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well welcome everyone to the healthspan podcast
where we talk about the science of increasing
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your health span so I'm your host uh Dr Robert
Todd Hurst I'm a board-certified preventive
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cardiologist and founder of healthspan MD a
medical practice that delivers Health Care as
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it should be with a comprehensive and connected
approach to helping our patients live a long and
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vital life so today's topic is a special one maybe
a little bit technical a little bit more clinical
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than usual we are going to talk about lipoprotein
little a and lipoprotein little a may be something
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that you haven't heard of but my guess is you
will hear about lipoprotein little a in the
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coming years because it's becoming more recognized
the impact this lipoprotein little a has on our
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health so first of all this talk about what is
lipoprotein little a so it is just a part a type
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of cholesterol it's a certain protein attached
to a cholesterol molecule and it's been called A
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lipoprotein a little a so um why is this important
well lipoprotein little a impacts our heart health
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it increases the chances of having a heart attack
in some Studies by up to 300 percent it also is a
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strong risk factor for an increased risk or stroke
for heart failure for blood clot problems and also
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for narrowing of the aortic valve which is called
aortic valve stenosis so the reason lipoprotein
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little a is becoming more commonly discussed among
doctors and also among patients is because it is
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the most common genetic cholesterol problem that
increases the risk of heart disease you know in
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in medicine we commonly talk about another
type of genetic cholesterol problem called
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familial hypercholesterolemia that just means a
genetic predisposition to having a very high LDL
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cholesterol and this is a big clinical problem but
it's uncommon only about one in 250 people have a
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elevated or have familial hypercholesterolemia um
but lipoprotein Lily elevated lipoprotein little
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a is is seen in May in up to 20 to 30 percent
of people um so you know the one it's a really
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common thing but number two we are increasingly
knowing what to do with this we have we're having
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tools that we didn't have in the past and so it's
becoming more prominent uh but also likely going
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to be more of an important Target for future
Therapies in helping people lower their risk of
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heart disease and you know lipoprotein little
a among Physicians is still a thing that's
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burgeoning meaning you know people are starting
to figure this out but I know it when I give talks
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to Physicians that uh CME or continuing medical
education events where there's you know doctors in
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the audience when I talk about lipoprotein level a
that's one of the topics I get the most questions
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on from a physician so I think Physicians have
a lot of uncertainty around lipoprotein level
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a and patients of course have uncertainty around
lipoprotein little a so um why are people starting
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to know more about lipoprotein little a well
another reason is that we're testing for it more
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frequently more advanced lipid test analysis are
including lipoprotein lla so people are getting
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that surprise they get their cholesterol you know
a standard cholesterol profile doesn't test for
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lipoprotein Olay these more advanced tests can
test for that and they're finding out oh my gosh
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I have this elevated lipoprotein level a and I
don't know what it is and or what what does it
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mean another way people are increasingly finding
out that they have a elevated lipoprotein level
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a is genetic testing so getting you know genetic
tests like the 23andMe and other forms of genetic
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testing people can be identified as having a high
likelihood for an elevated lipoprotein little a
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and they're trying to figure out what that is so
um one you know place to start too is what is the
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definition of elevated lipoprotein delay there's
still some uncertainty about this some different
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guidelines give different values but generally
A lipoprotein little a that is greater than 50
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milligrams per deciliter or 125 nanomolars per
liter that's considered elevated so it depends
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on the lab tests what units that they use so
lipoprotein little a another important thing to
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mention about this if you have lipoprotein little
a is that it is almost all genetic about nine
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ninety percent of your level of lipoproteinola a
is determined by your genes not by your lifestyle
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choices so in general people can't impact their
lipoprotein little a by doing anything lifestyle
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wise that would be beneficial however as we'll
talk about there is an important opportunity to
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lower your risk so maybe not make the lab tests
look better but certainly to lower your risk so
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um you know lipoprotein a little a in in the
healthspan MD practice we look at this as four
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principles for addressing an elevated lipoprotein
level and before I start should say that none of
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what I'm talking about is meant to be medical
advice this isn't a doctor-patient relationship
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these are things to talk with your doctor about to
determine what would be the best treatment for the
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elevated lipoprotein little a if that is your
uh if you've been identified as having that so
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principle number one is to optimize heart health
so as we talked about already having an elevated
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lipoprodinal a does increase the risk for heart
attacks for strokes for heart failure for blood
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clot problems for aortic stenosis and to lower the
risk particularly about of heart attack and stroke
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the goal is to optimize all other factors that we
know are important so you know there are over 200
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independent risk factors for artery disease or
heart attack risk and all of those can you know
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uniquely interact with your genetics to give you
your risk but there are 10 factors that are most
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powerful in predicting risk for heart disease for
for heart attacks oh interestingly these same same
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10 factors are most important in predicting
risk for cancer for dementia for a stroke and
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for just how long you live in our practice we call
these the health span 10 and they are 10 factors
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that most powerfully predict risk in somebody who
has high risk including if they have an elevated
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lipoprotein La then optimizing these 10 factors
is where we start so the first four of these are
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outcome goals these are the ones that we want
to get right and that is to have normal blood
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pressure normal blood sugar levels healthy
cholesterol levels and then a healthy body
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weight or body composition and then the other 6
are the tools we use to move those four outcome
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goals so that is nutrition physical activity sleep
stress avoiding toxins and then staying connected
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connected socially connected to your purpose when
we optimize those 10 things that's the people
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that get the most benefit in some studies people
that do the best at those 10 factors have over 90
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percent less heart disease about 50 percent less
stroke risk about 50 percent less heart cancer
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risk and about 40 percent less dementia and add
12 to 14 years of life so optimizing the health
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span 10 that's principle number one in approaching
somebody who has an elevated lipoprotein level a
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principle number two is aggressive lowering of the
LDL levels or more specifically the apoprotein B
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uh levels but in general most uh people get their
LDL levels it's kind of a surrogate for April B uh
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levels but for people that are at the highest risk
that's one thing that we know can mitigate that
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risk is to get that LDL into optimal ranges most
doctors feel like this is as at least less than 70
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milligrams per deciliter even more aggressive for
people at highest risk may be indicated so that's
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where you would talk to your physician about what
would be an optimal LDL or apob level to get to to
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lower to get to the lowest risk of future heart
disease without causing you any adverse effects
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principle number three is lower lipoprotein
level a levels and the reason that we don't
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start that is principle number one is because we
don't have currently great ways or easy ways to
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lower lipoprotein little a levels um niacin is a
vitamin that has been shown to impact cholesterol
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and it lowers LDL it raises HDL it raises or
I'm sorry lowers triglycerides and it also can
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lower lipoprotein little a levels although in
my experience when I I used to use this in my
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practice when that was kind of the way that we
were doing things um I I found it to be quite
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variable sometimes it works sometimes it didn't
niacin the prescription form is Nia span tends
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to have a lot of adverse effects particularly
flushing for people that that for some are it's
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intolerant tolerable but the main reason we don't
use niacin or niac span particularly much anymore
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is because we've had large outcome trials that
showed no clinical benefits so it looks like
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niacin Niaspan makes the labs look better but
doesn't change outcome doesn't change the risk of
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heart attacks and strokes and in one study there
was even a slight increase in bleeding in the
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brain which was a secondary outcome and certainly
not cause and effect but at least enough of a risk
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to say if there's not much benefit here or no
benefit here why would we accept any risk now
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we have some new therapies that do work that are
available right now one is a procedure it's called
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LVL aphoresis this is a procedure it's basically
like dialysis for your cholesterol people at
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really high risk really high cholesterol can come
in every two to four weeks and they're hooked up
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to a machine their blood is filtered it takes a
couple of hours and they get their cholesterol
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cleaned out of the bloodstream the cholesterol
lowered dramatically this is a infrequent there's
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not many places that do this not many people that
need to do this but it can be life-saving for some
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people to have really really high risk and really
high cholesterol tends to be also really expensive
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but can lower LPL lipoprotein a little A Levels by
up to 70 percent and you know this this data it's
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being done in Europe more than it is in the United
States or at least the research studies have been
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done more commonly in Europe and there's some
evidence that lowering lipoprotein little A Levels
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by ldla pherasis improves outcomes and and this is
a really important point and one that we we still
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don't know is you know for sure does lowering
lipoprotein little a actually change outcomes
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change heart attack risk and change stroke
heart failure aortic stenosis risk that's to
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be determined we we you know it makes sense that
it would be beneficial but we don't know that for
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sure yet and that's important to keep in mind as
we're exploring these new therapies for lowering
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protein little a another thing that is makes
this uh timely to talk about lipoprotein little
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a is just in the last uh several months there has
been a report in the New England Journal medicine
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the most prestigious medical journal in in the
world of a new medication not available not FDA
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approved yet but a new medication is called a
small interfering RNA medication that lowers
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lipoprotein little A Levels by over 95 so this
is an exciting development uh we you know it's
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still early in this process but something on the
horizon and that would be you know a medication
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that if it passes through the FDA approval it
meets uh safety criteria and is tested that might
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be our first fight where we find out does lowering
lipoprotein level a change outcomes for people and
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as we talked about in the beginning up to 20 to 30
percent of people have elevated lipoprotein Level
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A Levels so this could be an important medication
for our in our battle to decrease heart attacks
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to lower heart disease from being the number
one cause of death and disability and bring
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it down to being the preventable disease that
we we know it can be and should be and then the
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last principle I want to talk about is the idea of
lipoprotein little a increasing the risk of blood
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clot problems so lipoprotein little a has some uh
similarities to another Factor called plasminogen
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that is involved in the clotting Cascade and
so it's been talked about for years that maybe
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people with elevated lipoprotein little a should
take aspirin to lower their risk of forming blood
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clots well there's been no evidence that that
was of benefit and in my practice I did not
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make that recommendation and there still isn't
definitive evidence about this but there was a
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recent study that showed that in people who have a
genetic testing that shows that they would have a
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lipoprotein little a so important to note that not
this this research study did not assess if they
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had elevated lipoprotein level 8 just looked at
whether they had the genetics for elevated lipopro
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like those people that took aspirin did better
than those people who did not this is this is
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preliminary this does not mean that any everybody
with elevated lipoprotein little a should take
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Aspirin because aspirin does have adverse effects
as bleeding risks we generally don't use aspirin
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and primary prevention meaning somebody who's
not had a heart attack or stroke not had a stent
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or bypass surgery because the risks of bleeding
are about the same or maybe even a little higher
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than the the benefits of lowering the risk
of heart attacks but in people with elevated
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lipoprotein little a it's worth that discussion
with the physician and I think that that decision
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has to be made with your physician what is your
bleeding risk what is the heart disease risk would
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taking an aspirin make sense that's something
else that should be discussed between you and
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your physician so that's lipoprotein little a
our practice has been MD is specializes in the
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comprehensive connected approach to get people
that have higher risk for heart disease for a
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higher risk for cancer higher risk for stroke
they have evidence of metabolic disease blood
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pressure cholesterol pre-diabetes give them the
connected comprehensive care that we know is
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effective in lowering the risk for these diseases
so they can live a long and vital life so I if you
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have an elevated lipoprotein level a you'd like to
learn more about our practice we'd love for you to
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schedule appointment just go to healthspanmd.com
and uh and just submit a request for employment
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we'd love to see you okay so uh thank you all for
joining us uh today it's been a pleasure to to be
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here we look forward to seeing you back in the
new year to continue to talk about the topics
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important the science in increasing your health
span have a great day everybody thank you so
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this information is for educational purposes
only and is not medical advice don't make any
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decisions about your medical treatment without
first talking to your doctor thanks for watching
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