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All right. Um I'm gonna make you start now. So thank you for joining me today for the fourth tutorial. This time, we'll be covering the nutritional approaches to mitigate injury associated muscle loss. As usual, I will try and monitor the chat as I'm presenting and um there will be time for questions at the end as well. So, um, sorry issue with my right here. So, yeah, today we're gonna be first just looking at injury or disuse associated muscular atrophy. So the loss of muscle mass with injury associated immobilization. And then we're quickly gonna just look at the nutritional considerations for the immobilized athlete. And then we'll dive into the protein interventions and specifically looking at concepts to keep in mind with protein feeding that go beyond just the amount of protein you're eating. And then we're also gonna look at the role of some other nutrients including creatine and omega three fatty acids where we'll look at a critical analysis and we are gonna have a quick look at alcohol as well and then just add on just an overview of some recommendations. So the loss of muscle mass with injury associated immobilization has been shown to be measurable within five days of injury and immobilization. So that's what we see on the graph here where they measured the quadriceps cross sectional area. And there was already an almost 4% reduction in the cross sectional area of the quadriceps muscles within five days. And this continued to decrease over the course of the first two weeks of immobilization. And this really underlines the actual fact that muscle loss is the most rapid in the initial two weeks of immobilization um occurring at a rate of about 0.5% per week in those initial two weeks. So that is really where intervening with nutrition becomes almost the most important because it's the only thing we can really do since they are immobilized, we can intervene with training. Now, it's not just muscle mass that is affected, it's also muscle strength and it follows a similar pattern. Um but actually it progresses at three times the rate of muscle loss. So what we see here is after five days of immobilization, almost 10% of the muscle strength was lost. And this continued to decrease over the first two weeks of immobilization. And the reason why the rate is so much higher is that muscle mass is actually not the only contributor to muscle strength. As we saw in the first tutorial four weeks back on muscle hypertrophy, the gains in muscle strength you get with starting training is actually the first part is neural adaptation, it's learning how to activate the muscles and then comes the muscle size, the actual hypertrophy that plays into the strength and the same is true for the reverse. So when you losing muscle strength because of immobilization, yes, part of it is the muscle mass, but actually one of the biggest um factors contributing to this is the loss of or the change in motor unit recruitment capacity. And so this is obviously also something that you will relearn once you can start training again, but it's something to keep in mind. So here, we're just looking at the diagram depicting the fluctuations in protein balance over the course of the day. So the curve A that goes above the line shows a net positive protein balance. And that is where you are building muscle, you're in an anabolic state like in the fed state. It's the time that will most stimulate that. And then when you get below the line, as B depicts, that's when the ne net negative protein balance. And that means that muscle is being broken down to release the amino acids and that is occurring in the facet state. Now, adding resistance exercise allows you to maintain in a more net overall positive balance in two ways. Firstly, it enhances the muscle protein synthesis stimulus to feeding. So rather than just having the curve A we have, if you add resistance exercise with feeding, you have a plus the green. So you go even more positive. And on the flip side with muscle protein breakdown, which is the net negative protein balance. Rather than going all the way down in the fasting state, you're actually going all the way down minus the red. So you're going less negative and you're going more positive with adding resistance training. And this is one element that athletes when they're immobilized lose, they don't have that stimulus of the resistance exercise because they can't work out anymore. And as a result, partially of this, they end up spending more time in a net negative protein balance than in a net positive protein balance, which results in a decrease in muscle mass. Because all we're looking at here is an equation of, are you building muscle more than you're breaking it down or are you breaking down muscle more than you're building it? And in this instance, when you lose muscle mass, it's because you're breaking down muscle more than you are building it. Now, just to look at kind of the mechanistics of this. So here we have a muscle cell and muscle cells obviously is where we have, it's the muscle proteins and they consist of myofibrillar and mitochondrial proteins. Now, as I said, there are two factors playing into this equation. You have the muscle protein synthesis, building the muscle and the muscle protein breakdown, breaking down the muscle back into amino acids. Now, muscle protein synthesis primarily occurs via amino acids coming from the blood being taken up into the muscle cell and assimilated into proteins. But collagen proteins and mitochondrial proteins can also contribute to the amino acid pool. And muscle protein breakdown is when the muscle proteins are then broken back down into amino acids and enter back into the bloodstream. Or the muscle proteins contribute to other mitochondrial proteins or collagen proteins. But essentially, I want to show you this. So you have a visual representation of the two sides of the equation that can be impaired when you have muscle loss, you can have impaired muscle protein synthesis. You're not synthesizing as much muscle uh protein as you could or should or you have enhanced muscle protein breakdown or a combination of both. Now, wallet all in 2013, published a study which showed that actually immobilization seems to lead to transient muscular anabolic resistance. So I think many of us are familiar with the concept of anabolic resistance in diabetes where individuals are not responding to insulin, they're not able to take up the blood glucose, the blood sugars as well because they're not responding to the signals. This is a different type of anabolic resistance where they're not responding, the muscles are not responding to the signals to build protein. Um And that is essentially, and it's transient, it's during the period of immobilization. But what they showed here is that F sr is showing the fractional synthetic rates. And in this case, it's a measure again, of muscle protein synthesis. And they showed that from pre to post immobilization, the response in muscle protein synthesis to feeding was attenuated by about 30%. And that, that's a lot that's huge. And that is to the same quantity of protein feeding. So simply the fact that they were not exercising that they were immobilized or the leg was immobilized, impaired the muscle's ability to respond to the feeding stimulus. And this is always significant in the immobilization of athletes. Um There was also some indirect evidence from so markers that muscle protein breakdown was constantly increased in the early stages of immobilization. So the anabolic resistance plays on the equation of muscle protein synthesis, penia paired. But it seems that maybe there is also some elevation of muscle protein breakdown um being induced by the immobilization. Again, this was some in the right evidence. Um So it's a bit of, you know, we're assuming that there might be some in it, I would say from this study, the primary result is that muscle protein synthesis side of the equation is really impacted, but it is not uncommon or you know, it's not an odd thing to be thinking that muscle protein breakdown could also be impaired because um be impacted because there are some markers pointing towards that being the case. Now, in terms of muscle protein synthesis, this study it was on rats, but they showed that actually low grade inflammation also impaired muscle protein synthesis in response to food intake. Now, this is interesting because in most cases, limb immobilization in athletes or immobilization is due to an injury and injuries tend to have some level of inflammation. And so this is what they showed here where they had a noninflamed rat model. And they had a low grade inflamed lap mo rat model. And in the facet state, the muscle protein synthesis rates were the same, which is not surprising. But in response to feeding the noninflamed group that we see on the left hand side had an increase in muscle protein synthesis as we would expect. But the low grade inflamed group did not. So that is another thing to keep in mind that it's not just the anabolic resistance. There may also be the inflammation, impairing muscle protein synthesis even more. And because of this and because of the state of immobilization, there are some nutritional considerations to keep in mind with immobilized athletes. So there are two kind of broad phases. We can categorize injured athletes into that have slightly different requirements. The first phase is the immobilization phase. Um And here we are looking at an a reduced energy expenditure because they're not moving anymore, they're immobilized and this is usually around two weeks, postinjury. Obviously, all of this depends on the extent of the injury, the type of injury. Um but you were nutritionally trying to counter the negative consequences of the injury induced immobilization and we will get back to this in a second. Now, the second phase is the recovery phase. This is where energy expenditure increases because they are in rehab. They are trying to regenerate the muscle, rebuild the muscle and completely recover to be able to get back on the field, on the tracks, on the, whatever their sport is. And this again, broadly is classed as a 2 to 6 weeks post injury, but depends again on the type and degree of injury. But although it would seem logical and a lot of people make the conscious effort to reduce their calorie intake as a result of this. Um because you think I'm not training anymore, I'm not moving as much anymore. I'm Imo I'm immobilized. I'm on bed rest. I can't possibly be burning as many calories. I need to eat half as much. There is some reasonable thinking behind that. But it's important to keep in mind that the magnitude and the decrease of energy expenditure is actually not as great as often thought. And this can be attributed to three main reasons. Firstly, wound healing itself increases the metabolic rate. So surgery can increase metabolic rate by about 20% burn injuries by up to 100% depending on the severity of the burn and wounds, infections and traumatic injury can increase metabolic rate by up to 50%. So the injury in itself increases the metabolic demands of the body. And that is a very important consideration in the athlete who wants to get back on the field as soon as possible. Now, the second and this is maybe more relevant to people were in casts, but the ambulation can become more um energy intensive because especially if you have a casted leg. So this is what the study looked at. They measured energy expenditure in oxygen consumption in milliliters per minute per kilogram. And with just a normal walk, a normal person walking, they measured on average 10 mL per minute per kilogram. Now, if that person is wearing a short cast, so weight bearing cast, um uncomfortable bit difficult to walk in, but you're allowed to walk in it that already increases the oxygen consumption by about 50%. Now, if that turns into a nonweightbearing cast, so you're using crutches to get around that further increases the energy expenditure and overall ha in a caid and especially um using crutches for ambulation. You can increase energy expenditure up to 2 to 3 fold from just normal walking. That is another huge consideration. You may not be running around, you may not be training intensively but whatever movement you do cost you a lot more energy and effort and I think you can feel it. I mean, it's definitely not easy to be walking around with crutches or a weight bearing cast. Now, the third one is that an energy deficit reduces the rate of muscle protein synthesis. So we discussed this in a bit more detail last week when we were talking about healthy weight loss and how being in a hypo following a hypochloric Diep, being in an energy deficit impairs muscle protein synthesis. The same is true for the recovering athlete. He may, he's not performing exercise but still consuming insufficient calories to support your metabolic needs will reduce the rates of muscle protein synthesis because the body is in a scavenging mode. It's trying to find the calories, the energy from somewhere. So it's more likely to go to the muscle, to use it for energy than to y you like create energy, like use energy to build the muscle. Um And this again is what this study showed where they compared um weight maintenance on the left versus um energy deficit on the right. And as you can see, the mixed muscle protein synthesis was reduced. And the important thing to keep in mind with this is that it's not only affecting your muscle mass, it's not just that the athlete, the immobilized athlete is use is losing volume in their quads which they use for running. This also impairs the muscle protein synthesis in muscles such as collagens, tissue granulation matrix proteins, all of which and many more are empirical for wound healing. So by unders shooting your calorie intake, in terms of injury recovery, you are actually delaying the healing process, you're slowing down the healing process. Um and you're also losing more muscle mass, but really, it's a lose lose scenario. Um But one thing to keep in mind is that although the energy deficit reduces the rate of muscle protein synthesis, a positive energy balance and energy surplus also seems to accelerate muscle loss. But this actually makes sense. So, on the left here, we can see that with five weeks of bed rest, a high energy intake resulted in almost 4 kg of muscle loss on average. Whereas a low, a lower calorie intake only resulted in 2.5 kg um lost on average. Um So this is a significant difference. But if you think about like reasoning, why are we seeing this difference? Well, um this study also showed that the high calorie intake group had a 50% increase in plasma C RP, plasma C RP being a measure of inflammation. And the low um intake group didn't actually saw a decrease in plasma CRP. Um and this is relevant because if we think back to the rat study, a few slides back where they showed that the rats, the low grade inflamed group had impaired muscle protein synthesis. Well, this is an example of that, right, if you have the high cal high calorie intake does tend to lead to a more inflammatory state. And that is what they measured in the study as well. So we can kind of reason our way as to why they're seeing more muscle loss as well during the immobilization period. So both a positive and a negative energy balance, unfortunately can have detrimental effects on recovery from injury, which is why it is so important to carefully assess the energy balance um to optimize recovery from injury. Now, it's doesn't mean that you have to get a spot on to the calorie, but it's about being in the right ballpark and there are some other nutritional interventions as we will see in a second that can help mitigate muscle loss. But already being in the right calorie range is a huge and very important first step, but there are targeted interventions to overcome the anabolic resistance specifically in the immobilized athlete. And this probably does not come as a surprise to you, but that is protein. Um protein plays obviously a huge role in muscle protein synthesis. It's the building blocks but can also be a nutritional signal for muscle protein synthesis. Um and therefore tweaking the protein intake so that it can maximize muscle protein synthesis. Given the anabolic resistance is really important and that's where amino acid supplementation can also have a role as we will see in a second as well. No, this study by Pat Jones et al looked at essential amino acid and carbohydrate supplementation during bed rest. So here they um used healthy men and they had a 14 day period of like immobilization. And what they showed was that the experimental group, which are those who took the essential amino acids and carbohydrate supplements actually saw an increase in lean like mass. So they actually gained a little bit of muscle during the two week immobilization. Whereas the control group who consumed the placebo had a almost 400 g loss in muscle mass. And that is a very big difference. Now, this is in line with their measures of muscle protein synthetic rates which remained more or less at the same level in the experimental group, but decreased in the control group, it was already lower in the control group at baseline. And that's because they were not consuming the essential amino acids. And you can't build protein without amino acids and it subsequently decreased over the 28 day period because the anabolic resistance probably did not help. Now, if you're thinking ok, essential amino acids makes sense. But why carbohydrates? Um One potential explanation for the carbohydrates is that carbohydrates stimulate insulin. Insulin is one of the biggest anabolic signaling molecules in our bodies. And amongst others, it activates the IGF one pathway which is also involved in muscle protein synthesis. So it could perhaps have increased the signaling um when given alongside the essential amino acids to stimulate muscle protein synthesis. And that's also interesting in the bed rest where having a little bit of carbs with essential amino acids can help amplify the anabolic s um signaling. Now, we just talked about the role of amino acids, but it's important when thinking about protein feeding to not just think about the dose or the source. There is the dosage, there is the source, but there's also the pattern. How many times a day are you eating protein? The timing, when are you eating the protein? And as we just saw the nutrient congestion, are you having carbs alongside fats alongside or fiber alongside? All these things also play an important role. And we're gonna just look at a few of these in more detail. So in terms of dosage, this study was done in uninjured young adults and they found that the optimal intake for to maximally stimulate muscle protein synthesis was on average 0.24 g per kilogram, but ranged from 0.18 to 0.3. Now because we are for the interest of this tutorial dealing with injured immobilized athletes who do experience some level of anabolic resistance. It is better to aim for the higher end of that. So 0.3 g per kilograms would be about what an immobilized injured athlete should or immobilized injured person, to be honest, should be aiming for, to try and massively maintain their muscle mass. Now, that is per meal. So for an 80 kg individual that would be around 25 g of protein per meal, which is quite feasible. It's like a chicken breast. Um So that is the dosage. Now, it's really important as well to balance your protein intake throughout the day, to have it spread out to numerous meals a day. And this is what we see here. So, on the right hand side in the green, we see a balanced meal pattern where they have five meals a day. It doesn't have to be five anywhere from 3 to 6. Honestly, it's, it's great, whatever suits you better. Um But the key point here is that with every meal in the green, they are crossing the threshold for maximal muscle protein synthesis on the left and the right, the breakfast and lunch is suboptimal. And then they have a very high protein dinner which shoots them way over the maximum muscle protein synthesis stimulus. But again, whilst it may last them overnight. As we saw again in the muscle hypertrophy tutorial, there is some newer evidence that perhaps more than 30 g of protein can also be assimilated into um your muscles. But there is still going to be a large quantity of protein excretion simply because you are most likely going to eat that with other sources like carbs like fiber like fats, which will mean that some of the amino acids are going to get flushed out. It's not going to get fully digested and you will eventually enter the fasting state because the um 80 g of protein you have a dinner is not going to last you amino acids until the following dinner. Which means that the sub optimal breakfast and lunch leave you in a net negative protein balance for a very long portion of the day, which is obviously suboptimal if you're trying to enter the protein, um positive protein balance to build muscle, which is why all that to say that a balanced meal pattern is ideal, especially when dealing with anabolic resistance, where you need an immobilization where the only way to stimulate muscle protein synthesis is by crossing that threshold nutritionally because you cannot do so. Um you cannot help it with exercise. And the results of um a study who followed a similar um protocol showed exactly that which is in the balanced um protein. So balanced protein meal pattern had higher muscle protein synthesis rates than the unbalanced meal pattern. No, as we saw a few sites ago, essential immuno acids can be important and this was, was shown here again following knee surgery. So we have a surgery model. And on the left hand side, we see that the placebo group in yellow lost significantly more muscle. So percentage change in negative lost significantly greater percentage of muscle mass compared to the essential amino acid group. Um following the surgery. Now, the non-operating group also had some loss of muscle mass and that is because they were still immobilized, they just didn't have the surgery, um which shows that even immobilization without the inflammatory and surgery component to it still leads to muscle loss. Now, one interesting thing is that leucine, which is an essential amino acids seems to have a particularly um strong effect. So here what they did is um 14 days of complete bed rest in untrained mi middle aged adults and they gave them either alanine or leucine. And what they showed is that leucine was able to prevent almost like half of the muscle loss that the alanine group experienced. And it also allowed for a way superior maintenance of muscle strength. Now, if we think about leucine as amino acid, that makes sense because leucine is the king of amino acids. It's firstly, it's an essential immunolysis, which means that we need it from our diet. Whereas alanine is not, but what is so special about leucine is that not only is it a building block for muscle proteins, it's not just something that gets incorporated into muscle protein, it is also a huge anabolic stimulus. It is the greatest nutritional stimulus for muscle protein synthesis. Um which is why it's not surprising that we see these results and which is why perhaps a higher losing content in a diet, especially when immobilized and dealing with anabolic resistance. Um It's um sorry, I just got to start by, by comment. Um It's um yeah, losing just has a great, I don't know, potential. I'm sorry. So uh looking at the comment um with the point about losing in mind how beneficial will drinking milk before bed be for stimulating muscle protein synthesis or preventing muscle loss. Um Good question. Drinking milk is great for numerous reasons before bed. Firstly, whey protein. Well, milk, not whey milk has probably the highest losing content of any protein sources, um which is amazing. And milk also has casein, which is slower digesting. And therefore means that over the fasting period overnight, you will be more slowly simulating the amino acids over the course of the night. Which means that rather than having a huge peak in muscle protein synthesis, and then a rapid dip, you're able to kind of maintain the muscle protein synthetic stimulus over hours because the casein progressively adds the amino acids in essentially. And that's why drinking milk before bed is probably the best thing you can do nutritionally um in with preventing muscle loss or stimulating muscle protein synthesis. And this is also just in terms of um muscle hypertrophy or anything else, having a source of casein and a hall leucine containing amino acid such as milk is your best friend. Um So yes, I hope that answers your question. But more about leucine specifically to prevent muscle loss. This study looked at leucine and essential amino acid supplementation. But this time they looked at elderly and young individuals. Now, the reason why elderly individuals are interesting for our purposes is because age, age induced sarcopenia or muscle atrophy is in part linked to anabolic resistance. Elderly individuals experience physiological muscle anabolic resistance, the same that we see or similar concept as we see in athletes. Obviously, the mechanisms haven't been fully elucidated but similar concept of what we see in immobilized athletes but in athletes obviously it's transient. Um So what this study showed or what the study did is that they gave, sorry about the noise. They gave um 4.5 g of leucine with um no, sorry, they gave um 7 g of essential amino acids and um they then either gave the amino acids, essential amino acids with the leucine content that is normally seen in milk, which is 26% or in whey protein, which is 26% or they enriched it with leucine, which is 41%. And they did this protocol both in the elderly and in the young. And what they showed is that in the elderly individuals having the leucine enriched essential amino acids, um which is what we see in um the white significantly increased. Um the muscle protein synthetic rates compared to baseline in black obviously, but also compared to the 26%. So the non enriched essential amino acids that we see on the very left. Now, this was not observed in the young cohort and the young cohort enriching the essential immunolysis with leucine in this instance, did not have any significant further effect. And so that underlines the fact that in anabolic resistance, leucine becomes a key element to be able to cross the threshold for muscle protein synthesis. Because really what happens in the anabolic resistance that we're observing is that whereas for um a healthy young individual you need maybe, you know, 0.25 g of protein per meal to cross the threshold for people with the muscular anabolic resistance. You need a bit more than that. And so that can come from consuming more protein overall. But because losing is a key molecular signal, nutritional molecular signal for muscle protein synthesis, it makes sense that here enriching it with leucine actually helps cross that threshold that helps activate the protein synthetic machinery more. So, um so leucine plus essential amino assets. And as I said, this has the potential for application in immobilization induced anabolic resistance because we're dealing with a similar phenomenon, just a different cause essentially. But although protein is the king, it's the main character, the side characters and most of the characters in the movie, there is some behind the scenes room also for some other nutrients. And um the first of these being creatine. Now this study looked at the role of creatine supplementation after um 10 weeks of rehabilitation, which followed two weeks of casting. So we're now one step further, we're no longer in the immobilization phase. We're looking at the role of creatine once immobilization is over. And when they've done like as they're doing their rehab exercises to try and get their muscle mass and strength back. And what they showed is that with creatine in yellow and placebo in the blue, in the immobilized um limb on the left or an immobilized study group in the left, we can see that creatine helped to increase muscle mass with the rehab exercises compared to placebo. Now, what studies have not really been able to show is the benefits of creatine in regaining the strength or the power. And this really just speaks to the fact that the evidence um for creatine in this instance, is not huge, there's not, um there's still a bit of controversy about whether it has an effect or not. But if we think back about the mechanisms of creatine, again, looking back at the muscle hypertrophy study, there is some um mechanistic explanation as to why having it in the rehab phase may be helpful at least for muscle size. Um but again, not a lot of evidence. Um So it's not a must have supplement, but creatine does not have many known adverse effects. It tends to be a very safe supplement to take. So it might be worth taking it regardless since it can't really do that much harm. Um But there's the potential for it helping. Now, a supplement that does have evidence and positive evidence is Omega threes. Now, this was a systematic review and meta analysis done using 66 different studies. And what they showed was that Omega three supplementation was favorable for lean body mass and for muscle strength in um injury disease models. Now, the question is, does this translate to athletes because we're looking at 66 studies? But they were not done on athletes. The study populations were firstly, disease populations. This was primarily cancer patients or patients with CO PD and their cause of muscular atrophy is usually insufficient energy intake due to nausea, vomiting and also the inability to perform muscle protein synthesis, stimulating bouts of exercise. And although the muscle, the exercise aspect is true for the immobilized athletes too. What we don't know about these disease populations that were studied is whether they were previously trained cause that can impact the rate of muscle loss. It can impact the rate of muscle regain, it can impact a lot of different things. So that is one aspect where you know, you gotta ask yourself, is it really translatable to athletes? Now, the other study population were healthy individuals after fatiguing exercise bout and with these individuals, we really have no reason to expect and thus try to mitigate muscle loss because these individuals are not immobilized. On the contrary, they just performed a muscle protein synthesis activating bout of exercise and yes, they are fatigued, but this is physiological fatigue, they need to recover from the bout of exercise. So again, it's not exactly the kind of fatigue and recovery and um immobilization. We're looking up with the athletes, but there was a study performed in 2019 or published in 2019 who did look at athletes and this was a um double blind random controlled trial using healthy, recreationally active women. So they were not high level athletes, but they were recreationally active. Um They were using their muscles for exercise um on a regular basis. So they're already a more realistic cohort to be studying. And what they showed was that with 10 weeks of leg immobilization, what they showed is that consuming Omega threes, which we see in the gray from pre to postimmobilization, the Omega three group retained more muscle mass than um the control group and from preimmobilization to postrecovery, um again, looking on the left hand graph, sorry um from pre to post recovery, they were able to regain a greater proportion of their muscle mass than the control group. And this again, looking on the right hand side was in line with the rates of muscle protein synthesis where the omega three groups consistently had higher rates of muscle protein synthesis. Now this there are many different kind of possible mechanisms as to why omega three is having this impact. But the main one that is kind of put forward and that we have evidence for is that the omega threes actually get incorporated into the plasma membrane of the muscles and therefore able to alter the anabolic signaling within the muscle. And this is what this study by the glory et al showed. So they had um individuals take omega threes for four weeks and they showed that after four weeks of supplementation, the omega three content and especially EPA in the muscle cells doubled and this was associated with an increase in the activity of focal adhesion kinase. Now, focal adhesion kinase is a mechanism, um mechanically sensitive um kinase which influences muscle protein synthesis and also has a role also influences the phosphorylation status of Mtor C one and four C. One is uh if you think back again to the muscle hyper tutorial, the master regulator of muscle protein synthesis, it is the one that will receive all the different signals from exercise from nutrition and activate the anabolic cell signaling to build muscle protein synthesis. So, fish fermentation seems to increase the omega three composition of skeletal muscle, which in turn seems to prime the muscles to respond to anabolic stimulation in part through the action of focal adhesion kinase. Now to end on a slightly more somber note, alcohol consumption does not quite have such a positive effect. I thought this was interesting, especially considering the um widespread drinking culture that surrounds many team sports. But there have not been many studies performed on alcohol and muscle protein synthesis for ethical reason. But this study published in 2014, did investigate that and what they did is they looked at physically active young adults and have them perform resistance exercise, endurance exercise and high intensity interval training. After which they consumed 25 g of whey protein or 25 g of whey plus 1.5 g per kilogram of body weight of alcohol. Now, that's a lot of alcohol that's the equivalent of about 12 drinks. Um So they did not hold back. And what they showed, which I hope is not surprising is that co ingesting alcohol with the protein attenuated the muscle protein synthetic rates by about 25%. So if we look at the graph, we have the resting muscle protein synthesis on the left and then consuming the protein increases muscle protein synthesis for understandable reasons. But coition of alcohol with the protein attenuated that now you might think 0 25% that's actually not that bad. Um Which yeah, you're still getting the benefits of consuming the protein. But if we're thinking about the immobilized athlete recovering from injury with the anabolic resistance, the threshold to cross muscle protein synthesis is going to be greater than what we've seen in this study with the physically active healthy young adults. And we're also trying to recover as soon as possible. So maybe this is not the time to be playing around with the alcohol. Um But yeah, so with that, in mind, some recommendations to minimize muscle loss during injury associated immobilization are avoiding deficiencies and this includes energy deficiencies. So make sure you're in the kind of right calorie ballpark, then ample protein with a particular interest in leucine. Um as Jason mentioned, milk is great. Um And time protein intake may be advisable. So specifically looking at balancing your protein intake throughout the day. Um there is very positive evidence supporting the omega three supplementation and there are some potential benefits of creatine, although that evidence is still kind of controversial. Um and of course, do limit alcohol intake as that can impair the muscle protein synthetic response to um protein feeding. Now, I see there's a question in the chat. So I will answer that first. Um in regards to creatine is the reason why it affects muscle mass rather than strength related to the water retention, especially with the supplementation. Um That is very possible. Um The study did not look in detail as to why the muscle mass was gained. Um But I think that is a very reasonable guess as we would otherwise probably expect to be seeing some changes in strength. Um But again, that is that just underlines the point that a lot more research is warranted in terms of the mechanisms of creatine in general, but also in this particular instance. Um But I think that is a very reasonable guess to be making that it's due to the water retention. Um Yeah. So if you guys have any other questions?