Howard and Paul
Paul: [00:00:00] Is it your fear if you play too much tennis you're going to become Novak Djokovic. Is that also a concern of yours?
Howard: [00:00:06] I test people in the office all the time and most can't come close to what they should be able to
Paul: [00:00:14] Hey, Howard, how's it going?
Howard: [00:00:16] how are you
Paul: [00:00:17] I'm good I'm not nearly as buff as I should be Apparently
Howard: [00:00:22] I had a CAC score of zero today, so..
Paul: [00:00:26] You're telling me that that's. I don't want to accuse you of making anything up, but that's unicorn level stuff. Isn't it? I mean, it's really unusual,
Howard: [00:00:33] it was astonishing. I think the stats are only, I think 65 or70% people my age have a non-zero CAC score.
Paul: [00:00:42] Yeah, I was, I was looking at it the other day and, I saw that and I saw that there's the actually co almost a non-linear increase in, in CAC scores over about age 45, which is interesting in and of itself, because know, that's just shows you how quickly this stuff Excel. And it's super unusual once it's gone up to some, pick some level for it to ever come back down again. Well, I suppose it couldn't if you died or something, but I mean, it's otherwise not going to come back
Howard: [00:01:10] supposedly the PCSK9 inhibitors might regress them a little, but, and the statins can make it worse your risk of dying decreases
You're a lucky man
it's so hard as you get, over 30, 40, 50. Maintaining let's leave aside our one of our favorite topics, endurance cause today we're going to sarcopenia and, and muscle tone and the things you can do about it. It gets so darn hard to manage that stuff as you get older, but, and this is something, honestly, you forced a religious conversion in me on this. It's something that's just so crazy important
it's really astonishing, muscle mass, as correlates with longevity. and unfortunately what we fail to realize is that this has crept up on us, right? We find it harder to open jars, harder to lift things harder to move things. we don't, and we don't even think twice about it. We don't realize that this process has started nor do we know. How it ends. but for those of us who do it's not a pretty picture. I've seen this movie too many times,
Paul: [00:02:35] I bet you have. I mean, the fundamental issue is all else equal, even if I stay active, there is going to be an age related decline in muscle tone, as you get older. I ran into something, I think I sent it to the other day, but they were talking about how it's actually a little bit more nefarious than just the loss of, of, of strength or . I'm just gonna use tone for a specific reason here, but it's not just, it's not just strength. It's the idea that actually people stay fairly strong for quite a long time, as long as they're modestly active. my dad until relatively recently could have clobbered me in an arm wrestling contest. but what they lose even faster than strength is they lose power. So this ability to exert exert force per unit time, which I found really intriguing.
Howard: [00:03:27] right associated with, the muscle mass. I think we lose approximately 1% of muscle mass per year after 45 or 50. And it does accelerate a bit, but we lose 3% of our power, which is really an impressive number if you compound that over thirty years.
Paul: [00:03:47] Yeah, I'd say, you do finance financial math here. That's essentially like saying you lose all of it over the course of two decades,
which is astonishing right? I mean, that's an, that's a compounding loss of power and the power matters because for the most part, I'm not lifting heavy objects every day, all day, and as a practically wander around and do things. But is it nice to be able to hop up onto something, run three, five, 10, 20 steps. Power -- your ability to do stuff per unit time -- it turns out to be a much more functional measure that deteriorates quickly and all of a sudden it's gone and people didn't even realize it was
Howard: [00:04:23] and it starts as an inconvenience. you need your kid to help you lug 50 pound bags of mulch around, but as you get older, that's, what's going to slow you down. put you on a cane,
Paul: [00:04:43] I'm I'm a convert to this and I'm sure. Well, you obviously are. Maybe we're the only ones. No, that's not true. There's lots of other people. But what I find when I talk to people about this subject, is that. And no, this is no pun intended, but there are people are very resistant to the idea of resistance training or at the very least, if they're not resistant to it, they have a very strange idea of what they should do.
Like I'll see people lifting. I don't know, there'll be walking down the street, carrying two pound weights in their arms. Right. And that's nice. And I guess it's better than zero, but. I'm a bit at a loss to think what specifically they think they're doing. And granted, there may be some muscular skeletal condition about which I'm not aware and that's fine, but I see that a heck of a lot. And yet, and I also see, as I said, this incredible resistance and it's not necessarily that the cliche is that it's gender based that let's say for specifically, women are more resistant to resistance training, but that's not true either.
It's just seems like there is a general resistance to even doing it. And it's, I I've always had a bunch of hypotheses. Like gyms are scary places. I know. I hate gyms. For a long time I wouldn't go there cause they were all these great big dudes and weird shirts and stuff. And I just felt like there was two tests, too much testosterone.
I need to get out of here. Maybe fear of injury. I'm trying to think like what's, what's keeps people, why is there this, this strange idea that I should stay away from resistance training when these people are perfectly happy to walk around the mall for an hour.
Howard: [00:06:13] I think most first, most people will associate resistance training, with weight training, heavy weight training, and muscle heads, the muscle bodies and beach bodies, et But on the other hand, I also see. and discuss this with a ton of people who had the misconception of what exercise is, I'll see them. And we talked about, okay, you have a little bit of arthritis. the best thing that we can do for your longevity and for your knee is exercise. And they immediately come back and say, I walked two miles every night after dinner. And I pull out a handout that describes what exercise is to me. Right. And that's aerobic training, HIIT training, resistance training, and balance training. and Oh, I can't do all that. Sure. You can. And we start to go through how so? I think that people misunderstand how important maintaining their muscle mass is.
Paul: [00:07:13] Okay but, and I also think, and that's a really good point on the gym head thing. I get these crazy people complaints back from people saying, Oh, I can't do that. Cause I don't want to get bulky. I said, do you have the same reaction about playing tennis? Is it your fear if you play too much tennis you're going to become Novak Djokovic. Is that also a concern of yours? Because that's pretty unlikely . But this, but there's some strange thing where people think, if I start lifting weights, I'm going to look like, Schwartznegger in the seventies. And I don't and I don't want to look like that
Howard: [00:07:44] They do have, what a lot of people I'd say over the age of. 45 50. It's the fear of injuring themselves without a doubt they've been told perhaps even by a physician, don't overdo it. you have some arthritis, you don't want to make your arthritis worse the concept that, that arthritis is a mechanical process or wear and tear process still pervades, not only the medical community, but obviously the population at large, people don't understand it's a biological process and actually resistance training can mitigate the downsides of the arthritic process.
Paul: [00:08:30] I find people are so much more willing. They'll find 45 minutes to do voodoo, whatever. And that's great. I'm glad you do it. And it makes you happy. I'm all for it. But don't confuse that with targeted resistance training, targeted high intensity interval training, and even more fundamental, and I got into this the other day with someone who had, who had a back problem, just pulled a muscle in their back years ago. And then they pulled it again more recently and said, Oh, I can't do any resistance training because I'm afraid that I'll hurt my back. I'm just doing stretching and what have you.
Well, and so my answer was I get that and you need to be very careful. Backs are very twitchy, awful things, but did you hurt your back stretching? Was that how you hurt it because that's, that's the thing you're trying to make it more flexible. No, I didn't hurt it stretching. I heard it lifting something. Aha. So if you hurt it lifting something, would it not stand to reason that the thing you want to do at the very least is help other muscles in your back become more protective with respect to whatever the weak parts in, in the chain that comes down from your shoulders to your, to your butt, and to find ways to allow your other muscles that are healthier to be have, have a more protective role. And they looked at me like I was completely unhinged, which may be true, but I thought that was really interesting.
Howard: [00:09:49] People draw these strange associations, right? They associate whatever they're doing right before their back hurt with the cause of their back pain. so it may have been stretching. It may have been weight training. listen, I'm, I've had back pains since I was 18 or 19, and some pretty bad bouts. And so I've stood over my trap bar. Before doing deadlifts after two months about of back pain, sweating it, knowing it's not going to be bad for me, but worrying, significantly
Paul: [00:10:22] th that it's gonna hurt, right. Or it's gonna trigger something that happened before. So there's a word of art, a term of art that I only learned at one of my many meetings with my orthopedic guy years ago, which was this idea. One of the ways you can detect the problem is people show, like fear, fearfulness apprehension, right? This idea of apprehension. You've got an injury in the past that can really affect your willingness. To do other things, this, this apprehension that this may hurt, even if it hasn't hurt in decades, there's almost a, I I'm like a 19th century anti rational paranoia. Right?
Howard: [00:10:59] Correct. if you fall off a horse, you gotta get right back on.
And it's very similar in weight training and in leading an active life. oftentimes, it wasn't the weight training or anything else. It just happened to be a bad moment. I don't even know what causes, what triggers my back pain I've had. I've had plenty of scans and there's no disc herniations or anything else to blame the song. It just happens. I could sneeze one day and, and happens. I can wake up one day and be paralyzed and not move. But I f exercise, I'm solid um
Paul: [00:11:37] And the back is such a, I say this too often that I get a grudge against various parts of the body, but I have a particular grudge against the back because in evolutionary terms, it's a relatively recent development. We were, we were crawling around until relatively recently. So it's not particularly surprising that now that we're an inverted pendulum wandering around and it's not particularly surprising that the back takes the brunt of that because it's constantly trying to refocus this or rebalance this inverted pendulum over this narrow platform called our feet. And all kinds of crazy stuff happens. It gets exhausted and suddenly you get spasms, you get pulls, you get strains. I get it, but it's not a good reason to say therefore, anything that involves back movement is a bad idea. This is exactly the wrong instinct.
Howard: [00:12:19] Right. Causation is hard to prove, and it's hard to shake people have these eassociations that they have where they're convinced it was the causative element
Paul: [00:12:33] I will say my worst back injury ever just to digress briefly was during grad school. And I know exactly what caused it. I was trying desperately not to do my PhD thesis. And so I was playing a ton of Duke Nukem with a few friends of mine, and I would be playing until three in the morning because that was the best way to avoid doing my thesis. And it turns out that if you keep your hand perfectly poised on a mouse for five, six hours at a time over the course of weeks, maybe months at most, you're going to have terrible back spasms that will come on in a way you just never expected. And as soon as you stop playing the game, it'll go away. See this was. This was like one for one. So anyways,
what is it we're trying to achieve? We're trying to achieve a bunch of different things. Let's stay away from the aerobic side of things for a second, but with sarcopenia specifically, and muscle tone, we're not trying to achieve just strength and this goes back to where we started, but strength plus, strength plus power, the two things together. Right. And I think that's a misconception or a misnomer that people have that it's really just about strength. And so as we start, we're going to go forward and talk about what people can do, but is that a fair position to start from?
Howard: [00:13:42] Sure. And I'd like to add something to that, I'd like to, narrow down the focus even to the cellular level and the intracellular level, because. as we know, 80% of our body's glucose is burned by a skeletal muscle. and as we know, excess glucose, can be the root of significant evil when it comes to our longevity and health span. So the more skeletal muscle that we have. the more glucose that we're going to be burning. we also know if we're not active, our ability to burn that glucose diminishes our efficiency, diminishes a mitochondrial function, diminishes our exercise resistance, metabolic flexibility and all these other things that we discuss in other podcasts. so it affects our health. from a metabolic health perspective, it affects our health from a risk of fall , frailty, and so on.
Paul: [00:14:52] Let's talk about some of, so some of the consequences and try to scare people straight, like the old prison shows, one and you just mentioned it is, well, you mentioned two right there, but we can talk briefly about both of them one and it's fairly well demonstrated now that in terms of blood glucose and plasma concentration, that. We can have a pretty significant impact in particular on people who not just who are diabetic, but even on prediabetics and people with higher blood sugar than they should have that muscle alone can make a big different in terms of the numbers you're going to see. And that's really well borne out by the data. So that's one, one, one potentially nasty health problem. You can at least potentially mitigate,
Howard: [00:15:34] they're starting to find, metabolic abnormalities that are taking place in cells, perhaps five, seven or 10 years prior to the onset of type two diabetes and a lot of these, come back to root cause of a lack of exercise, and metabolic dysfunction and that metabolic dysfunction. Is probably secondary to our lack of activity, if not some of the foods we eat as well
Paul: [00:15:59] Yeah, our guests in our last episode, Inigo San Milan, talks about this direct relationship in terms of mitochondrial function, what the, what, the specific, the energy substrate was, how efficient the mitochondria are in that respect. And then the relationship to disorders like diabetes, and even like, potentially like cancer,
Howard: [00:16:23] and dementia and heart and heart disease and vascular mean, the list goes on and on and on. the mitochondria are of key importance and our health, longevity,and performance.
Paul: [00:16:42] the other one that we see a lot, and we've talked about this a little bit before, is. The consequence of poor muscle tone and balance combined, but they, they work together in a synergistic fashion is falls, especially among the elderly and falls among the elderly in particular can start a terrible spiral that leads to the very least can lead to poor health, but it can lead directly to death in many cases. And so this is something we really want to avoid, but why don't you talk a little bit about the relationship between strength, resistance training and what you see with respect to F well, sarcopenia and frailty among the elderly, and then the relationship from that to falls, broken hips and everything else.
Howard: [00:17:26] it starts, very quietly and it creeps up on us. we'll be walking along and we'll slip or we'll trip and. Well notice it was a more significant event than we realized it should have been. And perhaps we actually fell when we realized only a few years ago, we wouldn't have, because we didn't have the agility and more important, the recovery strength to ride ourself.
And we went down, now fast forward, if you're getting older and you fall on sustain a significant injury, the consequences. Of your recovery from that injury and the subsequent rest creates disuse atrophy. so your muscles are getting smaller and it's kicking you even further down the timeline of sarcopenia. And if you're not weight training or doing resistance training, you don't make it back to your baseline where you were before your fall. That's why it's not unusual. For people, who come out of an injury to use and require a cane. And if they don't do this therapy, they may stay on that cane. And now that cane is their center of balance and stability. and one day they're going to fall. and because of a lack of muscular covering, so there's a bigger, energy imparted to our hips. they could fracture a hip, and sadly, a significant percentage of those people who break their hip, will be dead within one year. It's a very difficult and tragic recovery process.
Paul: [00:19:07] Yeah Yeah I had it We had it How had it happen to my my one of my grandparents in the last say decade or so It was it was exactly that though that another wise healthy elderly person who had a bad fall and that's almost a code word Yeah It wasn't really they didn't follow it up an airplane or a tree They just fell over walking but bad in the sense that there wasn't a lot of muscle cover They fell They had a broken hip was broken in multiple multiple places Wasn't really re it Wasn't easily reparable Let's just say And that was so traumatic that it set off a spiral of things that led to a depressed immune system and eventually to pneumonia wasn't the broken hip that killed
Howard: [00:19:46] the spiral is, can be very rapid afterwards. And when I talked to the families, because a lot of times I treat them. Achieved many members of the same family. And I'll bring this up. if I'm looking at their son and daughter in their fifties or sixties, and I start to impress upon them the need for resistance exercise, and they don't draw the relationship between the demise of their parent and their own predicament. and it's pretty enlightening when you, paint that picture. That this, this, this is what you're looking at in 10, 15 or 20 years
Paul: [00:20:33] I don't know a nice way to say this. So it's going to be a very awkward, years ago, whatever I used to play a lot of squash in grad school. Squash is a sport that attracts a wide variety of let's just say people and body types. But one of the things you notice really quickly in the change room , because there's a lot of older men in particular who played squash or at least played squash at that time and most of them did not have an ass. And it was very strange and that always got me thinking that's a big msucle and it's obviously metabolically active requires a lot of work to keep it going, but it was gone. It was just like the legs come up and part like two chopsticks and hit the hip. And that's it.
Right. And I could be, this is maybe just me and a selected sample. Maybe elderly squash players have some gluteus issue, but it strikes me that as we get older, that is one of the first muscles to go. Am I wrong in thinking that? Or is this just all me being unhinged
Howard: [00:21:32] so, the, I think the glutes are unique in that they tend to go because we don't exercise them, but in generals, sarcopenia begins distally. So your calf, your fingers, et cetera. but, that's why, about exercises we're going to concentrate on hip hinges is the key
Paul: [00:21:58] Yeah. Well, I'm still worried about these squash players, but I, as I said, I have, I have theories in this regard, which are obviously crackpot ish, but nevertheless, this is my theory.
The, so let's talk about what people can do. And so what I try to tell me, and I was literally having this conversation with a friend of mine, same age the other day. He said, I don't have time for this stuff. And I said, you do have time. Not just because you waste a lot of time, like. Talking to me or whatever, but you have time in the sense that it doesn't, you don't have to drive to a gym. You don't have to do, I don't know, a rotation of 12 exercises, three times across 10 different apparatus and then free weights and so on. I like to tell people that, and this goes to your, your hinge point. And so we can go straight there, but there are. Various simple exercises that people can do that directly, affect the, as you say, the dis the distal muscles in particular that are prone to sarcopenia, but in particular, that mimic lifelike motions that were, were not just lying back on a bench, trying to build a big chest because that attracts the gender.
Howard: [00:23:10] So, there are many reasons why, I emphasize leg and leg strength or lower extremity strength. and I actually start at the core and go down. they are our larger muscles. They're going to benefit us the most, by being metabolically active, due to their size. They're going to keep us, upright, and walking, lower our fall risk and wase our recovery following an injury.
Paul: [00:23:40] So top couple of exercises that you, you would tell someone to do? probably not deadlifts, right? Somebody who hasn't is just getting into, trying to work those muscles, maybe unweighted, calf raises, maybe stride jumps.
Howard: [00:23:59] so I'll start e the core, dead bugs, abbreviated sit-ups where you just, you lifting your chin off the ground. Laying flat with your back against the ground, hands behind the, in the small of your back. And you're elevating your legs about six inches. you can try those online videos, but you're going to, you're going to be very, very sad when you can't keep up with the instructors. So I don't recommend that.
then I go down to the glutes and for the glutes. one of my favorite exercising, exercises is dead lifts, are dead lifts. However, I was instructed how to do them because it's very easy to do them improperly, and then you do risk hurting yourself. So they exercise that I rely most upon his squats. and for my, for my older folks, I use chair squats with a lineup, with the calf against the chair and they sit back and they try to, sit gently on the chair. They don't fall back into it. And then they try to arise from it without, without using their arms to push themselves up. People don't. I think that this is an exercise and they think as you stated that they have to go to the gym, but they can't do and with calf raises. Yeah. And with calf raises is, is there's actually a chart and you could look up how many calf raises is you should be able to do. And it's a surprising number and most people can't do them. So I don't believe the still,
Paul: [00:25:40] right? That's interesting. I mean, I will say I saw something recently about calf raises and I was amazed. Well, I thought the number was like, I don't know, I'll say like 40 or 30. I don't remember exactly, but I have stupid looking calves that are like grapefruits, so it's not normal, but nevertheless, I was surprised because I said, Oh, these numbers are way too low. People should be able to do well, I don't know, a hundred or 200 calf raises and whoever I was talking to was like, I can't do 15.
Howard: [00:26:08] No, it's true.
Paul: [00:26:10] It was just, I had no idea. This was the case.
Howard: [00:26:13] I test people in the office all the time and most can't come close to what the chart says that they should be able to. And when people fail to recognize and many people do is that there's two, two muscle complexes there that comprise our calf, right? The gastrocs and the soleus and the soleus. Actually it has more power and endurance. When we do a calf raise with our knees straight, we're primarily relying on our gastrocnemius. and we have to do seated calf raises. So you're sitting down and you're doing a calf raise. And if you don't have any weights to throw on your knees, I have a friend, a wife or husband, or partner sit on your knees while you do a calf raise in the seated position that will exercise your soleus by shutting down the gastrocs. And that's the muscle that you want to knock out when doing these
Paul: [00:27:11] I used to make my kids sit on my knees and I would do exactly that exercise, and just go up and yeah, but you can do it in a very easily hacked way that doesn't require a trip to a gym. And it's crucial because again, back to my bizarre squash change room theory of male fitness. You also noticed that most of those people have no calf muscle. It's just gone. It's just a stick from the knee tp the ankle. And that's obviously back to your point about how these things tended to be disappeared, disappeared, distally, first, this is obviously what's happening with respect to calf muscles.
So, okay, so squats, I like squats a lot. The only thing I find is people get terrified because they think, I know I don't want to do them weighted. And the answer of course is you don't have to do them weighted. Body weight squats are great, especially onto a chair. And the other thing I always, I try to remind people is technique matters. Even when it's unweighted, people try to keep, keep your knees behind your toes. Try not to let your your knees collapse inward. This is often a revelation to people because their instinct is to sit like they were sitting for dinner as opposed to sit, like they were just getting onto a toilet or something
Howard: [00:28:17] Right. Form is critical here and you're, you're absolutely correct. when you're squatting, you're sitting backwards, you're bending your hips, you're not leaning forward with your back
Paul: [00:28:30] Right And and you see that error all the time with people and it's one of the easiest ones to fix So so let's move upward. squats are great and they actually have some upper body impact in particular, if they're weighted, but even if they aren't .Upper body stuff, what do you like in terms of simple things that people can and should be doing without having to go to the gym in terms of preserving some upper body muscles
Howard: [00:28:52] Yeah. I'm a big fan of pushups daily, and I'm a huge fan of farmer's walk.
Paul: [00:28:59] You've told me
Howard: [00:29:01] because you lose muscle strain, distally, right? You're finding it harder to open jars now to grip things, to hold on to things, your grip strength is being lost and a farmer's walk one. It helps my balance, but you know what dies first in my fingers and forearms. so a few kettlebells go out and walk
Paul: [00:29:26] Yeah Yeah It's it's a fantastic and it doesn't happen again People think kettlebells Oh I don't want to carry a hundred pounds of kettlebells around You don't have to have a hundred pounds of kettlebells This can be anything right This could be a like a small milk jug This could be whatever you want it to be At least as a starting point It doesn't have to be some big heavy weight that makes fossilized holes in the floor
Howard: [00:29:45] Right It's an area under the curve issue So if a lighter weight you just do it longer
Paul: [00:29:52] it'll, it'll all get tiring. but now to get away from pure resistance and combine a little bit, bring it back to power for a second. Some of my favorite. Okay. Quasi resistance, but really more power centric stuff are things like, like box jumps, stride jumps, things like this, that force you to have to simultaneously think about balance and explosive power.
Howard: [00:30:16] Yeah. I'm a huge fan of plyometrics. my shins are not a huge fan of box gym. especially it's the boxes high, but but you're at you're absolutely correct. I'll do, squats where I'll simply be in a room with a high ceiling and I'll squat down and just thrust up in the air. So I'm jumping straight up. I'll do single leg, Jumps. So, balancing on one leg, I, I slowly squat down and then leap up and land on the other legs, slowly, squat down and li leap up and, and land on the opposite leg. you're right. These plyometric exercises or E centric exercises are really critical for strength and conditioning
Paul: [00:31:15] I was showing someone a a list of more or less what I've been mostly doing And he said you'll notice that almost everything you do And it was quite a shrewd observation I thought almost everything I was doing was was as he said was planar was in line So in other words I was was operating in a two dimensional world where I can go forward or I can go backward. There wasn't a lot of side to side. And he said, you'll notice that in the real world, it's three dimensions and you're often going in other directions than straight forward and straight back.
And, and the, the example for me was, I like to, I like to cross country skiing in my variant of cross country skiing that I like, which is skate skiing. That's an inherently, a highly diagonal thing. It's almost like skating on ice. And so, yeah. everything I was doing, wasn't really oriented towards some of the activities I liked most, which this friend of mine was good enough to point out. And I thought that was really interesting. And so since he, since he did that, I become much more studious about incorporating out of planar dynamic motions, which is a fancy way of saying hopping side to side and things like that, that force you to balance, but also get you out of everything's either forward or backward.
Howard: [00:32:23] a hundred percent. If I'll go down into a squatting position and. A leap to the left three times and back to the right three times or jump back and forth, side skaters. I think they're actually called, they, they are phenomenal and they, and they, and they do exercise the lateral and medial muscles, and they do a great job at improving your balance.
Paul: [00:32:48] Yeah. And, and this is something that you don't see, you don't see a lot of people doing. And so to the extent that you're just imitating people as you do this stuff, which many of us are, it doesn't occur, but it, nevertheless, incredibly important. So. It probably sounds like we're describing a long laundry list of things that people do when people are rolling their eyes and saying, this is exactly what I was afraid of. It sounds like 15 different things. It's not, right. I mean, you can do a couple of these things two, three times a week. And as you say, it's an area under the curve thing and get a great deal of benefit.
Howard: [00:33:23] Yeah. the dose is important. but the dose isn't very significant, and the weight is not significant. You need to go not to exhaustion when you throw up and fall on the floor, like a tabata, but you need to go until you're tired. When that last one is challenging. so it can be lightweight or bodyweight and just more reps or can it be a little way that could be you carrying a kettlebell or with a barbell strapped across your back. It doesn't matter. You need to go until you're tired and going to it. And if it's twice a week, you're doing fine.
Paul: [00:34:03] Yeah no it's a it's a dose response thing And I think the key that for people is exactly what you said The dose doesn't have to be very large It just
Howard: [00:34:11] just
Paul: [00:34:11] has to happen.
So All right Well thanks Howard
Howard: [00:34:15] Thanks Paul.