Balancing skills for longevity

Peter Bowes: Nathan Estrada is a physical therapist on a mission to help people improve their ability to balance as they get older. Age related falls are often the first sign of frailty and for some people signal a decline in health that’s difficult to reverse. Hello again and welcome to the Live Long and Master Aging podcast. I’m Peter Bowes. This is where we explore the science and stories behind human longevity. So what is it about balancing that is so crucial to our health as we grow older? And how could an app on a smartphone help us? Dr. Estrada joins us from Nymbl Science, which is based in the beautiful city of Denver in Colorado. Nathan, welcome to the Live Long and Master Aging podcast.

Nathan Estrada: Thank you so much. It’s an honor to be here.

Peter Bowes: Really good to talk to you. Before we delve into the issues, could you perhaps define what balance is? It isn’t something that we consciously think about necessarily every day, but as I’ve mentioned, it is so crucial, isn’t it, to our long term health?

Nathan Estrada: Yeah, Balance is one of those automatic functions that if you have to think about it, it’s bad, right? And sometimes I like to relate it to if you play tennis and you try to hit the ball, you’re a bad tennis player. If you’re if you’re walking around and you stumble and have to think about your balance, you just fell. And so ultimately, those automatic functions that are designed to protect us as we age start to degrade because we don’t train or practice them as much. When you’re a child, you’re jumping out of trees and playing sports and running around, and that’s when we gain all of our balance of reflexes. And then as we get later in life, sometimes we choose to maybe move a little bit less. And that moving less gives our brain less training. And then you get what you train and so suddenly bounce can decline and then our sensation of balance declines along with it. Suddenly we find ourselves to where that little automatic function that always stops us from falling, stops working

Peter Bowes: So that’s fascinating. I mean, there are so many issues that we are going to be able to delve into here before we do. I mentioned Nymbl Science is the company that you work for. You’re based in Denver. What do you do?

Nathan Estrada: So as the VP of Clinical. My personal role is to make sure that that what we do impacts older adults consistently everywhere that we do it right. So whether you’re helping 75 year olds or 95 year olds, anyone can improve their balance. And it’s never too late to start. But Nymbl, we’re really based on this single focused passion, which is how do we help older adults thrive where they want to live, which is quite a bit different than aging in place. Aging in place as a stagnant position. Thriving means that people are doing all the things that are meaningful to them and value generating in their life. And what we find is the single greatest limitation of people living meaningful lives is insecurity in their mobility. So what we do is we actually train that balance reflex again using smartphones, phones and tablets. And it’s a game that older adults can play that retrains the balance reflex and reminds the body how that works again, we combine brain and body things together because that’s actually how we live life. You don’t lose your balance when you’re thinking about it. You lose it while you’re carrying groceries and someone says, Hey, by the way, Nathan and I go, Hey, is that Peter or Paul behind me? Who said that? And then I stumble. So we’re able to retrain those things, and we do that at scale because we need more older adults proactively improving their balance rather than waiting for them to go to some kind of balanced class that no one does.

Peter Bowes: And you say play with the the app and the phone. Is that deliberate? This has got to be fun for people.

Nathan Estrada: Yeah, Well, I mean, shoot just because you’re 75 doesn’t mean you lose your funny bone. All of us enjoy certain things in life. And frankly, from a behavioral aspect, all of us, we all do what we want to do. And if you don’t make an experience that someone wants to do, then it’s a useless experience. So it is a game. It’s a brain game that you are doing at the same time you’re doing simple functional movements. So it’s not something you sweat at or that’s even hard because balance is not a back flip, it’s just a step. And so we’re retraining the body how to quickly to regain those balance reflexes, to have the mobility, to have those reflexes and to retrain the sensation of balance so that you can actually sense yourself falling in the first place.

Peter Bowes: And how did you come to this, Nathan? You’re a physical therapist. Just briefly, what is your background?

Nathan Estrada: So as a physical therapist, I started off in sports medicine and I was treating high level concussion and getting people who had a sudden insult to their balance back to high level sport. I then moved to adolescent athletes, had a great time, but then I just really missed this impact of helping people get back to life. It’s neat to bring people back to sport, but when you when you meet a 75 year old who for whatever reason, has convinced themselves that they should stay home to protect themselves from a fall, that they should avoid stairs, that they need to move into a ranch, remove all the throw rugs when you get them back to living a thriving life that is so much more meaningful. So that’s when I move back to older adults. I did Home Health. I loved seeing people in their own home, but then realized if I’m going to change millions of lives, I got to take me out of the equation. What can we get older adults to do without me coming to their home that can impact their balance in a rigorous and kind of valid way.

Peter Bowes: Now, balance, of course, is something and I refer to it before we subconsciously use our balancing skills all the time. And we do that from, well, the day we’re born, really, as we’re growing up as children, especially as younger children. But it is subconscious. And I’m just curious at what stage in our lives does it become generally to be an issue and that we might think, are I really I’m not quite as good as doing that as I used to be. And that could be the beginning of just acknowledging that it’s an issue to deal with.

Nathan Estrada: Well, I will let you know that balance tends to degrade in your late twenties or early thirties, depending on your lifestyle. And there’s a few different reasons for that change of behavior. Right? We don’t run as much. We don’t jump as much. We don’t challenge our body as much as we get older, as we think we’re maturing, which is a whole other conversation. Maturity doesn’t mean lack of mobility, and so it slowly declines, but it doesn’t decline enough to where you know it. Sadly, the first inclination that you get that your balance is getting bad, you start stumbling and you almost fell. And for the first time in your life to go, that was a close call. And so we’ve all had that experience too, where you got a curb or something like that and you didn’t react to how you used to. Well, that is the harbinger or the canary in the coal mine, and that happens usually in your forties and fifties. When people have to stop golfing it’s because their balance gets bad and they can’t control the ball anymore. And so then suddenly you get in your sixties and you’ve had some of those close calls, but then you cross a threshold to where your reflex is not fast enough and those close calls turn into actual falls.

Peter Bowes: And when that begins to happen is it exaggerated by the fear of not being able to balance. You perhaps realize that there is an issue and then you dwell on it and you think about it. And that doesn’t necessarily make things better.

Nathan Estrada: No, it doesn’t. In fact, fear falling is the second greatest predictor of a future fall behind the obvious number one predictor, which is a past fall. But how does fear falling really work is interesting. It’s really twofold. Number one, when you’re fearful, you don’t move. In other words, the more fearful you are, the less you challenge risky behaviors. And risky behaviors can get a very small definition right. I’m not going to go to my friend’s house anymore. I’m not going to use my basement anymore. Well, all those experiences were stimulus for balance training, and it changed our behavior so much that if you look forward the day you start being fearful of falling. If you take 100 older adults on that day with fear, four years from now, half of them will no longer be independent in their self care. So it’s not even just the mobility, but it changes our behavior so much that we actually lose our independence regardless of whether we fell or not.

Peter Bowes: That’s quite stunning, really, to think of it in those terms. And I guess for a lot of people, they leave it too late. And when we’re having this conversation, hopefully we’re going to increase awareness about the importance of balance. But for a lot of people, it’s maybe just something they put up with as part of the aging process, accepting it to be normal when it doesn’t have to be.

Nathan Estrada: Yeah, it’s an interesting construct. So there’s three universal truths that everyone should know. Number one, falling is not normal. Most falls are preventable and it’s never too late to start. And it’s really interesting, regardless of whether your you have really challenging balance and you can barely get out of a chair or you’re an Olympic ager and you’re skiing at 95, everyone can improve their balance. It’s not a it’s not a non pliable construct. It’s not like you lost your legs. What it is, is you lost your skills and skills can always be trained and retrained and reminded what’s going on. Another aspect of that preventative cycle is you said kind of waiting too late. Well, the medical system is what waits too late. Here’s what we do in medicine. We say, Hey, you just you fell and you broke your arm or you broke your hip. It’s time to prevent falls. Well, that’s actually a lie. Well, the fall already happened. You’re not preventing anything. You’re mitigating future falls. The average person who has a fall related medical claim or goes to talk to their doctor or a hospital has been falling for two years. So the problem that we have is that we don’t offer people solutions until the doctor knows or the medical system knows that you’re costing them money. And that’s the trigger. But the behavior of falling happens well before then. And that’s when we should be thinking about balance training before we have to be at the hospital.

Peter Bowes: And is it fair to say I often describe it like this, that a fall, the frailty that perhaps leads to the fall is sometimes the beginning of the end. And I don’t want to be overly dramatic about it, but the beginning of the end, because a person’s health suddenly seems to rapidly deteriorate from that point, having fallen and broken a bone, broken a hip, maybe the hip has been repaired, but somehow the whole body doesn’t seem to repair and the aging process appears to be accelerated from that point. Is it fair to say that.

Nathan Estrada: Well it’s fair to say that on multiple fronts we can just go over the numbers? And like I said, I’d like to stay on the positive side that you can always prevent a fall. But if you do fall and you find yourself in a hospital, a third of the older adults don’t survive three years. In fact, 71% have a second fall related medical claim within 12 months. And so once it starts, and that’s what we all experience, we all had family members who were living one life. They fell and then suddenly it changes to another. And it goes back to that fear of falling. You start making business decisions. Maybe life is too risky to move, and then once you stop moving, you decline. And that every day you don’t use a muscle. It’s four days of strength training to regain the strength you lost. So if you go to the hospital for four days, do you know what takes 16 days of rehab to even get back to the health you had when you got in the hospital? And that was the health that made you fall. And we. And what’s the average stay in a rehab? It’s not 16 days. And so we have this constant decline and we think that we’re giving people these skills and assets and giving them rehab. No, we’re just overcoming the detriment of the hospital stay.

Peter Bowes: And clearly, there’s a financial implication here in having to deal with everything that you’ve just outlined. And if this is happening too early in life, when it really can be prevented, that’s not great for the medical systems not here, only here in the United States, but around the world. Systems that are are stretched in trying to target resources where they’re most needed when perhaps some of those resources are being spent in areas in terms of preventable conditions.

Nathan Estrada: Yeah, Peter, it’s really interesting when you look at scope and scale of the medical spend, United States has the least cost effective program in the world, but falls account for 6% of the entire Medicare budget. It’s 8% of the Medicaid budget. And when you look at a 65 plus older adult, and that’s how we define older adults because of Medicare in the United States, 22% prevalence. So every year, 22% of the Medicare population have a fall related medical claim. And I thought that was unique to the United States just because we’re not very good at preventing falls. Well, we did a study in New Zealand and New Zealand, which has the world’s best fall prevention program, still sees people fall at 19% per year who have a fall related medical claim. Now we know a third of older adults fall, but not all falls result in medical care. So it’s about a 50 to $60 Billion annual spend in the United States just for older adults.

Peter Bowes: Interesting point. And maybe this is going off at a little tangent. You mentioned how we define what an older person is. And generally here in the United States, it’s when that person becomes eligible for benefits in their sixties. But leaving aside that, how would you define what an older person is? Some people refer to the over fifties in the UK it’s pensioners. When you’re getting your your Social Security again at some point in your mid-sixties and that age tends to change. But in my mind I’m in my sixties, early sixties, I don’t feel or consider myself to be old. I’m just interested in your perspective there.

Nathan Estrada: You’re old when you decide to act old. It’s a behavior for the most part. Most chronic diseases are fully preventable, and if you have a healthy lifestyle, most, most people go on. And that’s the whole reason why we have a book called Live Long Die Short, because it’s possible. So I define an older adult as someone who has for either shift of vocation or a shift of belief, has decreased their engagement in what they considered value generating, because that’s really that’s really the changing when you decide, like if you retire and you go, Well, I’m not going to do anything anymore, well then you’re old. You are an older adult. When you’ve decided that you no longer want to add your impact to the world. And so I think it’s really a declining of of engagement. So you look at someone my grandfather, he was a country Western bootmaker and a lot of my passion for falls comes from him because he died as a consequence of a fall. He worked for 72 years and he was walking ten miles a day well into his eighties. And you look at that and the reason why he was never an older adult. Until he decided to stop working. And that’s when he became an older dope because all of his behaviors changed.

Peter Bowes: You could say the headline of this is going to be, you know, you need never to grow old.

Nathan Estrada: Well, yeah, but I think growing old for most of us is actually a choice well before it’s a requirement. And I like to blame pensions and retirement plans for the world’s most successful campaign to get people to do less.

Peter Bowes: Yeah, exactly. And a little caveat to what I just said. You need never grow old. I actually see nothing wrong with growing old. Growing old can be a positive and should be a positive experience.

Nathan Estrada: Yeah. In fact, I kind of coined a term on all my LinkedIn post, which is aging is not less. It’s the belief that aging is less that drives it to be less. In my home health career, I would hear things like I thought there’d be more gold, my golden years, and I would look at them. I said, Well, okay, well, why did you stop digging? Right? I mean, why would you expect that there’d be gold on the ground in front of you? There is effort involved. There is behaviors to be had, and I think we forget that. And part of it is a misnomer that the body naturally degrades the degrading of the body and the decline of the body is far slower than we could ever imagine. It’s only accelerated by the behaviors of the human.

Peter Bowes: You’re listening to the Live Long and Master Aging podcast. My guest is Nathan Estrada from Nymbl Science in Denver, Colorado. We’re talking about balance. And one thing, Nathan, that peaks my interest is that you’ve referred to this, but I’d like to explore a little bit more deeply in terms of what we do in our everyday lifestyles. And I know there is an inclination sometimes by health care providers for people who are growing older, to try to make life as easy as possible, to remove the stairs, to have a single storey building for older people. In other words, take out of life those things that could potentially be a little bit difficult. And what I get from you is that that isn’t necessarily a good thing and that we need to just push ourselves a little bit to do those things that maybe we think we can’t do, but actually we can do.

Nathan Estrada: Yeah, it’s really problematic. Falls is the only thing that we thought we could fix by removing things from people’s lives. Right. When’s the last time you actually solved someone’s impairment by changing everything to make everything easier? You don’t teach a kid math by saying you need a calculator. So from that perspective, it’s really interesting. I think the second problem of making the environment perfectly sterile, as I like to say it, perfectly flat, no trip hazards is then you remove all the stimulus to lift your feet at all. I challenge you go to a skilled nursing home and we all know that older adults and skilled nursing shuffle their feet. It’s a problem. So that’s why we’re always worried about trip hazards. Who else shuffles their feet? All the employees. Because there’s no stimulus to lift your feet anymore. And so even healthy individuals accommodate to their environment and the lowest level of mobility required to do it. So when you add grab bars, when you do all those things early and removing throw rugs, that’s the one I like to really kind of bag on. People like to throw rugs more than they like your recommendation to remove them. And so as a provider, you remove it when you’re in the home, and then they go in the closet and they bring it back when you leave. And I think the second aspect of that is do you know where dangers live everywhere else in the world? So if you make the home safe and they feel secure in their home, but everywhere outside of the home isn’t safe, are they ever going to leave it? No. So the Dutch are the people who are really good at not letting people fall, but they do the complete opposite of the Americans. And the Dutch fall prevention program is to force people through a challenge of 20 obstacles that would normally make them fall. And it’s really designed to go actually. You think that your impairment is so bad that you can’t do all these things, but you’re actually really good at half of them and ten of them were challenging. So now that older adult can expand their life back to the things that they took out to protect themselves. And then they come back the next week and they go, You know what? I’m going to beat one of the ten, and then they figure out how to make that one safe. And then four weeks later, there’s only four of them that are still unsafe. Well, now they’ve expanded far beyond what they thought they could do, and they’ve expanded their life after to those levels. And you know what they’re doing? They’re moving more, they’re challenging more, they’re stimulating, and they’re practicing balance more. So even if they did fall, they’re far less likely to be injured anyway.

Peter Bowes: To get that message across, though, to a wider population, perhaps to employers, to care home managers, you need a real shift in paradigm, don’t you? Because the way you’re thinking is just the opposite to what you’ve been describing, that we need to do everything possible. Maybe there are insurance issues here as well that that big organizations want to make it as safe as possible because they’re afraid of the consequences.

Nathan Estrada: Yeah, I was talking to an architectural firm, designing senior living for independent and assisted living, and they said, Nathan, at what level of challenge should we have in this? Because our lawyers are telling us to remove all the stairs. And I was reminding them that stairs are the single most productive strength training part of someone’s day. And so you could either give everyone physical therapy all the time or you can have them go up and down a flight of stairs. You choose which one is easier and more reproducible. And not to mention that, but you should have grass that people walk on. You should have different surfaces and slopes because ultimately you want people experiencing the same life that they’re going to experience at their kid’s house or when they go to the wedding. Right. And so if you if you suddenly remove all those things, then older adults go, well, maybe I shouldn’t be doing them. And so we can add fear by changing the environment just as much as we can add fear by telling people they’re dangerous.

Peter Bowes: So, Nathan, let’s come full circle and talk about Nymbl science and the work you do and especially what you can offer people, anyone listening to this thinking, well, this, this really strikes a chord with me. How can I benefit from this technology that you’re involved with?

Nathan Estrada: Yeah, So two things. We don’t offer Nymbl directly to older adults, and it’s actually part of our mission. And I know that sounds funny. Peter. Here’s why. We believe that if a fall on a fall related medical claim on average cost the insurance company $15,000, they should pay for Nymbl to be free for every older adult. And so I’m on a mission to prevent a million falls, not by making older adults pay for more things, but by making their insurance pay for things that save the money. So what we really focus on is we are our customers are actually Medicare Advantage plans or government institutions, and we’re constantly expanding. How many people are eligible to have free accounts on our program? So, for instance, anyone in the eight counties of the Denver metro area, Nymbl’s a fully covered benefit from the state of Colorado, because the state of Colorado did an assessment and said we don’t have any skilled nursing beds for these people to go. If they do fall, we better do something about it. Fairly forward thinking as a as a municipality or a government. Most of the time our customers are insurance plans. So we have a partnership among many insurance plans to where if someone’s eligible, they know it because we communicate and we let them know. But if you want to participate, here’s what I love to do, is I always need people to teach me how I can make the system better. So we have a whole system that if you go and try to make an account and you can’t because you’re not eligible, we will give you an account. Just give us feedback on your experience so that we can make this experience even more delightful moving forward. More than happy to have that conversation. So we have a whole enrollment website which is FallsFree.com -you can’t enroll for free, but if you shake our hand and say you’ll tell us something to make it better, I’ll let you do it.

Peter Bowes: And so for those people eligible, they can access your technology. What does the process involve? How do they benefit from it?

Nathan Estrada: Yeah, so what it looks like is most of us meet us through some education that we send out proactively. But the first day it Nymbl on a phone or a tablet that you already own and it could be iOS or Android. It’s experienced starting off saying, Hey, welcome, you’re in the right spot. Many people have balance problems and everyone can do something about it. And we do a risk assessment and we look at 14 major risk factors for falls. Not to tell you that life is dangerous, but to guide us on what to present and what interventions would be most beneficial. And day one, frankly, is pretty easy. We let you play a brain game and then we say, By the way, here’s a simple functional movement like weight shifting side to side or stepping forward and back and go, okay, now try them at the same time. And it’s different. We’re not used to using the brain and body together like we did when we were maybe younger. So we’re retraining that coordination of while I’m distracted, I can still move. And then you do that for 5 to 6 exercises and we say, we’ll see you tomorrow. And then tomorrow you come back and nothing lasts more than 10 minutes. And it really is this it’s a brain game that you enjoy playing anyway that you happen to be moving during and that happened to be moving is being controlled by your reflexive center, your cerebellum, that little cauliflower in the back of your brain, which then the next time you stumble, you know what it’s recently done. It’s recently practiced, how to step, how to recover and what the sensation was. And so suddenly people that used to stumble and fall, stumble, catch themselves. It only takes about 4 to 12 training sessions of 10 minutes at a time to 40 minutes to 120 minutes to have meaningful change in balance and meaningful change is this. A 35% reduction in fall related medical care needed for falls at a population level when people got past 12?

Peter Bowes: And that’s quite striking and a phrase you just used brain body the mental benefits are perhaps not as easy for people to get when they’re concerned about the physicality of balance. And I know that you know that there is a lot of very good reputable science that will suggest that having better physical capabilities focused around balance can affect us in terms of our minds and our the way that we think. And even our memory.

Nathan Estrada: Yeah. So, Peter, the brain is such a powerful predictor of falls that we have a test called the walk and talk test. So if you have 100 older adults and you say, everyone start walking, and then you make a declaration, now start having a conversation, all the people that stop walking to talk are all your fallers because they’ve lost the ability to do two things at once. It’s called dual task tolerance or dual task interference. And here’s a funny thing too. Did you know that your balance is actually a brain challenge far before it’s a physical challenge? Most older adults don’t fall because they’re so physically weak that they melted into the ground and gravity one they fell because they never sensed themselves falling. And so older adults are the only population in the world that can fall and get a black eye. You could fall 100 times, Peter, because you’re a healthy, aging individual and you would never hit your head because you would always reflexively respond. But older adults, the reflex or the sensation of balance can get so poor that they fall like a tree. In the first thing that hits the ground is their face. And so we always wondered how. Grandma, how did you get a black eye? If I fell, I’d put up my arms. I would do something. Well, if you never felt yourself falling, you never responded. And feeling yourself falling is a cognitive function. The reflex is a cognitive function. Only then does the mobility matter, because the reflex tells the body how to move. So if you don’t sense yourself falling, you don’t have a bounce reflex. No amount of mobility stops you from falling.

Peter Bowes: And that concept of mind and body and doing two things at the same time, it reminds me of the phenomenon that happens when you’re driving a car and dealing with the physicality of driving the car and listening to your car radio or listening to some music at the same time, and then find yourself having to look at the directions using your your navigation device on the screen as well. And it sometimes becomes overwhelming that you need to stop doing something. And it usually is switching the music off while you focus on just finding the parking space that you’re looking for or whatever it happens to be. That’s to me, a classic example of how you can be overwhelmed by things to do.

Nathan Estrada: Yeah. So, Peter, I have a colleague, Dr. Terry McIsaac, who actually studied dual task training and driving safety. And what they found is that it’s something that can improve. A lot of us just start removing the stimulus to make us safer. Well, what if we started training the tolerance that way it didn’t impact us in a negative way? And I like to always bring up that you talk to your doctor and say, Doctor, I’m having a hard time walking and talking in medicine says, Well, then don’t do that. Well, I say, Well, then that means you’re not stimulating yourself enough to tolerate. Let’s actually do more of it. Let’s challenge a deficit, because accepting a deficit as a new normal makes that my new baseline. And so I’m accepting decline as normal. That is not normal. And so she’s found great outcomes on dual task balance training, improving driving safety, because that tolerance of all that stimulus actually matters.

Peter Bowes: And Nathan on this podcast, we focus on human longevity, living long, healthy lives. It’s not about living forever, but it’s just about living the best life possible and aspiring to a good health span. What is the correlation between what we’re talking about? And maybe it’s obvious that if you have a physically, physically debilitating accident at the age of 65, it may well help or may well hinder your longevity. But in terms of bigger picture, your work and longevity, how do they go together?

Nathan Estrada: Yeah, it’s really interesting. From a longevity perspective, falls are the number one cause of accidental injury and death for older adults in the entire world, and it has been for decades. So if you look at the one thing that is most likely to cause you to stop living the life you want to live, it is a fall. And because most falls are preventable, it’s the single greatest cause of preventable harm for older adults. Full stop. So from a longevity perspective, here’s what success is. Success is that you have enough mobility to participate in the things that bring you value. And so you have to think about that. That’s different for everyone. I’ve met some older adults that are wonderfully successful just walking in their own home because they’re able to offer all the value they want in the world within that environment. But if that’s not the case, then that then someone else in that environment, that is actually not longevity. So I look at it a little bit differently because it’s very human, it’s very individualistic. But here’s how balance affects longevity in the long run. A fall. Fear of falling directly degrades independence. That independence can be experienced at multiple levels. Some of it is I don’t leave my home. Some of it is what happens when you don’t have the balance to cook anymore. Right. Suddenly you’re eating out of a can. What if I know how the balance in the ability to go grocery shopping while I’m eating all pre processed foods? What if I don’t have the confidence to leave my home to go to preventive services outside in the community? What if I don’t have the mobility to visit my best friends? And so ultimately, we have to maintain a level of mobility and tolerance for the dangers of the world long enough to engage in the activities that allow us to provide value back. And that’s what successful aging is, at least if I had to define successful aging is I continue to add maximal value. And when I can no longer do that, I’m no longer here.

Peter Bowes: And from a personal perspective, do you have longevity ambitions? Do you have goals? Is it something that you and clearly, through the work that you’re doing, you do think about it, but from your own life and your own family and how you see yourself in the decades to come? Do you think about it a lot?

Nathan Estrada: Yeah, what a great question. I think my aspirations. Number one, I’m an older adult in training. I fully believe that – every decade of my life has brought more fulfillment and joy. And I have no expectation that that’s going to decelerate in any way, shape or form, because I continue to have expanding impact, because the impact is where I find joy when I look at what if I looked at success? A lot of it would be my grandfather, where he’s in his late eighties and he’s climbing on the ladder. Not because it was the safe thing to do because he had the skill set to deploy that. He was on the roof. He was still making Country Western boots, he was still traveling. He was doing the things that gave him joy and that allowed him to give joy to others. And so that’s kind of the handshake, a successful life lived. I have my minister likes to remind us, you don’t want people to have to lie at your funeral, right? You want them to build a taste, say great things about your life. And so I think successful aging is the positive impact you are able to have on others and that the environment that you lived in, human, relational, ecological, it’s better because you were here.

Peter Bowes: And I think that is a great it’s a beautiful point to make and a great way to end this conversation. Nathan, you’re doing great work. Thank you so much.

Nathan Estrada: It’s a pleasure. And thank you for being part of my mission.