Dr. Nick DiNubile
Longevity vs. Durability
Dr. Nick DiNubile is an Orthopaedic Surgeon specializing in Sports Medicine and is a Clinical Assistant Professor of the Department of Orthopaedic Surgery at the Hospital of the University of Pennsylvania. He is the author of the bestselling book, FrameWork- Your 7 Step Program for Healthy Muscles, Bones & Joints and is Executive Producer and host of the award winning national PBS television special, Your Body’s FrameWork. Dr. Nick has served on The President’s Council on Physical Fitness and Sports with Arnold Schwarzenegger and also sits on the board as well as serves as the Chief Medical Officer of The American Council on Exercise (ACE). He has worked with Philadelphia 76ers, the Pennsylvania Ballet, and countless athletes and celebrities. Most recently he has been named Vice President of The American Academy of Anti-Aging Medicine. We talk about boomers, injuries plaguing young female athletes and Dr. Nick raises the point that it’s not about longevity as much as it’s about durability.
People, Books, and Boomers mentioned in the episode:
04:46 We don’t always age symmetrically, some parts are young, while other parts are very old
05:14 Tuesdays with Morrie paraphrase: “Parts of me are every age”
05:56 In the late 1900s the #1 reason people used to go to the doctor was the common cold. In 2000, that changed to musculoskeletal issues. And has remained that way ever since.
06:23 Dr. Nick coined the term “boomeritis”
06:50 If you are over the age of 40 or 50, you’ve got weak links in your body whether you know it or not. You’ve got to find these weak links before they find you.
07:48 Dr. Nick talks about why we are seeing this shift to musculoskeletal issues. Two words: Boomers.
08:57 Imbalances in your frame, single sports or a singular training style can be very problematic
10:03 Aging changes your collagen
14:47 Getting people to care before they get hurt
15:34 Dr. Nick is seeing an issue with young female athletes – bones reach maximum density in your 20s, so you have to build this up early on
16:15 There is an epidemic of young female athletes with ACL tears. During reconstruction power tools are needed for young males, but young females can be drilled by hand which indicates early stages of osteoporosis.
18:48 Assessments are crucial so that people can get ahead of asymptomatic issues before they become injuries
20:31 Bert Mandelbaum
21:13 Tom Brady, Adrian Peterson, Drew Brees, Carson Wentz, Zach Ertz have all come back to sport at an elite level after ACL reconstructions, but are still at high risk for osteoarthritis.
21:57 20% of young female athletes with ACL reconstruction will re-tear that same ACL, and 10% will tear the other ACL
22:18 We need to train our young female athletes differently. After puberty, young girls start landing differently from jumps than boys do.
24:37 Framework, by Dr. Nick DiNubile
24:57 Longevity vs. Durability
25:42 In 100 years we’ve almost doubled the human lifespan but evolution is not fast enough to give you a body that’s going to last that long
26:44 We have to get people to do assessments to identify the weak links and get ahead of these issues
29:09 Framework lists the top 20 ailments and gives workarounds for strengthening exercises
31:19 People in health and wellness seem to all agree on the basic principles- Sleep, stress management, eat some vegetables, get some exercise etc, but people are still very confused on the how’s of everything
32:41 Ernst Winder, one of the first doctors that made the connection that smoking may cause lung cancer and he was ostracized by the medical community who were still investing in cigarettes.
33:39 The achievement of longevity will bring the challenge of durability to the forefront of modern medicine
34:21 In the end, its really the basics that will serve us best
35:52 Dr. Nick has done a lot of work with ACE to help make sure coaches and trainers are more aware of these musculoskeletal problems
38:00 Dr. Nick is the VP of the American Academy of Anti-Aging
38:42 Dr. Nick is most excited about the future of regenerative medicine and accelerating healing
42:01 American Council on Exercise (ACE)
42:13 Dr. Nick was on the The President’s Council on Physical Fitness and Sports, with Arnold Schwarzenegger as the chairman
42:19 Allen Iverson, Cal Ripken Jr.
44:18 Arnold Schwarzenegger told Dr. Nick it doesn’t take a lot more work to reach 100K people than it does to reach 100 people
46:18 Pain accelerates aging
51:25 Dr. Nick’s take on nutrition, inflammation ie. sugar, white bread “the whiter the bread, the sooner you’re dead”
52:26 For every extra pound a person carries, the knee reads it as 5-7 pounds, so there is an exponential overload on your joint with even small amounts of weight gain
54:55 Dr. Nick’s socials
55:09 What’s next for Dr. Nick – a book on female athletes and he expects it to be controversial
This season of The Ready State Podcast is sponsored by OOLER, makers of the chiliPAD. Kelly credits the chiliPAD with being the single most important product to improving the quality, density, and duration of his sleep. Juliet credits the chiliPAD with making Kelly less sweaty. For more info and discount codes, click HERE!
Kelly Starrett: On this episode of The Ready State Podcast. We’re thrilled to have Dr. Nick DiNubile. He’s an orthopaedic surgeon specializing in sports medicine and is a clinical assistant professor at the Department of Orthopaedic Surgery at the Hospital of the University of Pennsylvania. He’s an author of a bestselling book, Framework. Dr Nick has served on the President’s Council on Physical Fitness and Sports, chaired by Arnold Schwarzenegger and also sits on the board as well as serves as the Chief Medical Officer of the American Council of Exercise. He’s worked with the Philadelphia 76ers, the Pennsylvania Ballet and small athletes, unknown, like Allen Iverson and Cal Ripken Jr.
Kelly Starrett: Most recently he’s been named Vice President in the American Academy of Anti-Aging Medicine. We’re thrilled to have Dr. Nick on the show to learn more about aging and longevity and what he calls durability. Enjoy the show.
Juliet Starrett: Welcome to The Ready State Podcast, Dr Nick. We are so happy to have you on.
Dr. Nick: Oh, it’s my pleasure to be here. It’s my honor to be on with you guys. Kelly, I’ve followed your work a long time and I’m not kidding, when I tell you, a week does not go by in my office where I do not take a prescription pad and write your name on it. I usually spell it right. And I send patients to either your books, your YouTube work because I, like you, think that people need to take more responsibility and that they can care for their bodies, for their frames. They can do their own maintenance and your stuff is so innovative, it’s so fresh and you have a way of, I think, connecting with people that they will actually do what you say. So you’re on my prescription pad a lot, whether you know it or not.
Kelly Starrett: Oh boy.
Juliet Starrett: That’s so nice. Do you think Kelly could keep you as his pocket PR agent?
Dr. Nick: Absolutely.
Kelly Starrett: What I was just going to say is your poor patients will never get that time back. It’s just like a sinkhole. But also, I think this really sets up this conversation. This season, obviously clearly, we’re talking about aging, we’re talking about what are best practices. And one of the things that I think Juliet and I are confronted with a lot is that people have never been empowered. They just actually just end up old or end up older, end up like us. We’re just suddenly, I’m middle aged. I mean, I look in the mirror and I don’t have any hair and I look like my father with a beard and I just don’t know how I got here, except I have some smart friends who’ve said, “Hey, this has made me a better way.” But the average person isn’t instructed in the care and feeding of their body. They just sort of make it through on the genetic tolerance and beauty that is the human. Would you agree?
Dr. Nick: Absolutely. It sneaks up on you. And after the age of 40 especially… And I’m an athlete, I’ve been an athlete my whole life and I’m well into my 60s and I’m still competing at a pretty high level in tennis and your body changes after the age of 40. It ages and it doesn’t always age symmetrically. You could have parts of your body that are like newborn and other parts that are very, very old. Weekends with Morrie, that great book, he had a great line in it where he says that, “Part of me is every age, parts of me are every age.” It’s true. And you can age even prematurely when you’re younger with injuries or if you’ve abused your body, if you abused your frame, certain body parts can age prematurely.
Dr. Nick: Once your body starts to age and change, you can’t treat it the same as you did. You need to be moving. You need to be fit. There’s no excuse. You can’t stop, but you start getting into trouble. It’s no surprise that number one reason that people go to the doctor in this country, it used to be the common cold. And I was part of the research the American Academy of Orthopedic Surgeons did on this, when we were tracking these numbers. In the late 1900s, number one reason people went to the doctor is what you would think, the common cold, upper respiratory issues.
Dr. Nick: Around 2000, it changed and we thought it was just maybe an oddball kind of thing. Musculoskeletal issues became the number one reason that people go to the doctor and ever since the year 2000 that has stayed and the numbers continue to grow. So people have, whether it’s your muscles, your bones, your joints, and this is why back then I coined this term boomeritis, which was like the aging baby boomers. Arthritis, bursitis, tendonitis, and most importantly, fix me-itis. You know that mindset, they want to turn back the clock. They don’t want to accept the fact that their body’s changed and they’re going to do more damage out there. So, we spend about 5.7% of our GNP in this country on musculoskeletal ailments.
Dr. Nick: If you’re over the age of 40 or 50, you have them and you have these weak links, they’re kind of like the fault lines in your body, whether you know it or not, you have these weak links. I know what you try to do and what I talk about is find these weak links before they find you.
Kelly Starrett: What do you think… I can personally relate to that. I sort of feel like I have a collection of… Let me just first say is I’ve gotten out relatively unscathed after just the number of dumb things I’ve done with my life. Hucking myself off things, just taking lots of orthopedic risks. But I have started to sort of aggregate, I mean my credit score has been dinged as it were because I was going a little too fast on some skis. I broke my hand when I was a little kid and worked around that problem. So besides the obvious sort of trauma, injury, because I think everyone can relate to that and sort of the impacts that has, why do you think that is? Why have we shifted from the cold as we’ve gotten older to sort of musculoskeletal problems and complaints about that?
Dr. Nick: Well, I think part of it is the aging baby boomers. That glut of people who all hit a certain age at a certain time. And the boomers and myself included were different than our parents. My parents’ generation, they did very little. They were not active. They age not well because of that, being sedentary is as dangerous for you as smoking a pack of cigarettes a day. So, they weren’t active. If they ever went out and did something and were sore the next day, you know they’d never go back and do it. But we were the no pain, no gain. We were the no pain, no gain. Push yourself hard. I did all the contact sports. I did 15 years of martial arts. And I guess that takes a toll on you and over time you accumulate these weak links that I talk about.
Dr. Nick: They could be old injuries or an ailment that you developed along the way. With me, it was a football injury to my knee when I was a late teenager caught up with me later. It could be imbalances in your frame. There’s a lot of people who are working out and you know this well. I mean, you’re the king of finding these flaws in mobility, but sometimes your own workouts or your own activities, will create imbalances in your frame if you’re not careful how you train and what you do. And if you’re a once one sport pony or you only like to lift weights or only like to run, you’re going to have predictable imbalances in your frame.
Dr. Nick: I’ve taken care of the 76ers for 13 years, but for 30 years I’ve been the doc for Pennsylvania Ballet and the dancers are amazing athletes. They’re probably the most well rounded athletes out there, but even on their frames, you’ll find typical imbalances in a dancers body. So based on what you do your whole life in your workout, you get these imbalances of strength, flexibility or both. Old injuries you’ve never rehabbed. It could be your alignment. These people that are bow legged or knock kneed, you’re going to wear down one side of your knee, your genetics obviously, choose your parents wisely.
Dr. Nick: And then the effects of aging, aging does change your collagen, which is… The collagen, as you know is the one of the structural components in your body and kind of like gray hairs and wrinkles, the collagen changes, whether it’s in your elbow area, the tendons around there, your Achilles, your rotator cuff, and it doesn’t take much for it to get injured. So, it accumulates. And as I said, once you have these weak links are these vulnerabilities in your frame, you have a couple of choices. I think there’s three major choices that you face. One is you can resolve it, which would be great. Whether it’s really great physical therapy, maybe surgery or even the body itself. The body has amazing repair and regenerative capabilities, as long as you don’t interfere with it, if you don’t get in its way.
Dr. Nick: So if you can resolve it, that’s great. Most of us can’t fully resolve these ailments. And with age you don’t heal as well. Your tissues just don’t have that healing capability as when you were a kid. So you’re left with some not so great incompletely healed things. So if you can’t resolve it, your next step is to toughen it. So you have that weak link. Maybe you can toughen it or you can toughen the structures around it so it’s less vulnerable. If you can’t do that, the last thing, and then this is where I have a hard time with my patients because they just don’t want to accept the fact that they have this issue that’s probably you’re not going to fix, but you can learn to safely work around it.
Dr. Nick: There’s ways to continue to stay active and fit. I will never give anybody a pass on being active and fit, but they might have to do it differently. I mean, and you see that, I mean, you see the range. I mean you’re with the people who are pounding their bodies probably harder than anyone other than Navy SEALs. I mean, you’re looking at the CrossFit crowd, right? They really pushed to the limit and they will find those weak links at some point. And what do you do when you come across them? I guess you are able to get many of them back to that high level activity even, the CrossFit is not a real young crowd at times. I have a lot of patients who are in their 40s or 50s doing CrossFit. I worry about them a little bit, but they pull it off and some of them are willing to make the modifications. I mean, do you come across that?
Kelly Starrett: Well, first of all what’s really interesting is that the internet, I think in just modern modern strength culture has suddenly really democratized exposing people to serious strength and conditioning. Olympic lifting a decade ago did not look in popularity like it does today. When we started our gym 15 years ago, you couldn’t even buy a kettlebell in San Francisco. Now you buy one at Target, right? So the world has changed underneath this a little bit. And what I’ll say is, what we experience is that… And I think our gym and coaches do an extraordinary job of identifying when people have incomplete positioning that we have stripped out movement quality. We have stripped out having your native range of motion. The ranges of motion, frankly established by the American Academy of Orthopedic Surgeons, right? The American Academy of Practitioners.
Kelly Starrett: This is what normative ankle range of motion is. You don’t do it. You don’t have it, and you’re expecting to perform this movement without complete range of motion. And what we saw through our experimenting is that people will solve the problem in a creative way. Human beings will… Men will die for points, as Greg Glassman famously said. People will solve this problem. If I say you have to squat this deep, you’ll squat that deep no matter what. If I say I’m going to… Only thing that matters is how fast you run. You’ll run that way no matter what. So what we started to identify is trying to restore people’s positions, give them their native range of motion back, and then that meant that we had some breathing room and returning skill, changing nutrition, talking about sleep.
Kelly Starrett: We had a moment to aggregate those things. But the average person, if you come in with your body and you’re like, “Okay, I’m here, I’m ready to do gymnastics.” I’m like, “Dude, you are a 47 year old guy who hasn’t been upside down in a minute. Let’s talk about getting there first.”
Dr. Nick: Correct.
Juliet Starrett: So I’ve got a question and I posed a similar question to at least one other guest this season. And I’ll preface it by saying, I sort of feel like the 20s are the time where you can just abuse your body without care. And the 30s and 40s are maybe the time when you really need to sort of put the money in the bank in terms of taking care of your health, so that when you’re in your 50s and beyond, you have the best chance of feeling good and being able to do what you want. But a challenge we face, and I’m sure you see this in your own practice, is getting people to care before they actually get hurt. I mean, I’m talking about like caring about taking care of their tissues and their movement quality and all the things they could do to potentially avoid injury. I know you often are seeing people on the other end of it, who are already injured. But do you have any thoughts or advice on how to get people to care?
Dr. Nick: I think that’s a huge challenge because especially when you’re younger, you’re invincible, we know that. It’s interesting because you can get away with a lot when you’re younger, but there’s certain things that you really need. I think you just used the phrase banking earlier. And one of the areas where I’m seeing a lot of issues is with the young females, especially the young female athletes. Their bone health. You build your bones. I mean, your bones reach maximum density in your 20s and you really start building that in your teens. So there’s an example where if they don’t… It’s like a retirement fund, if you haven’t put it away when you hit 40 and you start losing you don’t have that nest egg to count on.
Dr. Nick: And I see so many of these kids with weaker bones, it’s pretty frightening. So some instances like bone health, there’s no way around it. You have to start young. And that’s hidden. That’s below the radar. I see it. I’m a knee surgeon in my real world and I do a lot of ACL reconstructions and we’re seeing an epidemic of young female athletes tearing their ACLs. I think we’re doing girls a real disservice with the way we’re just throwing them into these sports. Unfortunately, I think they need to do things differently and work a little harder to avoid this, but they’re not doing it. So we’re seeing an epidemic of life changing ACL tears. But when I do that surgery, we drill these… I gonna sound… I hope I don’t make people cringe out there. But when we drill the tunnels to put the new ligament in the femur and the tibia around the knee, we use power tools and when I’m working on a 20 year old guy or a young football player, I need all my might with power tools to get through, through to drill these tunnels.
Dr. Nick: A lot of these young girls, with all of them, I always start the tunnel by hand just to make sure I’m in the right place and we use the power tools to drill. With a lot of these young girls, I start by hand and I just keep turning by hand and I’m able to complete the tunnel. To me, that’s early, early stage osteoporosis, osteopenia, that’s going to really catch up with them down the line. With muscle it’s a little different. Muscle, you can build it any age. You don’t build it as well as when you were a teenager, especially guys with all the testosterone, where you can lift hardly anything and you grow.
Dr. Nick: As you get older, after the age of 40, you’re going to start losing muscle. But muscle is reversible muscle loss. But even that sneaks up on you. A lot of these mobility issues you talk about and weakness, I think it’s almost stealth the way it happens. The wake up call is that injury that somebody gets. They throw a baseball and all of a sudden their shoulders sore and they’re like, “How could you tear a rotator cuff just by throwing a baseball or starting a lawn mower? Or just picking up the trash And tear something or pull your lower back.” It’s because that’s… And they don’t understand this with musculoskeletal ailments but that’s been brewing for a while.
Dr. Nick: It’s like that heart attack that someone has. That didn’t just happen that day. They just found it that day. You know what I mean? They did the exertion, or they did whatever, where the coronary artery that was blocked then gets them into trouble with a heart attack. When we see it on the musculoskeletal side, they’re like, “Well, how did this happen? I want to be back to normal again. I want to be back to that teenage body.” But unfortunately it doesn’t work that way. So I think one of the great things you could do is assessment. If you can get somebody in for an assessment and show them the weakness, show them the imbalance, show them how tight certain muscles are, that’s step one maybe in getting their attention before the injury happens.
Dr. Nick: If you get an MRI on someone over the age of 40 or 50, you’ll see all sorts of changes that are… They’re probably asymptomatic with. Their muscles and tendons look differently than when they were younger. Their disks in their lower back look differently than when they were younger and these tissues are all more vulnerable. So, how do you get people’s attention? With me, it often is the injury where they come in. But if you can get in front of a crowd, we have to talk prevention. That’s true in all of healthcare. I mean, look at the money we’re spending in healthcare in this country. And I think last I looked at some of the data, it was well less than three percent spent on prevention. I mean, true prevention.
Dr. Nick: So, we treat everything like the wall street bailouts. We wait for something bad to happen, then we throw a lot of money and high technology at it and think we can fix it. But prevention is really the key and going to take you and I being out there a lot banging the drum, I think.
Kelly Starrett: Well, let me clear something up because Juliet said something, I think it was inaccurate. She said we abuse our body in our 20s. What I want to say is I actually didn’t have enough money to abuse my body in the 20s the way I would really have liked to. I think that was just… I was critically poor, so it was self-regulating already. Secondly is that I’m-
Dr. Nick: Probably abusing your liver-
Kelly Starrett: No, no, no. Just straight abuse. Not even alcohol. I met a colleague of yours, Bert Mandelbaum who also spends-
Dr. Nick: O sure.
Kelly Starrett: Who spends a lot of time talking about sort of this, the ACL injury. What’s interesting about some of the research that I saw presented at a symposium, the science symposium I was at, a week ago was this cascade of inflammatory issues that happens inside the knee upon ACL injury and that basically when you have that swelling in the knee, it can just trash the articular surfaces and you’re more likely after meniscus tear, after ACL injury, to need a total knee replacement and early onset arthritis-
Juliet Starrett: Aren’t a lot more likely?
Kelly Starrett: Yes.
Juliet Starrett: Okay.
Kelly Starrett: It blew me away.
Dr. Nick: You are, even if you fix the ACL, even if you have a perfectly done surgery and a stable knee and you’d go back to sports like you see, unbelievable, Tom Brady, Adrian Peterson, the list goes on and on. Drew Brees, I mean, these people who are doing… Carson Wentz for the Eagles, all ACL tears, all doing well. Well, maybe not our Eagles so much but-
Kelly Starrett: Zach Ertz is my boy. It’s okay.
Dr. Nick: Isn’t he? I love him. He is my favorite. He is an absolute favorite. But these players, they do go back but they still are extremely high risk for osteoarthritis. They’re going to get arthritis down the line even if the ACL is fixed. We haven’t been able to fix that yet and that’s going to take a lot more research to figure out why that happens. So, that’s my fear. When you see these teenage girls, especially soccer players, not only are they tearing their ACL, they’re then re-tearing the ACL graft a year or two later. 20 or 30% of them within a year of back to sports, either re-tear that same one 20%, or they 10% tear the other ACL.
Dr. Nick: So, that’s why I’m saying, are we doing them a disservice just throwing them out there and trying to clean up the mess after the ACL tears. They need to train differently. We know that around the age of puberty, girls start landing differently from jumps than boys do and you can retrain that. It’s part of my theory of why I take care of dancers for 30 years. And they say, “Well, if you’re a loose jointed, you’re more likely to tear your ACL.” Or, “If you’re female, you’re more likely to tear your ACL.”
Kelly Starrett: Not true.
Dr. Nick: Well, there’s no more loose jointed group of people than female dancers, yet I rarely ever see ACL tears. Now it might be the nature of their… But they’re jumping, they’re landing, but they learn to jump and land from when they’re really young and they have an unbelievable core strength. They have unbelievable mobility. I think that’s almost… If you were going to vaccinate people against ACLs I’d almost think you’d have to do something like what dancers do to retrain their body and especially retrain the landing gear.
Kelly Starrett: What’s amazing about this conversation is really the heart of, I think where Juliet and I tried to wrap our head around from even our business aspect, which is it’s difficult for people to appreciate inputs and outputs when those outputs may be 30 or 40 years away. Right? Because if you told a young mother and father that their daughter just torn her ACL, is likely to have her knee replaced, and it was preventable.
Kelly Starrett: That’s really a shocking statement and the same can be true about our nutrition, our sleep. So as a physician who’s on the end, really are at the pointy end of all the dysfunction and the injuries where people can occupy in their own society, they’ve got something else going on. How do we shift our mindset and where do we begin? You said, “Hey, we should really should start with kids.” But so much of this aging epidemic issue is really a behavior change piece. So to follow followup for Juliet’s question, how to get people to care, where do we as health professionals need to insert ourselves in from this reactive healthcare model into a proactive healthcare model? Because, that seems like the thing. We know what’s going to happen. You just don’t believe us because you’re young and fabulous.
Dr. Nick: Well, when I started, in the ’90s when I told you we started collecting this data and seeing how common musculoskeletal ailments were and what happens, how does the musculoskeletal system age? That’s what prompted my first book, the bestseller, which was called FrameWork: Your 7-Step Program for Healthy Muscles, Bones, and Joints. I said to myself, “Okay, if you could do everything in your capability to have a body that’s built to last or… How do you extend that warranty on your frame?” Because, I believe there’s two things going on here. You have longevity. I kind of believe at this point, if you take care of yourself, you have pretty good genetics and a little bit of luck. You’re going to live long, you’re going to live long.
Dr. Nick: I’m Vice President of the American Academy of Anti-Aging Medicine. When I go to those conferences, they’re always talking longevity. I’m the one who has introduced to them longevity is only one side of the coin. Durability is the other side. We kind of have a mismatch right now between longevity and durability. We’re living longer, most of us-
Kelly Starrett: That’s great.
Dr. Nick: But we don’t… And interestingly-
Juliet Starrett: Not living well.
Dr. Nick: No, and if you look at… I’m going to give you some numbers that are, that are crazy. So these are like a hundred years apart. 1796 lifespan, 25 years average. 1896 kind of when my grandparents came to this country, and just before my dad was born. So this was right before the 1900s lifespan, about 48 years. A hundred years later, 1996 we’re looking at about 80, being the lifespan. So in 100 years or so, we’ve almost doubled the human lifespan, right? But evolution is not fast enough to give you a body that’s going to lasts that long. So, that’s why I say there’s this mismatch between longevity and durability and so how do you get that extended warranty for all these added years?
Dr. Nick: That’s where I sat down and I said, “Okay, what can you do?” My book, it starts out with assessment. All my books, have an assessment. How do you find these imbalances or weaknesses or flaws that you have? The weak links. And then what do you do about it? And you said it, it’s about diet, it’s about exercise and the right kind of exercise. It’s about mindset. I mean, the way you think, how you manage stress, the way you sleep, all of these things together and each adds up points that you’re either going to get the extended warranty or not. And a lot of it is in your own control. You preach this and you have a line, I’m going to butcher it, but it’s about, “everyone should be able to do their own body maintenance” or something like that. Right? It’s one of your things you talk about all the time.
Kelly Starrett: Close enough.
Dr. Nick: Yes. So, I’d like to give people those tools to at least think about and assess their life of, “Okay, what am I doing right?” What am I doing wrong? And in all my tests I always have this red, yellow light, green light, that green light. “Okay, I’m okay here. Yeah, I sleep well, I manage stress. I eat the right things.” Other things might be a flashing yellow light. “Well, this is something you better take a look at. It’s not urgent, but here’s somewhere where you can make a difference.” And then the red lights are, “You better get this checked or you’re going to be in trouble. You have an issue here.” And again, it’s a very comprehensive, holistic approach and that’s what it has to be.
Dr. Nick: There’s no one thing you’re going to do. The other thing I do with my book is that I took the top 20 orthopedic ailments and I give people some work-arounds for their workouts because, sometimes your body doesn’t tell you the right thing. You think it’s right to do something. You know what I mean? But somebody with patellofemoral arthritis, I see a lot of that. When you have knee pain, common sense thing is, “Well I have to strengthen my quads.” Right? So quad strength is important for knee strength. But if you have a worn kneecap, which I see a lot of, and you go out and do some really great quad strengthening exercises like lunges or squats, especially if you’re not doing them right, you can really make things worse.
Dr. Nick: It’s the same thing if you have rotator cuff pathology in the shoulder. The way you strengthen your shoulder and the way address the imbalances could make or break things. So, you do the wrong kind of lifting overhead press, behind neck press, some rapid lateral raises, you’re going to get in trouble. So, for the top 20 ailments, I say, “Okay, instead of doing this, why don’t you try this at first? And then hopefully, if you resolve it, you can go back to the other things.” Or you may always need to be on the plan B where you have that modified program. But again, you don’t get the pass, you don’t get to sit on the couch. You absolutely need to keep moving, your body responds to this.
Dr. Nick: Your body remodels, it regenerates and your stuff so innovative, I think because you’ve found ways to mobilize damaged tissues to bring blood to those areas that are a lot of the… Blood flow is important for healing, but with age, a lot of the body parts don’t get the optimal blood flow. Your rotator cuff, your Achilles tendon, around the elbow. So you have some very innovative ways to mobilize tissue. I think in addition to mobilization, the thing that you’re doing is bringing blood flow to that area and you’re probably optimizing whatever healing you can do in that area.
Dr. Nick: It’s one of the reasons I also believe that aerobic training is important. When you get that blood flowing through your body, you’re getting a flush of blood flow, not just to your heart and lungs, but you’re getting it to all the nooks and crannies. Your body, that don’t get great circulation, in everyday life. And that’s part of why these tissues fail is because of low grade circulatory thing. A lot of the devices you and I work with and that I was part of the research with, whether it’s H-Wave or MarcPro also has been shown to increase blood flow into these nooks and crannies where you probably, it may have stalled, your healing process may have stalled in that area.
Dr. Nick: But your stuff is so innovative and that’s why I’m not kidding when I say they get a prescription pad with your name on it. Next I’m going to give them your cell phone number. And really thank you.
Kelly Starrett: The next edition of Supple Leopard will be even easier to use and heavier. So people are going to be able to use it as a training device.
Juliet Starrett: So, I love the idea of durability and I think probably everyone listening to this can agree that the goal isn’t to live to 95. The goal is to live as old as you can live and still actually feel good and be able to do things. I think those of us that work in this industry or field, excuse me, I think we all have sort of landed on these same basic principles that you sort of have to do for longevity and durability, which is sleep, stress management, eat some vegetables, get some exercise and we like to add on do some mobility work, take care of your body.
Juliet Starrett: I think people are still somehow just so confused and I’m not sure if under each one of those sort of pillars that there are… In the diet pillar for example, there’s 5,000 different diets and it’s what diet? How much sleep? Well, how much water do I drink? And how do I manage stress? And I think there’s still so many hows. Honestly, I think at least in our industry, health and fitness, we’ve done more to confuse people, rather than make it simple. But what are your thoughts on that?
Dr. Nick: You’re absolutely right. There’s a large segment of the population that aren’t even moving, right? So there’s that half of the crowd that we just need to get off the couch for their overall health. And then there’s the other half. And I know it’s not half and half. I wish it were half the population were exercising, but then we have the people you and I deal with that are very active and they’re getting into trouble. It’s tough. I mean, you said something about living long and there’s a doc I knew who was one of the fathers of preventive medicine, his name was Ernst Winder. He was one of the first docs who made the connection between smoking, that it might be causing lung cancer actually. He was ostracized by the medical community who were then still investing in cigarettes.
Kelly Starrett: Smoking doctors.
Dr. Nick: Yeah. The AMA, I think was a big investor in the tobacco industry. But he once said that should be the function of medicine to have people die young as late as possible. I think he was kind of in the right direction there. That your body is still functional, your mind is functional, but you want it to be later, later in age. That’s why I say that the achievement of longevity, which I think we’re achieving actually, there’s some anti-aging people that think by 2050 or so, we might be up to 140 in terms of how we live if we start being able to cure cancer and get rid of a lot of these diseases that take people out.
Dr. Nick: But I believe that the achievement of longevity will bring the challenge of durability to the forefront of modern healthcare. This is why we’re spending five percent of our GNP on musculoskeletal ailments. Our bodies are falling apart. So how do you get people to look into that future and see that that’s going to be them and take better care of themselves? Again, I think we just got to keep banging the drum. There is no shortage of health information out there, but are we any healthier as a result of it? I mean, and yes, there’s confusing health information and there’s a lot of people out there that are hucksters that are pushing things that aren’t right. But when you think about it, it’s really the basic stuff that gets you there.
Dr. Nick: You don’t have to be on extreme diets. Most of us know what’s right to eat and what’s not. You’ve got to keep moving. You’ve got to listen to your body, you get things checked, definitely get things checked sooner rather than later. But even that can get you into trouble. I have so many colleagues that if you walk in there with an ailment and they have an MRI that’s positive, they’re talking surgery before they talk anything else. That’s not always right. Especially as you age, you always want to look for non-surgical methods if you can, first.
Dr. Nick: Certainly, there’s things that need surgery. I’m a surgeon and I know that certain things always need surgery upfront, but there’s a lot of leeway there in terms of how you can manage your own body, avoid surgery, combining, I think one of the big areas that I talk about a lot is the… We have the world of fitness, we have the world of rehab and then we have the health care world and these are three separate worlds kind of that rarely ever are talking to each other. But if you look at the patient, the patient connects those three things.
Dr. Nick: So, these worlds need to collide. The fitness people need to know more about rehabilitation and how to modify exercise for people’s whose frames are not cooperative. That middle-aged patient who has ailments. There’s some well-meaning personal trainers out there getting people in a lot of trouble and it’s not their fault. So I’ve done a lot of work with ACE and some of their musculoskeletal and orthopedic certification where they can just learn to be aware of these kinds of things. There’s a lot of doctors who don’t really know a whole lot about exercise or rehabilitation, but the patient carries all of these three areas around with them all the time and they’re the connections. So we need to be more connected to each other and use each other’s capabilities. But, it’s a challenge. It’s a big challenge and it’s not going away.
Dr. Nick: When you look at the money that’s spent in this nation on musculoskeletal care, and it’s why I spend almost all day on the phone trying to get a surgery approved. These insurers are now denying legitimate surgeries and we’re having to fight for every surgery we do. I had a high school… This guy’s a top level high school football player with a big tear in his meniscus. He made it through the season, his knee is swelling, he’s having trouble. He’s also one of the top track and field athletes in Pennsylvania. So he’s got a window of opportunity now, it’s the holidays. I want to operate on him tomorrow and hopefully get him back, training for his track and field season and he’s being recruited by every college in the world.
Dr. Nick: His surgery was denied all week. I finally got somebody to approve it today. It’s, “Are you kidding me?” So they know. I think they realize how much is being spent on musculoskeletal and we’re a big target that they’re trying to deny a lot of this stuff. It’s complicated.
Kelly Starrett: Man, it’s complicated.
Dr. Nick: But this kid-
Juliet Starrett: My God, it’s so complicated.
Dr. Nick: Kids like this, you tear your meniscus, it does not look repairable. So you lose that meniscus. Is he at higher risk for arthritis in that knee? 10-15 years out? Absolutely. Is he higher risk for knee replacement 20 years, 30 years from now? Absolutely. But the future is very bright in orthopedics. We’re doing a lot of things now. With regenerative medicine, maybe we can prevent arthritis. You get that early damage in a joint, we can now regrow articular cartilage. We can regrow joint cushions that have been damaged in earlier stages. So it’s… But again, the high tech is so costly and it’s big surgeries and if you can prevent those issues upfront, you’ve done a lot.
Juliet Starrett: So you mentioned earlier you are the Vice President of the American Academy of Anti-Aging Medicine.
Dr. Nick: Correct.
Juliet Starrett: I’m curious about what people are researching, what’s promising, what’s going on in the anti-aging research universe?
Kelly Starrett: I haven’t been able to buy the pill. Which pill do I need to buy? Doc, help me out. Give it to me, I’ll buy two of them.
Dr. Nick: You need a better placebo.
Kelly Starrett: I have one. It’s called my wife and she’s like, “You have a man cold get over it.”
Dr. Nick: Well, yeah, everybody wants that pill that’s going to turn everything around. I wish it were that easy or the exercise pill. Remember that one? There was going to be a pill that just, you didn’t have to exercise. But I think the exciting stuff for me is in the area of regenerative medicine where we’re able to accelerate healing or regenerate areas that are damaged that you… In the past, orthopedics was more about Mr. Fix it. You break something, you kind of fix it and you get it hopefully kind of close to what it used to be, but it never is going to be the same.
Dr. Nick: Now, the idea that you can regenerate something and get it back to when it was new. It is very exciting and we’re doing that in some… We’re just on the verge of it. Here’s another area where if you listen to the radio or you look at airplane magazines, you see all these ads for, “Come here, we’re going to inject this. It’s regenerative medicine.” There is no single injection right now that’s regrowing anything. But there’s a lot of them being done and people are getting false hope that their arthritis is going to be cured with an injection of some stem cells or blood cells.
Dr. Nick: Although I do think stem cells and PRP have unbelievable potential and there are great times to be using them, but I think the marketing has gotten a little head of the science with a lot of this regenerative stuff. But I do think it is the future. So, it’s very exciting on the musculoskeletal side. But again, when I go to those meetings, it’s not a lot about musculoskeletal. They’re still talking about aging and the brain and cosmetics and things like that. But I tell them-
Kelly Starrett: It’s true. I feel like it’s really hidden, it’s lost. You’re absolutely right.
Dr. Nick: The durability side is it’s there and it’s huge. That’s why the three of us are going to help solve that problem. Right? We’re going to… I think we can… Getting the right tools that people can self-assess or maybe you go to a personal trainer or a physical therapist and have this quick… I got the idea with my car. When you bring it in, they had this sheet they run it through and it has the red, yellow, green, and here’s all your stuff and this all’s good and this maybe is going to need something next time and this you better get fixed right now or you’re going to be in trouble. You know what I mean? And I’m like, “So easy. Why we do that with our body?”
Dr. Nick: And you do that, I mean, when you assess people you do head to toe or do you just focus on what they came in with? I mean, I’m sure your preventive stuff looks head to toe with somebody based on what they want to do. Is that correct?
Kelly Starrett: We have a full assessment for what we think are moving vital signs. Really our minimums saying, “Hey look, this is what everyone agrees you should be able to do. And you’re pretty far away from that.” But simultaneously, because movement is a complex topic. And even just as you’ve hinted at, Juliet’s hinted at, the right kind of exercise, the right diet, right? Maybe not the standard American diet, maybe not bench press and elliptical. We’re going to have to be a little more sophisticated than that. It takes a minute and I think it’s okay to engage in a conversation in a practice.
Kelly Starrett: One of the things that Juliet and I always ask about and we say, “Tell us about your health practice, your body practice.” That sort of infers that this is not a game you’re ever going to win, but a game we’re going to constantly be playing. And there are times when you can play really well and there’s times when you have newborn children chasing careers, when you’re just scratching 200. So, I think it’s okay to say, “Hey, let’s begin a conversation about this.” One of the things that I’ve been wanting to ask you about, because you spent so much time in basketball and ballet and you were on the American Council… You are the Chief Medical Officer for the Americana Council of Exercise, right? You’re on the board. You are on the Presidential Physical Fitness and Sports Council.
Dr. Nick: With Arnold as my boss. My friend and my boss.
Kelly Starrett: With Arnold. So you’ve got Arnold, you’ve got Allen Iverson, Cal Ripken Jr. Some really legends have touched you. Do you see if you could just pan back and to see sort of through-line narrative, what are some behaviors, if you could see those things and then also talk to every person on the planet about sort of those through-line narratives or best practice and what you think is a key message? What do we need to hear that we’re not hearing in specifics?
Dr. Nick: Wow. That’s a tough one. If I could answer that one.
Kelly Starrett: That’s right. You wouldn’t be… Yeah, we would all be on the beach.
Dr. Nick: We’d be all beyond the beach. But I think it varies from person to person and you almost have to individualize a lot of this. Again, I get back to the assessment. If you see what they’re doing and what they’ve done, what their fitness routines are, what their sport is, you can almost predict certain patterns of issues that they’re going to have. So you either identify the weak links that they don’t know about or the obvious weak links that they have and then you try to rehabilitate them. You either rehab them or find other ways to help them resolve and just stay ahead of it with regular assessments. I mean, people need to be… They need to be checked, but it’s not how we work in this country. People only come to me when they’re hurt.
Dr. Nick: Now, when I see them, I’m pretty thorough with my exam. I might not go head to toe on a knee injury, but I’ll certainly go from their core down to there to their foot when I examine their knee. So I’m picking up those kinds of things.
Kelly Starrett: Which is already really miraculous.
Dr. Nick: Yeah. And I do, I take the time. I take a lot of time with patients. I probably don’t see as many patients as any of my colleagues do.I do spend time with people and I do try to… But there, I’m only affecting one person at a time. That’s why working with the American Council on Exercise, A4M, you have a bigger reach that way, you understand that. I learned this from Arnold. Arnold Schwarzenegger is a dear friend of mine and we would talk a lot and he saw some of the things I was doing and he thought I was pretty innovative, pretty creative, and he would say, “The work you’re doing, it doesn’t take a whole lot more work to reach 100,000 people than it does to reach 100 people. If you have the information and you know how to use it, it doesn’t take that much more work to reach a larger number of people.”
Dr. Nick: I’ve always kept that in mind that I’m always trying to think of how can I reach more people? So, whether it’s… I’m on Twitter, Dr. Nick USA, I used to have a boatload of followers and then somehow when Twitter… A lot of mine got purged, maybe they were Russian bots or something like that. I went from about 40,000 followers to less than 10,000 but still, I’m on there. I’m always trying to get information out there. I speak at conferences. I try to change, if you change one or two doctors mindset, you have the potential to change…. You’re looking at hundreds of people that you can change.
Dr. Nick: So, I try to think beyond the my one exam room in one patient at a time. And I like to write, I like to speak. I write books, I was on PBS, but then you get so busy you don’t do this. So that’s why any opportunity to work with legends like you guys and to share some of our ideas and look for ways that we could reach more people. Whether it’s through working with ACE that has a… They have an army of personal trainers as do some of the other fitness certification organizations. You start reaching these people and then they’re reaching their 100 people. It’s almost like those, what were those? Multi-level marketing schemes where you go to one person and they go to three persons, then they have another 20 persons.
Dr. Nick: So you start reaching a lot of people and maybe you can change some lives. One other thing just struck my mind that you guys will be interested in, maybe you’ve not seen this data and this is a little shift, but I think it’s really important is you know what kind of an issue we have in this country with chronic pain, right? I mean, it’s a significant number of people in this nation have chronic pain and unfortunately a lot of them also have opioid issues, but pain, whether you know it or not, and I’m sure you probably know this, but the audience may not, pain accelerates aging.
Dr. Nick: Now, all these people with chronic pain, there has been some amazing studies done on this looking at even 20,000+ 50 year olds and finding that middle aged patients with chronic pain can resemble in terms of how you’re looking at them on functional scale and their functional capabilities, functional decline, they can look like someone who were two to three decades older physically.
Dr. Nick: So, a 50 some year old can look like an 80 year old just because they’ve had chronic pain, whether it’s because they’re in pain and they’re less… Whether the mindset, the opioid use may be part of it. I’m not talking about only people who are on opioids. These are people who are not even on opioids, but opioids are a whole nother area. But we have a big problem with chronic pain in this country and once you have chronic pain, you talk about age accelerators like that early injury when you were a kid. This-
Kelly Starrett: Wow. It’s true.
Dr. Nick: So, you have these 40 year olds that are like 70 year olds because they probably are less active. They’re not moving as well. They get into these functional movement patterns that are really abnormal and they’re not using their body, right? You’ve seen this with people with back pain where I had this myself, a friend of mine years ago, clowning around every year he’d find me on the beach and tackle me and we’d laugh and get up and just brush it off. One year he came from behind, I didn’t see him coming and so I couldn’t tighten up or roll with it and it changed my life. And my back was… I couldn’t play tennis. I couldn’t do a lot of things. It was only because I had, at the time I was the 6ers physician. We had an amazing chiropractor who was able to mobilize segments in my back that hadn’t moved in years, honestly.
Dr. Nick: Once he was able to mobilize them, I was able to do some work, a lot of conditioning work, core work, things that I couldn’t do before to maintain what I had. With that segment moving, I’m good again. I mean, my back will still go out. It used to go out more than I did, but now it’s manageable. It’s something I can manage. It was because I know I got into a situation if I had just left that alone and sat around and woe is me and feel sorry for myself, I would have never broken out of that. So, I guess it’s the two kinds of patients we deal with. Some people, they’re afraid to move, they don’t want to do anything.
Dr. Nick: There’s others that want to just blast through it and do crazy stuff even with their ailments. So that’s why you have to individualize a lot of this. You see what the mindset of that person is and see what you are able to fix. And again, I can’t thank you enough for some of the innovative things that even… I’ve used some of your kinds of things for some knee issues I’ve had where it’s not just range of motion. You’re talking about mobilizing something in a completely different way than what the typical orthopedic surgeon who looks at the patient and says, “Oh, your motion is fine. I can measure it with a goniometer. You can straighten all the way in and you can bend almost all the way, so you’re fine.” Well no, not if you follow Kelly’s stuff that there’s other areas of muscle, tendon, and joint mobility that are just different than whether it can straighten or bend all the way. Am I correct?
Kelly Starrett: Only about 100% correct. One of the things that I… We just really appreciate your message. My father’s a physician, my grandfather’s physician, and one of the things that I think we kind of come up against all the time, Juliet and I, is maybe healthcare, when I have catastrophe or pathology, healthcare is very clear and very easy to understand. And sometimes I tell people, “Hey look, you are running into your physician with a problem that’s not a physician problem.” That the physician may not, she may not be set up in the current way we’re paid for healthcare and compensated for healthcare and how it’s managed, an eight minute visit is not the place to understand your complex knee running mechanics and your lifestyle and your nutrition.
Kelly Starrett: I have friends in Australia who are neurosurgeons who’ve opened gyms and that’s how they’re expanding their practice. And I feel like physicians like you who are working with dancers, working with athletes, spending a time in public health is really the model that we need to take an all healthcare. We’ve got to bring the mountain to Mohammed, for lack of better word. Simultaneously we’ve got to do a better job of giving people the tools to be able to use their physicians and use their healthcare appropriately, not as an emergency break.
Dr. Nick: Correct. Yeah. Stop the wall street mentality, the bailout, wait till you’re badly damaged and then try to turn back the clock, not going to happen. So the one other thing you guys mentioned that I think is important is the nutritional side that what you eat, food is kind of a medicine. When you look at inflammation that occurs in low grade inflammation in your body, there’s a lot of things out there that are readily available in everyday life that it’s almost like they’re inflammatory molecules that you’re eating and you’re creating inflammation. And there’s other things that you can eat-
Kelly Starrett: You mean these like sugar.
Dr. Nick: Sugar, white bread, the whiter the bread, the sooner you’re dead. Sugar. There’s a lot of things out there that create low grade inflammation in your body. And again, eating the right kind of bread or vegetables, sure it’s not going to completely cure things. But again, this is one factor where we could do so much better in this country, to be choosing those foods that are actually anti-inflammatory rather than pro-inflammatory. And when you look at being overweight, when you’re overweight, not only is there a mechanical load on your joints, for every extra pound that someone carries, your knee reads it as five to seven pounds, right?
Dr. Nick: So there’s an exponential overload on your joint with even small amounts of weight gain. The good news there is that if you lose weight, if you lose three pounds, your knee thinks you lost 20 pounds. So I try to tell patients, let’s just start with a little. An even 10 pound weight loss has been shown to slow down the progression of osteoarthritis. But in addition to the mechanical load that obesity plays, those extra fat cells are… There’s not only a metabolic stress, but there is an inflammatory stress in your system. There is higher grades of inflammation when you’re carrying extra body fat. So it’s kind of a triple threat to the body. It’s the mechanical load, it’s the metabolic load on your system with diabetes and other things, heart disease and things like that. But then there’s the chronic low grade inflammation that it also creates.
Dr. Nick: And again, the fitness crowd that you’re working with, probably obesity’s not the issue, but it is for a lot of the population. It is one of the reasons that people have musculoskeletal ailments. I mean, people who are obese, it makes sense that you would say, “Okay, I understand why they have higher incidents of knee and hip arthritis and knee and hip replacements. I can kind of understand why they have more back pain.” Right? “And this, but why do they have a higher incidence of rotator cuff tears?” Well, that’s an interesting thought. And it’s because of these other effects that obesity has on your frame.
Dr. Nick: Obviously obesity, you’re not walking on your hands so you’re not affecting the shoulder, but much higher incidents of rotator cuff issues, higher incidents of problems with surgery if you’re carrying extra weight. So, get the weight off, get moving. Yeah. Try to eat a little better, manage stress. All these things that I say, but I don’t even do all the time. I’m pretty beat up and I’ll eat my pizzas every Friday. You got to have pizza.
Kelly Starrett: Your last name is DiNubile.
Juliet Starrett: Yeah.
Kelly Starrett: You have to.
Juliet Starrett: Have to.
Kelly Starrett: So one is that I just want to say that I’m always telling Juliet, “Don’t worry. I’ve actually got big knees.” So I’m so set, right? I can handle this extra mass I’m carrying around baby.
Dr. Nick: Big knees.
Kelly Starrett: Big knees. Where would we find you on the internet so we can read about more? And also what’s next for you? What are you working on?
Dr. Nick: Okay, well my website is drnick.com, just D-R-N-I-C-K .com. My Twitter feed is a Dr. Nick USA. It’s just D-R-N-I-C-K USA on Twitter. What am I working on? I think my next book might have to do with the female athlete and I think it’s going to be very controversial. I think I need to help change this whole process because when I see all these young girls with concussions and just the concussions and ACL, there’s more than that. But just on the concussions and ACL tear, we’re going to have a significant issue going forward because it is epidemic rate right now.
Dr. Nick: Every high school girl’s soccer team has at any given time, three or four kids with ACL tears. It’s unbelievable. And this is… We always talked about ACL tears being career ending when I was in my training, then we thought, “Well, we have this solve, we can fix them.” So it’s only season ending. So they get back and play the next year. Sure they do. But really, it’s a life altering injury and these concussions we’re seeing are not like when you and I were younger and I’m older than you guys, but where you got your bell rung and it was kind of funny and you went back and did whatever you had.
Dr. Nick: We realize now that there’s a significant issue there. And females are really at much higher risk on some of these issues. So, I want to try to change the way we think about that. I want to keep doing my work on how we change the way we think about our frame, our musculoskeletal system. How it functions and how it fails and how it thrives. I mean, I really want to make an impact there. I’m an old guy with relatively young kids, so I’m always interested in what my kids are going to be doing.
Dr. Nick: Neither one of them is going into medicine. So, we’ll see how they play out. And then I want to try to keep being a better tennis player, a better dad, a better husband. But I still… Like Arnold says, “It doesn’t take a whole lot more work to change the world than just to change your own household.” So I’m always going to be looking for ways to make an impact.
Kelly Starrett: Well, Dr. Nick, count Juliet and I in.
Juliet Starrett: Thank you so much.
Kelly Starrett: On your projects and what an absolute pleasure. Everyone knows we’re sort of a mutual good friend and I’ve been trying to connect with Dr. Nick for an age and this is the first time we’ve ever spoken and I feel like, “Wow, if I could clone myself and move myself out to the East Coast, it’s you.”
Juliet Starrett: Well, we’re so grateful for you. Thank you so much for being on.
Dr. Nick: I really, really appreciate you having me on. Hopefully this is the beginning of maybe some interesting things we can do together. I really, really look forward to collaborating with you. And I will continue to write your name on prescription pads.
Kelly Starrett: Thank you, Dr. Nick.
Juliet Starrett: Thank you.
Dr. Nick: You’re welcome.