Living Well, Staying Strong | Elizabeth O'Donnell, MD #myeloma

追加: 2026-05-23

[00:00:16]Good morning. Thank you so much. It's a really nice to see some familiar faces.

[00:00:21]Um, my name's Betsy O'Donnell. I'm a medical oncologist at Dana-Farber.

[00:00:25]Um, but in addition to my training in medical oncology, I actually did um, some additional training in lifestyle medicine, which is the evidence-based practice of the incorporation of six pillars of of lifestyle that I'll talk about. And for many years I ran a lifestyle medicine program uh, at MGH. So today we'll just be talking a little bit about things like diet and exercise and how they can impact our well-being. So as I noted, lifestyle medicine is evidence-based lifestyle behaviors where we're really looking at things like diet, exercise, sleep through the same lens that we would any other recommendations we're making. You know, have they been studied? What do the clinical trials look like and how are we reaching these conclusions before recommending them to our patients? And so in general, what is the goal of talking about lifestyle medicine?

[00:01:13]There are data that support the fact that lifestyle attention can improve quality of life, can potentially mitigate the side effects of treatment, can improve physical function, mood, can help energy levels and potentially improve cancer outcomes in certain cancers.

[00:01:30]And so the first of the six pillars of lifestyle medicine, and these are they, uh, that I'll be discussing is exercise.

[00:01:37]Um, in full disclosure, uh, my truest love in life has always been sports, so I love to talk about exercise. So please feel free uh, to ask me any questions. Uh, but why exercise? So there are data that support the fact that exercise can improve quality of life. It is one thing that has actually been demonstrated to improve cancer-related fatigue. It can improve mood, specifically anxiety and emotional well-being. Can improve libido. Patients may sleep better if they've exercised more and it may improve social functioning.

[00:02:11]And so there have been some large data sets that have looked at systemic reviews and meta-analyses of the impact of exercise in cancer patients and just demonstrated improvements in quality of life, fatigue, and anxiety as noted.

[00:02:25]They also look at physiologic outcomes, things like body mass index, muscle strength, and cardiovascular fitness. And also exercise has been shown to be safe. We'll talk about a little bit more in the context of multiple myeloma where we do have to be more careful. But overall and thinking about these things, it is worth discussing. So the American College of Sports Medicine and the American Cancer Society historically have recommended 150 minutes of moderate intensity exercise with resistance training.

[00:02:54]And in resistance training looks at eight to 10 exercises, about 10 to 15 reps with at least one set per session.

[00:03:01]These were updated actually demonstrating that moderate to vigorous activity reduces cancer risk. But that you can exercise as few times as three times per week for at least 30 minutes and see benefit.

[00:03:16]What does light, moderate, and hard exercise mean? People always ask, "Well, what is what is moderate exercise?" So this is a very kind of uh broken down way to think about it. When we're exercising lightly and an exercise can be walking. That's you know, how how do we get to moderate intensity? Just walking. So a light exercise would be no noticeable change in breathing pattern.

[00:03:37]Moderate would be that you could talk, but you couldn't sing a song. And then vigorous is you can say a few words, but you'd have without having to stop and catch your breath. And so when we think about activity and particularly when we think about the context of a cancer diagnosis and specifically multiple myeloma where we know we can see impact on our bones and bone health.

[00:03:57]It's hard once you get out of the habit or maybe you weren't in the habit of getting into exercise. And so try to start with something you enjoy. An activity and movement can be dancing in your kitchen with some music on. It really doesn't have to be going to a gym, lifting weights and those are not that is not what we're talking about.

[00:04:15]We're talking about avoiding inactivity, preserving lean muscle mass, particularly when you're on medications like dexamethasone long-term that can impact your lean muscle mass. Start slowly.

[00:04:28]Rome was not built in a day. There's no need to jump into things. If you are currently sedentary and not doing a lot of activity, start with 10 minutes a day going for a walk in your neighborhood.

[00:04:37]The weather is getting better.

[00:04:39]Although today really is not a demonstration of that. We are getting closer, I hope, or I may be moving somewhere warmer.

[00:04:46]Uh but um try and move at least every other day and increase the intensity. Find classes or social engagement. It's easier to do things when you have company in doing it for most people. I think it is important for patients and we'll talk a little bit more in detail to talk to a fitness expert or physical therapist, particularly if you've had bone complications.

[00:05:08]Set goals for yourself. Goals can be I'm going to walk 10 minutes 3 days a week.

[00:05:13]I'm going to walk 15 minutes 4 days a week. Um find a friend, find somebody else in this room that you might connect with and text and keep yourself honest.

[00:05:24]A lot of us have smart devices that tell us how many steps we've taken per day.

[00:05:28]Set a step goal. It really again, we don't need to be training for the Boston Marathon, but we just need to be moving so that we don't um lose our lean muscle mass. And that's really the most important principle is just trying to avoid inactivity, especially when someone is newly diagnosed. There's a tendency for people to want to jump in and help um and really take over some of the normal activities. And I encourage you to really try to continue your activities of daily living, doing the laundry, doing the things that you've historically done for mobility, for engagement, um and really just for preservation of of function.

[00:06:08]A very underutilized service that people might not be aware of and I want to highlight this and physical therapy today is cancer rehabilitation.

[00:06:17]So, physical medicine and rehabilitation is a subspecialty uh within internal medicine and uh there are many providers. A lot if you're in a Boston hospital, we have these providers. You can be referred to them and they can help you do safe return to activity if that's something you desire.

[00:06:35]Really thinking about any limitations you might have specific to your myeloma.

[00:06:40]So, inquire with your doctor if this is something where you've had bone complications, but you want to get back to activity, these and physical therapy are available. Physical therapy can be covered by your insurer. And if you're if you are returning to activity, cancer deconditioning is a reimbursable code.

[00:06:57]So, you can do supervised physical activity under the guidance of a physical therapist as part of your cancer treatment. Many people don't know this. Inquire about this. Some providers don't know this. Um and at a minimum, that physical therapist can help find the right things that you can do safely.

[00:07:16]And so, it is essential, however, that you talk to your myeloma physician before you start exercising. We don't want you to get injured and we specifically want to make sure that it is safe for you to resume activity.

[00:07:30]There are specific questions uh that we often use to determine whether someone should start activity. There are both considerations for bone and myeloma, but there are also cardiovascular considerations. And so these are just some screeners that we as physicians can use in determining whether or not it is safe for someone to start unsupervised activity. But again, in multiple myeloma, there are really two factors that can impact long-term wellness. One is just the relationship of the disease to your bones, and second is the long-term use of steroids and trying to prevent losing uh lean muscle mass.

[00:08:06]The next pillar that I'm going to talk about is sleep.

[00:08:09]Sleep is something that I think is uniquely impacted in multiple myeloma because of our use of dexamethasone.

[00:08:16]Dexamethasone is an important medication in our armamentarium, but it is also important to understand that we've never studied the lowest possible dose to achieve efficacy. So, 20-30 years ago, before we had daratumumab, our CAR-T cells, or bispecific T-cell engagers, we used to use dexamethasone as one of our primary treatments at what we called high dose, which was 40 mg 4 days in a row. Now, we've significantly backed it down. There was a trial that compared that dose with our 40 mg per week, found equal efficacy but less side effects.

[00:08:51]But we've never actually studied the lower doses of dexamethasone and what could be efficacious. And for anybody who's been on dexamethasone, which I imagine is many people in this room, it can highly impact your sleep.

[00:09:03]Some strategies that can be employed for mitigating the adverse effects of dexamethasone is decreasing the dose. If you're using it as part of the pre-medications for some of our therapies like daratumumab, we needed at those higher 20 mg is really all we have to have it at for those initial doses, but we can de-escalate that if you're not tolerating it. We can also step down the dose. So, we can do, you know, 12 mg and 8 mg instead of 2 days in a row instead of 20 on one day.

[00:09:36]Always take that medication in the morning if you can, so that it has, you know, peak activity during the day and starts to tail taper off as the day goes on.

[00:09:46]But sleep is extremely important to our health. We spend up to a third of our lives asleep, and important things go on when we sleep. So paying attention to that is something that I think we could do better. My husband jokes, he said no one teaches us how to sleep, and it's kind of a funny thing to think about. But when we look at what our sleep requirements are, the goal for most adults is to try to sleep for 7 to 9 hours per night. It is common for patients with cancer to have sleep disorders. We've talked about dexamethasone, but there are other factors, too. Pain can be an important factor as can stress.

[00:10:23]And when you're having these types of symptoms, particularly pain if it's interfering with your sleep, these are very important considerations to bring up with your provider.

[00:10:32]Sleep hygiene can help. So setting a routine can be important. Your body gets used to your circadian rhythms get adjusted to when you go to bed and when you get up.

[00:10:43]So try to get into a routine, prepare to sleep. We'll talk a little bit about blue light, but our phones are not our friends at bedtime. So how do you get ready to go to sleep so that you are mentally and physically in a place where you can achieve good sleep.

[00:11:01]And when you exercise during the day or when you're more active, you tend to be more tired in the evenings. What can you eliminate? So caffeine, nicotine, and alcohol. Even though alcohol is something that can make you feel somewhat tired, it actually disturbs sleep patterns. So trying not to drink alcohol particularly later in the evening, trying not to eat right before bed, and and avoiding screens leading up to bedtime. Sleep and blue light, blue light is the light generated by our phone does activate the brain and suppresses melatonin, which is a natural chemical that our brain um produces to help us fall asleep and can interrupt our circadian rhythms.

[00:11:43]Other ways to think about sleep, take a warm bath or shower, do some gentle stretches, read a paperback book. I have one right now that I'm reading that puts me to sleep after two pages. It's going to take me a long time to get through it.

[00:11:55]Um and uh The Far Pavilions, I think it's called.

[00:11:59]Anyway, a lavender-scented eye pillow is something that or or also guided meditation or soothing playlist. Um there are uh a number of apps now that do have uh sleep uh meditations that you can use, but you want to calm the body.

[00:12:14]Music can also calm the body. It can reduce distractions of thought uh and prepare the brain's response to sleep and make it part of your ritual.

[00:12:24]The next thing I'm going to talk about are social connections.

[00:12:27]Um Help Getting through chem especially myeloma. Myeloma is a marathon. We talk about this. And you know, a lot of people find that when they're first diagnosed, they have a lot of social support, uh but over time this is a long-term illness. How do we preserve and maintain the things that enrich us um and keep us connected? The most important predictor of human happiness and longevity is having strong social connections. Things like blood pressure and heart rate can improve with just even short-term positive social interactions. So, thinking about your day, thinking about what are the activities that could potentially lead to positive interactions can be beneficial. If you are isolated, there are a lot of things physically and emotionally that can be isolating.

[00:13:13]Treatments, being immunocompromised. I think people who uh remember what it was like to have myeloma during COVID, it was it was a very hard time. Um and so, these can make it people feel more socially isolated and trying to use places like this to identify peer groups and other people who can share and with whom you can find connection.

[00:13:34]Patients need and this is for the caregivers in the room support through all phases of treatment just from not just from time of diagnosis to active treatment but throughout the course of one's illness.

[00:13:46]It can mitigate stress.

[00:13:48]It's great to find people who share commonality and common experiences and really diminish that feeling of loneliness or isolation that some people experience as they go through cancer therapy.

[00:14:00]What are some silly but wonderful night things that you can do that may potentially help you feel more engaged?

[00:14:05]Small things. As you walk down the street or anywhere just quick hello's gay look gay excuse me.

[00:14:11]Eye contact and and just engaging with people even that can really stimulate feelings of well-being.

[00:14:20]Sometimes too social media can it can be a positive but it can also be a negative for some people.

[00:14:27]You know, there is the grass is always greener people tend to to put up the highlight reels of their lives.

[00:14:34]Sometimes the news can be another stressor. So really be mindful of how social connections may or may not be impacting your wellness and protect yourself that way.

[00:14:44]Stress is another thing that we don't talk about having multiple myeloma is stressful not only for patients but for caregivers. So how do we think about stress mitigation in our lives?

[00:14:55]We all know who this is. This is a picture of President Obama before and after his eight years in presidency. You can find similar images of all of our presidents.

[00:15:06]You know, stress is a real thing that affects us physiologically as well. I'm not going to go through all these but this is just what fear and stress all the different systems in our body that can be activated by by a stress reaction. And so how do we start to think about antidotes to stress? What are the types of things that may help?

[00:15:26]Meditation, yoga, tai chi, prayer.

[00:15:30]These are all, you know, available activities that could potentially help to mitigate stress. We talked about exercise, eating well, too.

[00:15:39]You know, things that, you know, don't spike your blood sugar and and and have you come crashing down. Trying to maintain a more even diet can potentially help. Focusing on positive emotions, humor, laughter is the best medicine. And again, finding social supports and having good sleep.

[00:15:58]Also, identify what your stressors are.

[00:16:00]You have to protect yourself. This is a critical period in your life as you go through myeloma therapy. What are the things that are stressing you? What of those are changeable? And if there's anything in your medical care, too, that is a particular stressor, I think it is important, I know I can speak for Omar and me, that we care very much not only about the outcomes of our patients, but their day-to-day happiness. And so, you know, we want to know the ways in which we can help you in your life. So, talk about it with your team and and let us, you know, really try to brainstorm how we can enhance quality of life as you go through your therapy.

[00:16:36]What you think you become, what you feel you attract, and what you imagine you create. So, how can we visualize a path for ourselves that's positive even as we go through therapy for multiple myeloma.

[00:16:50]As I mentioned, meditation can be beneficial.

[00:16:53]And this is something if if you are not in a position to engage in activity, there are other things you can do that may be of of potential benefit.

[00:17:02]Meditation has been demonstrated to lower blood pressure and heart rate, potentially improve inflammatory bowel syndromes. There may be some cell-mediated immunity improvements and improvements in inflammatory markers.

[00:17:15]And also, how can we improve our mental health um, and stress responses. Uh, yoga can be gentle. There are a lot of yoga problems out there. We have patients who do chair yoga.

[00:17:28]Um, one of uh, you know, the different cancer centers both uh, in Boston at MGH and Dana-Farber offer these types of resources to their patients. No matter where you are, you may be able to engage in targeted um, things for cancer patients. And be very careful not to do anything that feels uncomfortable for you.

[00:17:48]I'll talk a little bit about substance use cuz it comes up frequently. Um, alcohol uh, and our outgoing um, Surgeon General at the start of this last administration identified alcohol as a carcinogen. It is one of the uh, known carcinogens. So, the less you drink uh, the lower your risk of cancer.

[00:18:08]There are six specific types of cancer uh, that can be um, tied to alcohol use.

[00:18:14]Alcohol includes all things including wine, cocktails, uh, and beer.

[00:18:19]So, what happens when you drink alcohol is that your body breaks it down to a chemical called acetaldehyde. This can be DNA damaging um, and prevents your body from repairing damage. The DNA is our instruction manual and so as we continually expose uh, ourselves to DNA damaging agents, there is a potential for harm. So, what are the current recommendations? Men are uh, they It is suggested the less you drink the better, period. Uh, but the recommended consumption uh, through American Cancer Society is one drink per day per women and two per men. And here's just a listing of what equates to one drink.

[00:18:59]Um, something that comes up very frequently with our patients is am I am I am I allowed to drink while I'm on therapy?

[00:19:06]Um, it's a little bit nuanced because alcohol does affect your uh, uh, the function of your platelets. So, if your platelets are low, this is just one example, uh, you know, you really do need to talk to your doctor about the safety of it. Uh, but again, you know, in a long-term illness, too, you know, a glass of champagne at a at a graduation celebration, things of this nature, you want to also balance that with enjoying quality of life.

[00:19:31]Marijuana comes up a lot. Uh, there are two different components. There's the THC and the CBD. I'm by no means a marijuana expert, but um, we do get a lot of questions about it. It is an evolving field. Um, one of the reasons why marijuana, which has been demonstrated to improve nausea and vomiting, can't be studied is because on a federal level it is a schedule two and illegal substance and therefore cannot be included in clinical trials. However, there have been clinical trials done in Canada and Israel, uh, that have demonstrated some of this benefit. It is always dangerous to inhale, um, things into your lungs.

[00:20:08]Um, and so, but there have also been studies that show that patients who are using marijuana effectively may need less, uh, pain medication.

[00:20:18]You have to be careful of distinguishing the euphoria, uh, from the THC, um, and, um, you know, balancing that with potential, uh, antiemetic benefits.

[00:20:30]Um, there are different strengths, so I know people do have medical marijuana and there are a lot of providers now, uh, even in Massachusetts, who can help guide this, but recognizing that these are not drugs in the same way that their their doses are studied and what you see is what you get. And so, there can be variability into in terms of the strength of that which you purchase. So, be very cautious, uh, that should you choose to use these medications that you're obtaining them from providers who have experience prescribing.

[00:21:01]There are, uh, chemically based drugs that can be prescribed for mitigation of nausea. Marinol, uh, is one of them. We don't see as much nausea in multiple myeloma as some other therapies, but it just to be aware of kind of the spectrum. Um and finally, um and and kind of hopefully um in a very interesting way, I know a lot of people have questions about nutrition. So, when we think about what a healthy plate looks like, this is from Harvard's uh School of Public Health.

[00:21:32]You can see that vegetables represent um the largest portion of the plate with healthy uh excuse me, it's fruits and whole grains uh and healthy protein occupying the other um parts of of the healthy eating plate. Um the AICR recommendations for cancer preser- uh prevention are seen here.

[00:21:54]Um and again, um you know, they are the things that we've talked about in terms of lifestyle.

[00:22:00]Um really trying to eat a diet based in whole grains, vegetables, fruits, and beans, and we'll go into a little more detail. Avoiding the consumption of things like red and processed meats. So, um the general guidance is not to eat red meat more than once per week, and processed meats are things uh you know, like hot dogs, uh deli meats, uh that may have preservatives in them in large quantities.

[00:22:24]And so, how can we tie this back to plasma cell dyscrasias? Um so, this is work uh done by one of my colleagues, Urvi Shah, down at Memorial Sloan Kettering Cancer Center, uh looking at the National Health and Nutrition Surveys, which are a large um you can see 25,000 uh participants in this study, trying to identify foods uh that may be associated with a higher versus lower risk of MGUS, the precursor to myeloma. And what you can see, not surprisingly, is sugar-laden beverages are put patients at a higher risk uh in this epidemiologic study, and those that lower the risk uh are vegetables, whole grains, fruits, and cruciferous vegetables in particular.

[00:23:10]Again, if you surround yourself with people who eat well, this is one of the recommendations from the American Cancer Society, you will be more inclined to eat well as well. So, trying to mirror the healthy choices of those around you.

[00:23:23]In terms of some specific recommendations, looking at labels, trying to avoid added sugars, really trying to focus on things that are unsweetened and unsweetened also includes not the artificial sugars as well.

[00:23:40]Again, limiting consumption of red meat, trying to avoid processed meat. I love bacon, but we have to watch out. Ham, cold cuts, salami, and and consider replacing red meats with other forms of protein so that you are eating adequate protein. And trying to avoid fast and processed foods. Some healthy alternatives for things when you really just want to bite into something or snack on thing include carrots and hummus, fruits with peanut butter or nut butters, nuts in general high in protein and healthy fats, cottage cheese and yogurt, keeping things that are easy to snack on. Overnight oats can be a nice and easy thing to prepare that gives you high impact in the morning.

[00:24:24]Some tips from our nutritionist, just keeping frozen fruit or vegetables in the freezer that you can easily have access to. Roasted vegetables are a great way to to get vegetables into your diet. A little olive oil, a little bit of salt, maybe some garlic.

[00:24:40]These are easy to prepare and and really do complement most foods well.

[00:24:46]You can add fruits and vegetables to your breakfast as well. People don't often think about having vegetables at breakfast, but you can sneak some in. Things like edamame or carrots actually, um, you know, are reasonable things to think about incorporating and also, um, snacking with things such as nuts. When we think about other, um, whole grains or high-quality foods, um, things like hummus or other bean-based dips that can be combined with raw vegetables or whole grain crackers are healthy alternatives to other types of snacks.

[00:25:20]Um, try new whole grains. There are farro, quinoa, a lot of different grains out there that some of us have not historically consumed, uh, but really trying to broaden your palate and try, um, alternative grains can be another way to incorporate them into your diet.

[00:25:38]This is again work from our colleagues at Sloan Kettering looking at high-fiber diet, um, and they've shown data in mice, uh, that a high-fiber diet diet may, um, delay the evolution from smoldering to myeloma and this is something, uh, that they are following in some clinical trials that I'm going to talk about.

[00:25:59]Um, so eat food, not too much, mostly plants from Michael Pollan. And so, um, this is the old American plate. It looks like the type of plate I would have had growing up in my household. The new American plate, you can see, focuses much more heavily, um, on on fibrous foods.

[00:26:18]Can we be mindful when we eat? So, thinking about what we're eating, what we're chewing, what does it taste like?

[00:26:25]How many bites have I had? Am I hungry?

[00:26:27]Am I eating in response to emotions?

[00:26:30]Um, am I distracted, therefore I'm eating without thinking about how many bites I'm taking? Notice the texture of your food. Take a bite. What does it feel like? What are the flavors? Um, how do I feel after some of these foods?

[00:26:44]Being conscious of what we're eating.

[00:26:48]Um, the role of of the timing of eating.

[00:26:52]So, how might the timing affect your metabolic uh health? Lean women were randomized to eat early versus late, and those women who ate later in the day were found to have metabolic alterations that were detrimental to their health. The gut microbiome is something that is um the bacteria that are naturally in our stomach. It's something that is very into and along our GI tract. It's something that is very occurring in terms of our interest. How does that impact our health? The bacteria in our gut interact with our immune system. Is this modifiable? My colleague uh Katherine Marinac is an epidemiologist at Dana-Farber, who's done an investigation of prolonged overnight fasting in patients with precursor disease, and we'll be seeing those results uh very shortly. But, the idea is that it can potentially improve metabolic health and sleep.

[00:27:43]So, I'm going to just in the last few minutes talk about initiatives to study these things. How do we move the field forward? How do we go from general ideas to actual data and evidence the same way we would uh when we're making any recommendations to our patients. So, again, this is a study uh led by my colleague Dr. Marinac that was a randomized trial of prolonged overnight fasting versus an education control, and we anticipate those results in the coming months.

[00:28:12]Um I just conducted and completed a study of the gut microbiome and plasma cell disorders. So, there is a growing amount of evidence for the relationship between the gut microbiome and plasma cell dyscrasias, and there are certain bacteria uh that may be associated with better and worse outcomes in in um plasma cell dyscrasias.

[00:28:35]Um and these are some of the specific types that we can see uh that may be associated with progression of disease.

[00:28:41]And why is this important? Because we have the ability to alter our microbiome. It is fluid. What we eat determines the diversity of the bacteria in our gut. So, if we can understand uh the the relationship between our our microbiome and progression, then we can potentially address that. So, we've just create uh we've just finished uh a study looking at 100 patients with MGUS, 100 patients with smoldering, and 100 patients with multiple myeloma, looking at the microbiome, and we hope to have those data available for ASH.

[00:29:15]This is a very large cohort of patients uh by our standards, and we're really excited to see if there are signals um that can help guide us in in recommendations for nutrition for patients to potentially prevent progression. One of the other really exciting stories in terms of the gut microbiome across multiple different types of cancer is that the microbiome may actually be related to our response to immunotherapies. This has been demonstrated with checkpoint inhibitors in other cancers, with CAR T cell and lymphoma. And so, because we are fortunate to have clinical trials at Dana-Farber in the high-risk smoldering state for patients who are untreated, we've done an analysis of the microbiome in individuals with smoldering who have never been treated and received by specific T cell engagers and CAR T, and we're comparing that to the microbiome of individuals with multiple myeloma heavily pretreated before and after um and looking at that um in terms of response. And again, we hope to have this data for ASH. There are studies that are currently enrolling if nutrition and being a part of this research is interesting. My colleague Arvin Shah at Sloan Kettering has an ongoing trial right now. It's a randomized trial looking at a whole food high-fiber diet versus supplements versus placebo. You do not need to go to Sloan Kettering. You can enroll online, and this is something that you can do if this is of interest to you um to really try to learn more and gather evidence for exercise. In addition, they have a study of randomization of patients who are newly diagnosed on Dara RVD to again a high fiber dietary intervention versus usual um care and these are all decentralized. You do not need to go there. Meals will be delivered to your home. Um and these are ways in which we can learn more about diet nutrition.

[00:31:06]Obesity comes up a lot. Excess body weight is associated is a second leading cause of cancer. Um multiple myeloma is one of the 13 cancers associated with excess body weight. We know that obesity significantly increases the risk of transformation to MGUS to myeloma.

[00:31:24]We are about to begin a study of tirzepatide, uh which is a one of the new GLP-1 GIP drugs in obese individuals with MGUS and smoldering um to see if we can learn more about [snorts] risk reduction through addressing obesity. This is for individuals who have a body mass index greater than 30. Patients do need to have more than 1 g per deciliter of monoclonal protein to participate in the study uh and not have evidence of multiple myeloma. Um patients who are at high risk for multiple myeloma uh have high risk smoldering also are ineligible or those who have had bariatric surgery or taken uh GLP-1s uh within the last year.

[00:32:08]So, I've just done a very uh whirlwind overview of some lifestyle considerations um and I really appreciate your time and attention. Thank you.

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