Exercise Physiology Plus Menopause Physiology for the Midlife Exercise Rx

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What are you waiting for? Good night. In this episode discussing the midlife exercise prescription, I host Dr. Kathleen Jordan as we discuss from a medical exercise specialist, my side, and a physician, her side, the mashup of menopause symptoms and exercise solutions to mitigate and amplify good health. Midify or mitigate health risks, disease risk from changes due to symptoms of hormone change, and amplify good health now and for the decades ahead. In case you're curious, I have a couple stats. Nearly 50% of medical schools offer any training at all in exercise physiology. That means 50% of our doctors don't have any exercise training available to them. Stay tuned. 0% of any medical school require it. At least 80% of physicians don't feel comfortable recommending exercise, at least getting specific with it. When a doctor recommends exercise, then they're often helping you get moving at all. The suggestion to walk, which is actually the most common recommendation, or to do Pilates can be helpful. The match to your highest priorities comes from direct knowledge of the physiology of exercise plus the physiology of menopause for the ideal midlife exercise prescription for you right now, because it most certainly can change from your late 30s to your late 40s to your late 50s, there will most likely be 3 different ideal exercise protocols. And within that, if you and I start the ideal program today, you know, in a month we can't still be doing that exact same workout. Hopefully you know that there is progression. There's a start, we move from A to B to C, and we need to have periodization, which means we don't go upstairs all the time. We go up, up, up, and we come back down for rest and recovery week that ensures we do not get an injury. We stay healthy, fit, and resilient—muscle, bone, tendons, and ligaments. I'm Debra Atkinson. You're listening to Flipping 50, where I address your top struggles and concerns. But most of all, we hope to inspire you, because struggles and concerns sounds a little like a downer. So we hope to inspire you to expect and demand better products, better services for this second half. I share here what to eat, how to move, and how to change your mindset so you can have the energy and vitality that you want, you need, and you deserve in this second and better half. Today my guest is again Dr. Kathleen Jordan. She's described as a proponent of digital health and solving access issues. Dr. Kathleen Jordan has consistently leveraged innovative technology and patient care After scaling her own medical practice, she became chief medical officer at Dignity Health, then shifted to leadership roles as women's healthcare startups. She was chief medical officer at Tia, focused on young women, prior to joining Middie Health. Her career highlights include establishing telehealth services at Dignity Health, attaining the Health Equality Leadership certification for the hospital and its programs, establishing a new trans health program in San Francisco, for which she was awarded the Leadership in Innovation Award, helping TIAA grow from one site to a multi-state organization with leading healthcare system partnerships. She joined Middie with the goal of helping all women in midlife feel better and live stronger, longer. Her expertise has been tapped by the Washington Post, CNN, Yahoo News, and many other media outlets. She's a graduate of the UCLA School of in Stanford University. And here we go. Dr. Kathleen Jordan, thank you so much for being here.

It's great to be here. Thanks for having me.

All right, so I mean, this is actually so great because we need to unpack this. I think in the medical field versus, you know, the health and fitness field, there can be a little bit too little or too much or not quite right on target information going back and forth. And I'm sure as physicians, it's easy to say that and say pointing fingers at the fitness industry, because collectively there's a very diverse set of what qualifies to put you, you know, as a trainer in the fitness industry. It's very loosey-goosey right now. And, you know, I think for trainers, often, you know, we get clients who will come in and, and they've been told exercise, but they've been told to walk and, and that should cover all their needs. And, you know, we all know that that's probably not true. Those of you who are listening probably am preaching to the choir, but I am so looking forward to unpacking this and talking a little bit more about what collectively you're doing to make healthcare accessible, very accessible to so many more women. But Let's unpack this. What fitness and, and exercise recommendations do you have for a woman navigating menopause or perimenopause? Maybe we should start with what benefits do you absolutely know and want to see for every woman who's in midlife from exercise?

Yeah, I think the, the loudest and brightest advice we give to women on exercise is simply Yes, yes, yes. Exercise is so helpful in many, um, for many reasons. It's really not just about calorie burn, you know. I think that can be a motivational reason that people get into exercise, but there's lots of data on how exercise helps us in so many ways, and specifically for things that affect women in midlife, you know. You know, the easiest that comes to mind, and probably most studies, that it helps bone health. But it helps our muscle strength. It helps with our balance, which then helps with fracture prevention. It helps with posture. It helps mental health. It helps stress management. It helps sleep. And there's actually even a lot of studies that show that it prevents breast cancer. So regular exercise prevents breast cancer. And then there's a ton of evidence about how it influences cholesterol levels and even our— the way we metabolize blood sugar. So it goes way beyond just calorie burn.

Yeah, so love that. And we've taken up the, the anecdote that really it's not, you know, what exercise does to calories, it's what those calories, those that you burn or that you eat, do to the hormones. Because it's hormones that determine fat storage or fat burn. And in midlife, the rules change, right? So what What you used to do that worked is most likely not going to work now.

Oh, I hear that so often from women. Um, you know, at Middie Health, we see women from across the nation of all different backgrounds on a telehealth platform. And they tell me, you know, for instance, um, they tell me their weight, but they also will talk about their cholesterol, their blood sugar. And, you know, they are frequently surprised, like, I have not changed a thing, but all my numbers are worse, right? My, my pounds are going up, my cholesterol is newly high for the first time, and they really haven't changed a thing. And it's true, our bodies are changing. The hormone shifts from menopause in particular shifted rapidly for women, um, and it's been great to be a part of sort of helping them wade through that.

Yeah, I mean, and we say the biggest challenge is, of course, you mentioned bone density And, and yet it's that drop in estrogen when it's really, you know, at the bottom, especially in menopause transition, becomes more drastic and obvious for muscle loss. I mean, even the women who are exercising can't seem to gain lean muscle or hold on to it, and really becomes noticeable because I think that's where most of us feel like my skin is thinning.. And so that is calling attention to the lack of muscle tone. And it potentially was there all along as we were trending down in estrogen, but that is a protectant for both the muscle. It's a stimulus for muscle and a stimulus for bone. So we have to have something that picks up the slack where that left off for a woman who doesn't do hormone replacement, at least, or Sometimes even if they do, they've got to start lifting heavier. Doesn't mean more often, it doesn't mean long sessions, it just means probably have to have more stimulus than you've ever needed before in your life.

Absolutely, I couldn't agree more. Um, exercise is such an important component of just living healthy and living well. It, it does help with our muscles. I think what I see often in women in midlife is they may present with concerns about hot flashes, night sweats, or, you know, skin and hair changes that you mentioned, and may not appreciate all that's going on inside, right? Where the drop in estrogen makes our bone density really dramatically drop off in those first few years and then continuing for years after, and our muscle loss as well.. And as those, as those decline, we are headed into frailty. And frailty is a, is a big deal sort of in the next decade, right? That's when we see fractures. That's when we see half of women getting into osteoporosis. Um, so people aren't necessarily worried about fractures when they're late 40s, 50s, perimenopause and menopause. But what we do now sets us up for success. In the future decades and what we hope to be a very long and healthy life. So true.

We, we love to use the term, you know, it's a two-for-one. So you use it now and potentially we— I'll come back to this— you can decrease those hot flashes and night sweats actually with the right kind of exercise. So if you're out there and you're saying not working for me, I often have that response, but sometimes you have to unpack. Are you doing it in the way that gets the best results? But it's, it's today so that you optimize the way you feel and you look, getting some confidence back today, but also so that your 85-year-old self will thank you. Yeah, definitely.

You've got to— yeah, right, yourself. Yes, that's the goal.

Yeah, yeah, absolutely. Yeah, but we don't want to wait until we're 85 to start and realize, okay, I'm in a big deficit right now, because you can gain strength. You'll have a little harder time gaining muscle mass at that point. So a little bit harder to help you control blood sugar levels and help you control body composition. So we want some lean muscle mass in order to help boost metabolism in a positive way. Awesome. So coming back to hot flashes and night sweats, by the way, so most of the literature related to exercise generally says It's got to be of adequate intensity so it can decrease hot flashes and night sweats, and specifically strength training. So I know a lot of women will say, you know, I really hate the idea of getting hot and getting sweaty, and high-intensity interval training isn't attractive to many when strength training can be. You don't have to breathe as hard, you're not, you know, as into it, it doesn't cause as much anxiety. While you're doing it. So a lot of women find that, you know, in coupling that with walking— do not underestimate the combination of those two things. But making sure that you're reaching muscular fatigue, that's a must so that you're getting enough overload both for the muscle and for the bone.

Yeah, I love that you share that expertise around because I concur with all of that.

Talk a little bit about other diseases. I mean, obviously insulin resistance is a big deal. We see it show up in belly fat and so prediabetes. But what about, you know, cancer, heart disease, still the number one killer? And you, you talked and alluded about cholesterol levels, blood pressure levels, even though they're not doing anything different. What, what way do you see a difference in the women who exercise regularly versus those who don't?

With those kinds of numbers and risk? Well, let's go back to sort of the changes they're experiencing. So our, our estrogen levels are what really drastically declines in menopause, and we have these responses to them. You know, hot flashes and night sweats is one, which is a sort of brain response from our thermoregulation. But our metabolism changes, so our insulin sensitivity worsens. Lots of data on that. Our cholesterol level panels worsen. Lots of data on that. So we're sort of— we start to gain mid, mid-belly. Lots of data on that. So for whatever reason, when our estrogen levels deplete, we start to see our stomach gain weight. And central weight gain is actually more linked to bad cardiovascular and health outcomes than sort of distributed weight gain. So first, I think women want to hear that what they're experiencing is normal. They're not doing anything wrong. But in order to address it, it does require some adjustments, right? We certainly invoke exercise as being a tool, a major tool in many of the things going on. We do use hormone replacement therapy when clinically appropriate as well, as it can also help. And then just understanding that people need to be screened for these. So you mentioned prediabetes. Once people enter menopause, the insulin and our glucose management worsens, and we get— we, 30% of us get prediabetes. So I would highly encourage people to get screened for that. I also wanted to share one sort of fun experiment I did actually this week. You know, for my job at Mini Health, I've been experimenting with glucose monitors, right, so I could pick the best one for our patients. And, uh, I did a trial where I ate the exact same food, um, one morning, uh, without exercise and watch what it did to my glucose. And then I went and did an exercise class, just a cycling class. And then I, and then I ate the exact same thing and it was remarkable. Um, just having done the exercise changed my glucose swings. I had much lower peaks and a much more steady day. So it, it definitely impacts the way we utilize our energy even beyond that period of exercise.

Yeah, so love that. So my spike comes every morning from caffeine, and I'm not willing to give it up. So I've decided, you know, and, and we use blood glucose monitors with our community as well. So 4 times a year, we all do it collectively as a group, and I can see their data for those who decide I'm sharing it with you, releasing. And it's, you know, the kinds of things that we're doing. I go for a walk within 30 minutes of having it because I know if I don't, it will spike. I've established the trend. But even changing sequence of the foods you're eating, even without changing the foods you're eating, has a major influence on blood glucose levels and spikes that occur after meals naturally. There are so many little tricks and tools that, that you can do. And maybe that's— this is one of those times to distinguish movement from exercise. You and I were talking in the green room that sometimes there's quite a bit of resistance for women to exercise, and the number one obstacle being time. Mm-hmm. But the other one, you know, I don't enjoy it, right? So, you know, I think if you distinguish movement from exercise— so when it's, when it's exercise, it is definitely, if I am going for a walk or I'm going to, you know, lift weights or I'm going to do Zumba, you know, it is a structured— something is going to happen. There's a warm-up, there's the main thing, and there's a cool-down. And there's an arc and there's some kind of a plan or protocol put into it. And I think a lot of people can, in, in a mindset, maybe have had a bad experience with exercise, whether it was in their youth or it's something you haven't done for a really long time. And newsflash, none of us likes to do things we're not good at, and it's hard to be good at something you haven't done regularly. But movement is really something that none of us can escape for the reasons, you know, I just pointed out. The continuous blood glucose monitor, knowing that blood sugar levels go up if we're sedentary for long periods of time. Just breaking up sedentary times by getting up, walk down the hall and go to the restroom, you know, come back, get your cup, go to the kitchen or the break room, fill that up. Just that little bio break of 5 minutes, if you do that several times during, say, an afternoon, in a morning, where otherwise you were sitting, you've done yourself a huge favor. As opposed to strap yourself to the desk from 9 to 12 and then from 1 to 5 and do it again. That even decreases blood sugar levels, even when the movement doesn't happen close to the meal. That can have a major impact. So movement, no sweating required, just movement can be really supportive.

Yeah, that's why when we talk to patients at Middie, I, I avoid being prescriptive on an exact regimen, right? You don't have to do Pilates. You certainly can. It's wonderful for you. You don't have to do a certain thing, but I, I encourage women to actually find something they enjoy because if they enjoy it, then they will continue to do it. Like join a pickleball team. Set up a regular walk date. Maybe, maybe uphill would be good or a fast pace, but set up a walk date with your friend. So really finding things they enjoy will actually set them up for sustained activity levels that actually supports their best health outcomes.

Yeah. And I think historically we— there's— I have two responses to this really. So I'm kind of compelled to say, and weight, you know, if someone's goal though is bone density, It is mitigating muscle losses that have happened, and we want to gain that strength and gain lean muscle mass so that we're aging really well. There is a specific match to, am I doing the exercise that will actually help me with that? So when we want specific outcomes, we can't do random exercise. There is that— we have to keep that in mind, but we have to get started. Right. And I think that's really what you're pointing to, and that is the joy factor. We call that at Flipping 50, it's one of the 10 tenets, you know, and, and it's got to be there. You either have to really enjoy the activity itself or be able to tie doing the exercise that you don't necessarily love with being able to do longer or better activities that you do love. I have an older sister and I long ago gave up trying to persuade family members to exercise. I decided this was not helpful or good fodder for holiday dinners. Nobody was happy when we were finished with this conversation. But, you know, she, for the longest time, had started and stopped exercise and really never found a groove until she started ballroom dancing with her husband. You know, she came to the realization that when she was strength training, it helped improve her posture. She had more stamina. She could hold herself and do the movements so much better. It made that much more enjoyable. They got a greater skill level coming into their ballroom dance. That's what it took, you know. Now, still, did she enjoy the strengthening sessions? Not so much, but it had a payoff, and that was worthwhile for her.

Yeah, I totally have heard women share that experience as well. The other thing, Debra, I would like, um, your listeners to know about is sleep. You know, so many women, right, are just exhausted. It's such a common common, common complaint of women in midlife— exhaustion. And I think that prohibits them from engaging in daytime exercise routines, right? So 60% of women have major sleep problems that— with a sudden onset and increase in sleep issues in midlife, driven hormonally, driven— it's multifactorial. Some of it's the stress that comes with midlife. For whatever reason, there's a doubling of sleep apnea, doubling of restless slag. There's a ton of sleep issues that present in midlife, and there's lots of ways to help with that. Hormone replacement therapy helps, stress management helps, exercise actually helps. Um, but sort of getting over that exhaustion and making yourself feel better can help you engage in a really, um, great exercise regimen.

Yeah, love that. And I have a little personal experience with that. Even before, you know, I narrowed my niche to working with women in midlife going through menopause transition. And so my experience with insomniacs, you know, in exercise was that we really— you can't wait to have a good night's sleep to get the exercise. It's the exercise that'll help you get the good night's sleep tonight. And I mean, the studies are very positive, really, for, for someone who's feeling, I'm too tired to do it. Even a— this has been almost a decade old now, but Sleep Foundation poll of people who are just getting started in exercise, self-selected. So we really, we'd almost call it movement, but 10 minutes a day, and they were choosing walking. But, you know, it could be your equivalent of walking if you're saying, you know, you can't do that because of weather or because of ankles, knees, or hips. You know, it's what's the equivalent of that but it was self-selected intensity. So nobody was imposing this fast, or, you know, this is where you should be breathing, or your heart rate should be here. But just 10 minutes of exercise a day at a self-selected pace improves sleep— personal recordings of it— by 33%. So, you know, it's the matter of, you know, which comes first, the chicken or the egg. And really, the movement, the exercise comes first in order to set that habit to get a better night's sleep. And there are a lot of other factors too. But yeah, so glad you said that. But the other side of that coin is sleep is what really ties the progress together. So those of you who are exercising and feel like, I'm not getting rewarded for the exercise I'm doing, like, I don't see the evidence, not gaining the muscle, not losing the fat, or, you know, um, it's still struggling through it— a lot of that is We need the sleep because we're releasing growth hormone and testosterone in deep cycles of sleep. So if you're getting woken up either by hot flashes or night sweats or a snoring partner or, or a dog with, you know, seizures, which, you know, most women will leave their spouse but not their dog to a different bedroom, and, you know, that can be really disruptive And so really looking closely at, am I doing everything to keep it not just cool, dark, and quiet, but disruptions to a minimal, so that you can get the rewards? The sleep is like the seal-the-deal piece.

Oh, absolutely. Sleep, sleep helps so much as well. Um, and you know, it's where I see some of our most grateful patients. They say, I finally slept the first time in 5 years, and they feel better, and they're ready to engage in, in the whole world again.

Yeah, it can be so depressing. I recently got a puppy, so 16 weeks old, so it was 8 weeks ago, you know. And a couple weeks into it, I realized, man, this is very different at 59 than this was at 43. Like, I'm depressed. Like, I can see how easily somebody could, you know, who's losing sleep night after night— and we've outgrown it, you know, and we're back to sleeping, but that was rough, really rough.

Yeah, no, I, I hear you for sure.

Let's talk about this. So there are quote unquote 34, if I'm not mistaken, identified symptoms of menopause, and some of them are just so lesser known and overlooked that many women, maybe they don't have the, the wake-up call, which is hot flashes, maybe night sweats, and now we'd probably recognize belly fat gain, but some women don't realize or— and feel very isolated, like, am I crazy? You know, because their symptoms don't match the norm. What are some of those overlooked symptoms? Oh, there's so many.

I know you mentioned the 34. There's another list of 60. There's another list of 100. But, um, I think the main thing to realize is is that by definition, hormones affect our whole bodies. We have receptors in our glands, we have receptors in our hair, our scalp, and our skin, and we have receptors in our liver that change our metabolism. There's also just an overall anti-inflammatory property of estrogen. So when we lower estrogen, we can get some more inflammation. So we have women, and there's lots of data on this, that have like small joint aches general aches and pains that come with the estrogen depletion. Um, more known might be, you know, skin changes. So estrogen depletion changes our collagen deposition. So some of it's around muscle loss, and some of it is around actual changes to the skin itself. Um, hair thinning, right? So, and then our testosterone doesn't decrease as much. So what we see is a relative increase of testosterone to estrogen. So the ratio changes. So you could— then you can get sort of the unwanted hair growth, acne, things like that. So we go through all this hormone changes in our teenage years, then we're sort of plateaued at our fertile years, and then menopause, we get to relive it all again, um, on the— on its way down. The gift that keeps on giving.

Yes, lovely. You know, I did not need to know about that list of 100, thank you very much, but geez. Oh my gosh. Okay. What do you see when you see or hear people coming in? I mean, what are the greatest complaints? We've covered so many. So this may be like just bringing them up to the surface again, something that we've talked about. What are the biggest challenges that women experience with midlife hormonal transition that, that exercise might play into for them? And one thing we haven't really discussed is anxiety and depression.

I'm glad you brought that up because that is— it's— the link is lesser known, but, um, what we see— so our hormones affect our, our brain neurotransmitters. We see changes in serotonin, changes in dopamine. That has wraparound effects that changes, um, it can exacerbate pre-existing conditions of depression. It can make us more label— if you look at the perimenopausal woman, so perimenopause is in our 40s, and their hormones aren't steadily down, they're on a roller coaster, right? So they're up and down. So, you know, they can get labeled as moody, but really they have really chemical changes going on behind that. Um, so I think appreciating that and understanding that is important. And then also understanding there's things you can do to sort take control of it as well.

And then one thing I want to say relative to that, just slightly off topic, but you know, where exercise is concerned, for those of you who, whether you do like it, you've always liked it and experienced this, or women who are struggling to get started and you're getting lots of encouragement, you know, you should exercise now because it's going to help with this, and and are struggling to do so, I think a lot of women default to feeling like I'm lazy, I have no discipline, I have no motivation. I hear those words a lot. And I— to that, I think that's not it. And often I think it's a lack of clarity about now what should I be doing and knowing. So you're potentially doing the wrong thing. And none of us is motivated when we have no idea what to do. You know, and nobody wants to waste time or energy that we have. Those are limited commodities. But the other thing is we have this lack of dopamine receptors, so we don't get the positive charge we used to from exercise. So when you're, you know, you're doing the same thing and you're feeling like you're left flat, like you don't get that little bit of high, that feel-good to as great an extent. It's not you, and it's not that you failed anything with that workout. It's potentially the, the lack of receptors. So this is where we have to work a little bit harder too, by, you know, all the best favorite tunes, you know, in your iPod, you know, you're listening to all the things you love, you're walking with a friend, you're feeling your podcast set with things that make you laugh or inspire you. You know, all those little things can really help. Walking outdoors in sunshine can be more helpful than inside on the treadmill.

Yeah, but, and I like to also emphasize, it's not all bad news. While it's normal to have these changes, and it may be a time to adjust lifestyle that might be a little bit harder The good news is there are lots of tools to help you feel better and to do it right. Um, right. And there's lots of data, like making adjustments in our 40s and 50s actually adds 10 years to our life expectancy. There's lots of data on doing that with diet and exercise for sure. What are your thoughts?

And I feel like having you here as a physician, I have to take every advantage of you, so here I go. What are your thoughts for those women who are wondering about semiglutides like Ozempic?

You know, some of the most, um, profoundly impactful work that we do at Middie, I think, is really changing some, some of these women's lives for the positive. It has been incredibly rewarding to have these as really effective tools for women with obesity. They, they work, right? So I had a woman who has struggled with obesity her entire life and has tried everything, is really good about lifestyle, is good about exercise, but she has a different metabolism than everyone else and suffers from obesity and all that comes with it— self-image, self-appreciation, but also the cardiovascular risks, right? And then that leads to immobility. So going on the semaglutides has really rocked her world for the positive. She is able to engage in exercise more. She also just reports, like, for the first time in her life, her whole thought process isn't obsessed with dieting and the con— and, and identifying herself as obese. So she, like, the whole world opened up for her. Now, they're not for everyone. There are risks and benefits of all drugs every time. So it's It's not that we want to turn every woman into a pill-popping culture or have the same body habitus, but for women who need it and really have insulin resistance and have true obesity, these drugs work. First and foremost, they work.

So what happens when a woman goes off?

So There are a few things. There is what we call a hangover effect where you actually have the continued change metabolism for a short while so you can maintain it. It also, if you've been on it long enough, it will hopefully have changed your lifestyle, right? It changes your relationship with food. It decreases your appetite. So hopefully you've established patterns that actually are sustainable. So for about 25%, they'll keep the, they'll keep the weight off. For about 75%, they gain, on average, they'll gain about half of their weight loss back. But over time, some of them will go back on the meds and then avoid the full weight gain as well. So I think we're still trying to appreciate, NIH is doing a trial on how to, how to get more of these women to act, or all people, not just women, more persons to benefit from long-term and sustained changes.

Awesome, great answer. Okay, where is the best place for listeners to follow you, to connect with you?

Come to our website, joinmidi.com. M-I-D-I stands for midlife. joinmidi.com. We have practitioners in multiple states, and we'll be opening in all 50 in 2024. So if we're not quite yet open in your state, you can join a waitlist and we will tell you when we are open there. And our team is amazing.

So great. And so describe it. So literally you've got telemedicine delivered to women to— for the purpose of making it much more accessible, putting it in front of people who otherwise can't find great resources.

Say more about that. Yeah, our commitment is really on delivering access. To women across the nation. So we open up in your state after we're on most of the insurances in the state. So people really need and should have insurance-covered care to good care. So one, that's how we deliver on access. And obviously telehealth, we have women that, you know, work jobs where they don't get paid when they're not there. So I have women that do it on their lunch break from the factory. So telehealth really is part of the access issue. And then, as you know, sort of a healthy lifestyle and weight is a chronic issue and needs supports along the way. So sometimes it's smaller, more frequent visits, and you can't take a half day off work to go to an in-person visit. So that's how we deliver on access. I think the clinical approach is that we really try to look holistically, and we look at the evidence. So not everyone needs pharma, right? Some people, it's exercise. Some people, it might be a supplement. Some people, it might be a hormone, hormone replacement therapy. Some might be— so our commitment is to deliver all the best evidence on possible solutions and work with you to pick one. So you meet one-on-one with a very trained clinician who has passed our training, what we call MIDI University, and also has all the supports of experts behind the scenes.

Very cool. Very, very cool. Okay, listeners, I have no doubt you're going to have some questions about this. So we're going to put the link to connect and join MIDI in the show notes, and you will find our show notes at flipping50.com/midlife-exercise-rx. That's Midlife Exercise Rx. And what are you waiting for? Let's start flipping 50 today.