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The personal blog of Peter Attia, M.D.

How you move defines how you live, Part II

How you move defines how you live, Part II
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In the summer of 2009 I was preparing for a swim that nobody had ever done before. Marathon swimmers are always looking for a body of water that has never been swum by someone else. The span of ocean between Catalina Island and Santa Barbara Island (SBI) seemed like a perfect spot. Four years earlier I had swum from Catalina Island to Los Angeles and three years earlier I had been part of a relay team that swam from SBI to LA.

This stretch of water between Catalina and SBI would be a tough swim for reasons too numerous and mundane for this post. The swim was scheduled for a window in early September, but by early July, my right shoulder was really hurting during any training swim that exceeded six hours. By late July, the pain was getting very sharp by hour four of each training swim. After an arthrogram (an MRI where they inject contrast directly into the shoulder joint) and a visit with an orthopedic surgeon, we had what appeared to be a diagnosis. I had a torn labrum.  The surgeon recommended surgery, which would require being in a sling for six weeks post-op and a period of no swimming for nine months.

I asked the surgeon if continuing to swim for a few more months, despite the pain, would reduce the chances of a successful surgery. He said no, and so I decided to suck it up and keep training. I did, however, decide to opt out of what I considered would be a very tough Catalina to SBI swim—something I estimated would take at least 12 hours in very rough water—in favor of what I assumed would be a much more manageable LA to Catalina swim. Generally the currents make this swim slightly easier than swimming from Catalina back to the mainland, which I had already done in 2005, only 18 months after really learning how to swim. It took 10 and a half hours, so I assumed this would be a pretty straightforward swim. (Any ocean swimmers reading this are laughing at this point. Such hubris always gets you spanked.)

The story of this swim is one of the most painful of my athletic career. A last-minute change of the current—head on—turned this into 14 hour-plus swim, in some of the roughest chop (first and only time I was ever sick in the water) of which the last eight hours I was screaming under the water from the pain so my crew would not hear me. Unlike my first Catalina swim where I was able to enjoy the marine life and sights and sounds of the ocean, this was my equivalent of Ali’s third fight against Joe Frazier (“the closest thing I’ve ever known to death,” he would say following his victory). Ali had it worse, to be sure, but this was unsettling pain.

Parenthetically, if anyone is wondering how dark it is when you’re swimming in the ocean at 2 am, it’s really dark, hence the glow-stick on my back so they can see me when not shining giant light down from the boat (which I hate, as it makes it impossible to see the bioluminescence–the swimmer’s reward for swimming in complete darkness).

A week following the swim I had another arthrogram which showed the tear was, more or less the same, but at the last minute I decided to forgo surgery. The thought of not swimming for 9 months was too unappealing. Instead, I took a break from marathon swimming and focused only on Master’s swimming and racing in the pool. For the next two years I did mostly fine, especially as I focused on less volume and more intensity, and mostly on breaststroke, fly, and medley.

By 2012 I was spending more and more time on my bike, but it was clear my right shoulder was getting weaker and weaker, even as I limited my swimming to one hour per day. Soon I could not do many pushups and certainly could not bench press heavier than 135 pounds. I recalled a former swim coach telling me that once it got the point where you could not shampoo your hair, you were hosed. Though I didn’t shampoo my hair, I knew I was at this point in late 2013. I could not bench press an unloaded bar or do even one pushup without terrible pain.

I was scheduled for surgery in early 2014 and during one of my sessions with Brian Dorfman shortly before the procedure (I’ve made reference to Brian before, including on several podcasts and in Tim Ferriss’s most recent book, Tools of Titans) I mentioned it to him. At this point, Brian was primarily working on my lower body as I was deeply in the throes of time-trial season on the bike. Brian, being Brian, examined my shoulder in depth and just “declared” that my pathetic strength and agonizing pain was not due to my labral tear. Before I could object, he elaborated. It was not that I did not have a labral tear—the MRIs made that clear—but he hypothesized that the tear was not the proximate cause of my pain and complete loss of strength. For that, he said, I could blame my deltoid, triceps, and subscapularis.

Brian asked if I would be willing to delay surgery for six months to give him a chance to work on “the fix.” He told me it would be tough, and painful, to manipulate these tissues and, of course, I would need to make a lot of changes to how I exercised my shoulders.

Brian had previously rescued me, miraculously, from a left knee operation that also seemed inevitable by fixing my glute meds and hamstrings, so I was willing to give this a try. And so began the amazing transformation of my right shoulder and, ultimately, my left one, too. Just as Brian had predicted, within six months I was back to about 80% of previous function and today I’m at 95% which implies I have no functional limitation and no pain. And no surgical incisions.

My friend Terry Laughlin, founder of Total Immersion swimming, used to always tell me when I was learning to swim that practice did not make perfect. Only perfect practice made perfect swimming. This is true in life, of course. Specificity matters a lot. In the same vein, the only reason the Brian Dorfman experiment worked is because it was done correctly, both in terms of what Brian did to me and in terms of what I had to learn about exercising my shoulders.

This experience was at least part of the motivation for the next video series Jesse Schwartzman and I wanted to prepare for you. Both in my own life and in my practice (i.e., in the lives of my patients) it has become so clear that a very proactive strategy is necessary to offset orthopedic injuries as we age. In some cases, like mine, the injuries are brought on by years of overuse. Before swimming, boxing probably did the most damage to my shoulder, having resulted in a dozen subluxations between the ages of 13 and 20. In other cases I see, the injuries are more a result of underuse. I can’t reiterate this next point enough: to pursue physical bliss into your “senior” years (you know, into your 40’s), requires a shockingly deliberate effort and incredible consistency. It’s not “hard,” but you have to embrace that coming back from injuries like mine is much harder than not having them in the first place. Furthermore, there is no assurance that I will manage to escape the next surgery. My goal is to avoid the drama next time.

The neck and upper back series below can be used as an active recovery workout by itself. Too often we see people push through too many high intensity workouts a week, leading to overtraining. The series can be done as a standalone day, and it will still give you a sweat and count as your exercise for the day.

Having said that, if a few of these moves feel particularly good and needed for your body, you can also choose to add some of these exercises as part of your regular warm-up routine, or repeat the exercises for multiple sets as part of a circuit. Try not to be concerned that you may not get all your usual strength training exercises done every workout, as these moves take time to do correctly, and will take up some of your budgeted exercise time. As we age, we need to increase our ratio of proper tissue warm up and range of motion practice, relative to actual intense exercise. Tissue becomes less elastic, and motor units lose their signals, so if we don’ use it we lose it. This is true of athletes, and normal civilians.

In the spirit of the first post on movement preparation, Jesse and I have (once again with the awesome help of Elliot Stern* and Kelly Choi who shot, produced, and edited these videos from start to finish) put together a sequence of movements and exercises designed to get your neck, upper back, and shoulders ready to do anything, free of pain.

(*If you’re looking for someone to help you with video, I can’t recommend Elliot enough, and if you want to reach him, you can ping him at: eliestern427@gmail.com)

Here is a link to our tear sheet to help you recall the sequence of movements and the important cues for correct execution.

Introduction


Direct link: https://youtu.be/FjRorW4n8Rg

There are three main videos in this sequence:

I. Soft tissue preparation


Direct link: https://youtu.be/XZOrnznGzH4

II. Dynamic stabilization


Direct link: https://youtu.be/q2I1I_qH0jE

III. Loaded exercises


Direct link: https://youtu.be/V9pc82gupX0

In addition, there is some extra material:

A shoulder diagnostic test


Direct link: https://youtu.be/hXtW8bgm4hs

Exercises specifically for the rotator cuff


Direct link: https://youtu.be/cIjKtVc4J0Q

Exercises to improve scapular health


Direct link: https://youtu.be/v5xnJArYWjM

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About the Author:

Peter Attia, M.D., is a physician in private practice in NYC and CA. His practice focuses on longevity and healthspan. His clinical interests are nutrition, lipidology, endocrinology, and a few other cool things.

Discussion

  1. Bruno  June 11, 2017

    Peter,
    Thanks for the post and videos.
    For about 20 years I’ve suffered with excruciating shoulder pain especially after I was done with my college tennis career. I’ve continued to play recreationally but never over serving since I was mostly playing doubles. Now I am close to 40 and trying to make a comeback playing singles tournaments. During my first tournament I realized I can barely finish a singles match without serving underhand.. I feel the same sharp pain as you mentioned on your post. I will follow your prescribed strength exercises and check back later if there is any improvements. Thanks

    (reply)
  2. Michael VanGilder  June 11, 2017

    Thanks for the videos. Great job with the general mobilization and stabilization exercises. I would encourage you to think more about the notion of specificity of movement that you mentioned earlier in your blog. In my practice, we treat patients with pain and dysfunction with activities that are primarily upright and gravity-dependent. It is our thought that, if we are truly addressing patients’ functional limitations, we need to have the majority of their mobility and stability exercises closely replicate authentic proprioceptive/neuro-musculoskeletal demands. Thus, if a majority of the patients’ mobilization and stabilization exercises are not in an upright, gravity-dependent position, we’re missing the boat from a proprioception standpoint.

    (reply)
  3. Anne  June 11, 2017

    Thank you so much for this series. I have been struggling with shoulder workouts due to impingent. Many of these exercises are shown to me by trainers but they arent coaching them so thoroughly. Thanks again.

    (reply)
  4. Jake  June 11, 2017

    This is fantastic! Thank you, Peter!

    Being an archer, shoulder and scap health/stability are front and center in my mind. While I’ve not had any issues besides the occasional nagging shoulder, I’m definitely going to incorporate this sequence into my weekly routine to make sure I remain injury free (knock on wood) from the volume of arrows I shoot.

    How is your archery coming along? What does your setup look like? Any insights you’d like to share?

    Cheers!

    (reply)
    • Peter Attia  June 11, 2017

      Thanks, Jake. Archery has definitely introduced some nuances to my routine. It’s the first sport I’ve done with such an obvious asymmetry. That said, I freakin’ love it. That sound…that feeling…that need for total control over my breath and my emotions… addiction.

  5. Leslie  June 12, 2017

    I can’t thank you enough! My computerized broken posture thanks you! I’m trying to figure a way to work these into daily routine movements. Rebelling against the screen!

    (reply)
  6. Derek  June 12, 2017

    I agree that exercise can help one’s well being, but believe it must be within the limits of one’s capability. And those limits may be adjustable downward as well as upward. Here is my reasoning.
    I was a very fit fighter pilot in advanced training at age 20 when I caught paralytic polio. Polio attacks motor nerves and after two years rehab I was left me with substantial residual paralysis. Eventually, I became a professional engineer engaged in research in what was basically a sedentary job. I am now 87 and along life’s way found that too much exercise destroyed the weak residual nerve fibers left over from polio. Most polio survivors understand this and for them the maxim is “Use it and Lose It.” Fortunately, I have not had to apply the same maxim to brain exercise . . . yet.

    (reply)
  7. Bob  June 12, 2017

    Excellent post Peter, appreciate the level of detail.

    I’ve been looking for more effective ways to increase shoulder strength and was interested in your comment about reduced reliance on the overhead press. Can you recommend an exercise or two for deltoid strength, or point me to a resource?

    Love this serious of posts, thank you!

    (reply)
    • Jesse Schwartzman  June 13, 2017

      Hi Bob. The take away here is that you want to strengthen the deltoid in biomechanically advantageous exercises. The shoulder socket is simply not designed to lift heavy loads overhead continuously over time. You also want to avoid overhead pressing through a tight shoulder sliing where you have to work through pec and lat tightness. Having said that, is you have perfectly open shoulders (as assessed by our diagnostic) you can do high reps low weight overhead pressing to get some hypertrophy (15-20 reps) Also light resistance dumbell reverse flys, front raises, and scaption are good choices for most people. But compound moves like pull ups, push up variations, rows, and carries are my personal favorite for delts.

  8. Ray Jennings  June 13, 2017

    So Peter, I love the videos and your recent blogs are all great. I have followed you from the inception of your blog…please take the time to tell me, how does your daily intake differ from 2014 post “What I actually eat Part III”.

    (reply)
  9. Tom  June 13, 2017

    This is solid gold advice. I was in a similar position as a 55+ year old crossfitter. Kipping chinups and one poorly executed overhead squat pushing for an extra plate took its (inevitable?) toll. I was fortunate enough to find a great Kerlan-Jobe trained surgeon who confirmed the partial tear and then told me I did NOT need surgery. He even suggested the tear may well be from previous injury. My pain was mainly from impingement, imbalances, etc… Very similar PT routine and constant diligence paid off for me. My biggest suggestion is that people have the patience and resolve to take the time and actually DO these exercises. And perhaps most important — do them now as prevention before you get hurt!

    (reply)
  10. Glenn  June 17, 2017

    Peter
    I’m not on Twitter, but I occasionally check your twitter postings for valuable content since I’m a big fan of yours. I’ve tried to listen or watch all of your contributions on media (ex. Tim Ferriss blog and book). This is a great series. It’s good timing since I’m battling chronic bi-lateral infraspinatus tendonitis. Now my wife has some issues with her neck, which is causing dizziness and nausea. I plan to forward the link to these videos to her. Keep up the great work!

    (reply)
  11. John  June 21, 2017

    Sorry Pete I know it’s a bit off topic. But I remember you had talked before about your small period using pills for some injury you had and how hard it was to get off of it. I mentioned before if u could do a podcast or article on it and you said that would be a good change of topic. I think it’s something that can help a lot of people who follow. Sometimes it’s not just our food addiction that keeps us from healthy diet or keto. If u have any time to expand on ur experience and how to overcome that would be great. Appreciate you always.

    (reply)
  12. Chi Duong  June 25, 2017

    Dear Dr Peter,
    This is a fantastic post. Thank you so much for this sharing. It is very helpful.
    These days my colleague is having lower back pain neck because of many hours per day working at a computer. We have followed your videos during our break time and it really works.

    Would you like to give us more details about how often we should do these exercises during office hours?

    Thank you in advance!

    (reply)
  13. jayne  June 29, 2017

    Thanks Peter and Jesse!
    These videos are so very helpful and very well done.
    I appreciate the work everyone did for this and I have already started working on these.
    Thanks again.

    (reply)
  14. George  June 29, 2017

    I only came across your blog today. I went looking for part X about cholesterol but there didn’t seem to be one…

    I am interested in statins.

    Can you think of any situation ASSUMING someone makes lifestyle changes i.e. loses weight, stops smoking etc when statins should be prescribed? Primary? Secondary prevention?

    if ‘yes’ could you tell me why please – if it is for anti-inflammatory effects then surely these can be achieved through lifestyle?

    THANK YOU

    (reply)
  15. Charlie  July 4, 2017

    Jesse – about ten years back the long head of my right triceps was removed due to a sarcoma. This has left me with some upper body asymmetry both in musculature and strength, becoming more pronounced with the resistance training I’ve followed diligently for the past 5 years. In order to avoid pain in BOTH shoulders and arms I must restrict loading and certain movements, like pull ups. My surgeon assured me the muscle will not grow back but that the surrounding/supporting muscles will compensate to fill the ‘gap’. Do you have any recommendations that could help me improve balance in strength and movement in my upper body, given the situation of my right arm?

    (reply)
  16. Edie  July 22, 2017

    Love these, am wondering if there is anything specific to neck pain from sports.I am an active 52 year old that is trying to keep playing tennis despite 2 years of neck pain. MRI/rehab/neurosurgeon say I have mild cervical stenosis, bone spurs and cervical spondylosis. Thus making tennis flare my neck up terribly as well as swimming. Running doesn’t seem to bother it. My goal is to keep playing tennis howerver. I suspect that tight and weak upper back, traps etc are causing me to fire up the wrong muscles when I play thus causing the neck pain. Have seen PT/trainers and the whole routine of providers. I had a HAGL lesion 3 years ago that I worked through with PT but not surgery and wonder if the weaknesses caused by that have created imbalances. It was on my right shoulder and I am right handed with tennis. Am going to try this routine and see if I can offset some imbalances in strength, weakness and tightness. Any suggestions would be appreciated.

    (reply)
  17. Bill In Oz  September 6, 2017

    Peter are you still interested in Cardiovascular disease ? And do you still stand by the explanation you provided in the post last year on CVD ?

    I ask because I think the explanation has been superceded. If you are interested look here at Dr Malcolm Kendrick recent post on what causes heart disease:

    https://drmalcolmkendrick.org/2017/09/05/what-causes-heart-disease-part-xxxvi-part-thirty-six/#comment-75004

    (reply)
    • Peter Attia  September 8, 2017

      Not sure how this explanation “supersedes” the the one I’ve provided. Lipoproteins are necessary though not sufficient for atherosclerosis. The other two ingredients are endothelial damage and inflammation (see recent CANTOS publication in NEJM).

    • Bill In Oz  September 16, 2017

      From what I have read in your writings you suggest that Lp(a) number in the blood stream is the main driver of CHD. And Lp(a) is a lipid and a ‘spin off’ or development of the Cholesterol hypothesis..
      But Dr Kendrick suggests that there are numerous ’causes’ of CHD – smoking, NO, physical or emotional stress, etc that all over time cause inflammation & damage to the endothellial layer of arteries. Then arterial plaque as the body’s repair mechanism. ( Perhaps as a consequence of insufficent vitamin C..)

  18. Todd G  September 14, 2017

    Hi, Peter! I love your website, especially the volumes you’ve written about cholesterol. I asked my primary doctor to run a lipoprofile and I have the results. For the past three years, the standard cholesterol test she gave me indicated I was st an increased risk of CVD. The lipoprofile test is a little more ambiguous, although mostly points to hyperlipidemia. I know that my mother and sister have high cholesterol. I exercise, do intermittent fasting, supplement with d3, k2, fish oil and magnesium, I eat mostly whole foods exercise and am pretty trim, like my mother and sister. If I post the results could you take a look? Or do you ever offer paid consultations in New York? I live in Queens. Hope to hear from you, thanks much for all you do!

    Todd

    (reply)
  19. pd  September 17, 2017

    i am skinny (5’6″ 125 pounds) yet due to Lp(a) have high cholesterol (240+) and with a high-risk family history of diabetes (mom, dad, elder brother all have diabetes). if i skip b’fast i can’t even stand (low sugar) and need to eat every 2-3 hours.

    any recomendation on how to follow a keto-diet ?

    (reply)
  20. Dave Lull  September 19, 2017

    Dr Attia,

    In your video “Soft tissue preparation” your collaborator says:

    “The crux of deep breathing is that you’re breathing out longer than you’re breathing in.”
    “. . . three breaths a minute . . . .” (5 count inhalation, 5 count hold, 10 count exhalation.)

    Can you provide citations for or links to the research reports supporting his opinions?

    (By the way, the Resperate website also mentions a “prolonged” exhalation as being key to relaxation:

    http://www.resperate.com/wp-content/uploads/2017/02/RESPeRATE_clinical_Info_Kit.pdf )

    The following is the only research report (summary) about this that I’ve read and it supports “equal inhalation-to-exhalation ratio” as leading to relaxation:

    https://drmalcolmkendrick.org/2016/06/19/what-causes-heart-disease-part-xvii/#comment-58518

    [quote]
    Dr. Malcolm Kendrick Post author
    June 29, 2016 at 7:19 am

    If you can slow your berating [sic] to six a minute (actually five point five), this appears to have important effects on vagal tone, resulting in a more coordinated heart rate variability (HRV), calmness and relaxation. This rate, coincidentally or not, is used by many religions around the world. See paper below:

    Breathing at a rate of 5.5 breaths per minute with equal inhalation-to-exhalation ratio increases heart rate variability.
    Lin IM1, Tai LY2, Fan SY3.
    Author information
    Abstract
    OBJECTIVES:
    Prior studies have found that a breathing pattern of 6 or 5.5 breaths per minute (bpm) was associated with greater heart rate variability (HRV) than that of spontaneous breathing rate. However, the effects of combining the breathing rate with the inhalation-to-exhalation ratio (I:E ratio) on HRV indices are inconsistent. This study aimed to examine the differences in HRV indices and subjective feelings of anxiety and relaxation among four different breathing patterns.
    METHODS:
    Forty-seven healthy college students were recruited for the study, and a Latin square experimental design with a counterbalance in random sequences was applied. Participants were instructed to breathe at two different breathing rates (6 and 5.5 breaths) and two different I:E ratios (5:5 and 4:6). The HRV indices as well as anxiety and relaxation levels were measured at baseline (spontaneous breathing) and for the four different breathing patterns.
    RESULTS:
    The results revealed that a pattern of 5.5 bpm with an I:E ratio of 5:5 produced a higher NN interval standard deviation and higher low frequency power than the other breathing patterns. Moreover, the four different breathing patterns were associated with significantly increased feeling of relaxation compared with baseline.
    CONCLUSION:
    The study confirmed that a breathing pattern of 5.5 bpm with an I:E ratio of 5:5 achieved greater HRV than the other breathing patterns. This finding can be applied to HRV biofeedback or breathing training in the future.

    P.S. You are right, the normal breathing rate is much higher than six a minute.
    [Close quote]

    (reply)
  21. Gary  September 27, 2017

    Hello, Dr. Attia,

    I found you through Tim Ferris’s podcast and I’m glad I did! You are helping many people wake up and live better lives so thank you! Quick question: If you or a family member found out they had smoldering myeloma how would you eat and attempt to control this condition with hoping to stop it from ever progressing to multiple myeloma. (without prescription based therapy). I am grateful for any suggestions.

    Best

    (reply)
  22. Jeff  September 30, 2017

    Peter –

    Love all the articles and especially LOVE the hour long YT presentation you did. 2 questions, hopefully framed in a way in which you are able to answer:

    1) Is the amount of protein for maximum ketosis (in your opinion or through your research) a fixed number (approximately < 150g as previously stated) or must it be in proportion to the amount of fats? As example, I currently consume 2,300 +/- Calories so while 65% of my calories consumed are fats (30% protein, 5% carbs), the number of actual grams of fats and grams protein are fairly close (150gF/160gP)

    2) When you were experimenting with Ketosis, did YOU (not taking as a recommendation, but matter of fact question) carb spike on the weekends as popularized by Di Pasquale's "anabolic diet"? Any opinions on this?

    (reply)
  23. Eric  November 1, 2017

    Hi Dr. Attia,
    I recently heard your excellent podcast on the “STEM” website in which you stated that the best muscle fiber to develop is Type IIb. I’ve done some “googling” and it appears those fibers are not easy to develop. Even a hard squat set of 5 reps may get handled by the Type IIa fibers and leave the Type IIb relatively unscathed. The modalities that seem to work best for Type IIb development are plyometrics, and paradoxically, isometrics. You do mention interval training as one of your exercises and it sounds like that would develop Type IIb. Could you share if you use other methods to develop Type IIb muscle fiber in your program?

    Thanks,
    -Eric

    (reply)
  24. Robert Poon  November 7, 2017

    Dear Dr. Attia,

    I just wanted to let you know that I’ve had the privilege of reading your blog posts, as well as multiple lectures on YouTube over the past year and have gained much insight.
    Because of this, I have taken an interest in exploring how my body and mind function under different physical conditions (during extended fasting, certain forms of exercises, effects of various macronutrients. etc.) using the precision xtra to monitor (again, thanks to you!) fluctuations in my glucose and ketone responses.
    In addition, as an avid swimmer and surfer, the wealth of knowledge from your blog has provided me with ways to improve my cardiovascular and muscular fitness as well.

    I also wanted to let you know how much I appreciated reading, amongst many others, your specific blog post titled “ Why we’re not wired to think scientifically (and what can be done about it)”. As a current philosophy major and neuroscience minor, I cannot disagree with the fact that critical thinking is of great importance not only in science but also in trying to make the world a better place. And most importantly, your blog has given me the opportunity to become a true “critical thinker”.

    I’d love to elaborate on some of my self-experiments mentioned above, but at the same time I feel it’s probably best for me to keep my comment short.

    Yours Sincerely,
    Robert

    (reply)
  25. Theresa  November 8, 2017

    Hi, I’m new to your site but very interested and reading as time permits. I would like to know if you have any recommended reading for me who has surgically induced menopause and midsection weight gain. Specifically, I am interested in knowing if the ketogenic type eating would actually work in the absence of estrogen. I haven’t been able to find anything online (via Google Scholar, PubMed and the like); but I’ve read all of Dr. Diana Schwarzbeins stuff and she recommends hormone (estrogen) replacement to address the problem (no can do…estrogen induced endometriosis was the reason for the surgery and adding estrogen back seems pure folly). I am also concerned about my lack of estrogen now, and potential for MI in my future. I have read that post-menopausal women have rates of MI (and MI death) similar to men, which scares me. I now getting serious about dietary changes but don’t know where to begin. I am also unsure about whether I should bother getting blood work done to see where what my artherosclerotic status is. I look forward to your reply. thanks! great info on this site!!

    (reply)

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