show notes thecbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice, changing articles, guidelines and news in internal medicine.
- [78:51]
A
And we're committed to high value practice, changing knowledge, and we want your feedback. So email us@scurbsidersgmail.com a reminder that this and most episodes are available for CME through VCU. Healthcurbsiders.vcuhealth.org Special thanks to our writers and producers for this episode. Dr. Ashley Randolph, Dr. Leah Witt, the whole Penn Geriatrics, you know, fellowship program. Thank you to all of you and to our whole Curbsiders team. Our tech production is done by Podpaste Elizabeth Broder. Does our social media Jen Water runs our Patreon. Chris the Chu Manchu moderates our Discord. Stuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Waddo.
- [79:34]
D
I've been Ashley Eileen Randolph and as
- [79:37]
B
always, we're in Dr. Paul Nelson Williams. Thank you and goodbye.
- [79:58]
C
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