[00:00:00] Frankye Myers: From Riverside Health System, this is the Healthy You Podcast where we talk about a range of health related topics focused on improving your physical and mental health. We chat with our providers, team members, patients, and caregivers to learn more about how to maintain a healthy lifestyle and improve overall physical and mental health.
So let's dive into learn more about becoming a healthier you..
So I'm Frankye Myers, assistant Chief Nursing Officer, uh, for Riverside Health System, and I am really excited today to have in our studio Dr. Diane Maddela. She is an O B G Y N with Riverside Partners in Women's Health. And today our episode is gonna be talking about perimenopause and menopause, how your body changes and what you can do.
So I'm really excited to have you, Dr. Maddela.
[00:00:55] Diane Maddela, D.O.: Good afternoon. I'm excited to be here.
[00:00:57] Frankye Myers: Great. Briefly tell me a little bit about why you decided to pursue a career in OB G Y N.
[00:01:04] Diane Maddela, D.O.: So really it was the variety that the specialty had to offer. Um, you know, ob, g y n, you, you see women at all different stages of their life between adolescents to fertility bearing.
Um, obviously pregnancy, perimenopause, menopause. We dabble in preventative medicine with women's well exams. We do procedures in the office and in the operating room. And I mean, if, if the miracle of childbirth doesn't really end, I don't know what else would. So, I mean, with all those facets of the specialty, I mean, it was a, it was kind of a no-brainer for me.
[00:01:41] Frankye Myers: Oh, great. Great. I know that I, my OB, G y n retired. Um, a few years back I had such a great relationship with my OB, G Y N and she kept me on track with not only things around my OB G Y n, um, needs, but also just from a. Uh, a disease prevention perspective, making sure you have your mammograms, making sure you have your colonoscopy, uh, a baseline, um, e K G.
So she really kept me on track with so many things and we had such a great relationship and I trusted her so much. So I just value that so much. So thank you for what you do in that space.
[00:02:25] Diane Maddela, D.O.: It's very important that I think women have a good relationship with a gynecologist or an OB G Y N because there's so much to navigate in every stage and every decade of a, of a female's life and things that a lot of women, I think, take for granted and think, oh, I'm supposed to feel like this because I'm in my forties, or I'm supposed to live like this 'cause I'm in my fifties.
I mean, I think. That's kind of where the downfall of medicine has come, where we haven't encouraged women to seek help for these symptoms. 'cause yes, it may be normal, but there are ways to help you feel better as you go through these, these stages of life.
[00:03:02] Frankye Myers: Absolutely. I wanna talk a little bit about menopause.
Something that I know a lot about this from my own personal experience. So menopause is a normal part of age, right? In that natural transition, uh, for females. Um, talk a little bit about menopause and, and some of the things that may occur in the body, um, and some of the mood changes that I know I have experienced and what, what women should expect.
[00:03:31] Diane Maddela, D.O.: Yeah. So I, I think what happens a lot of times is perimenopause and menopause kind of get mixed up. Um, so let's go through the definitions just so we're on the same page. Um, so perimenopause is the transition or the prodrome before menopause. This is when women's hormone levels start to fluctuate in relationship to decreasing fertility and decreasing ovulation.
So it's that fluctuation that occurs. Um, typically, believe it or not, starting after the age of 35, I think a lot of women think of perimenopause or menopause later in life, but, um, you, we start to see these hormone fluxes as early as 35. Um, so when these hormone levels start to change, this is typically when women are the most symptomatic, you know, so I, I have women come in and they say, you know, I just don't feel the way I used to, or, I have no libido, or my periods are, are heavier than they've ever been.
You know, they start to notice these symptoms as early as 35 all through into their, um, early and mid forties. Okay? So the definition of menopause. Is the absence of these hormones in which you have ovulated your last egg. And because of that, the estrogen, progesterone, testosterone secretion that occur by the ovaries, um, no longer occurs.
Now there is some small amounts of hormone that are still secreted by the ovaries, even after menopause, but it's less bioactive and um, minimal amount of hormone. So after that woman, woman ovulates her last egg, this is when your periods stop. And that the definition of menopause is going an entire year clinically without a menstrual cycle.
Once she does that, she's officially in menopause and believe it or not, symptoms can get better at that stage, although they can also still persist as if they were still in perimenopause. But the key factor here is that they're no longer having menstrual cycles.
[00:05:32] Frankye Myers: Okay. Okay. That's great information. I know for me, um, Do you, it, it was really challenging and I don't know that I knew I was actually going through perimenopause or menopause.
Um, do, do you typically follow like whatever your family history is, like your mother. Is there some similarities in when they will occur? As far as age or, I've heard people say that sometimes based on when you start your cycles may be a sign when you may enter, uh, perimenopause or menopause. Yes. As there ab yeah,
[00:06:13] Diane Maddela, D.O.: there's absolutely a link.
Um, hereditary wise, a lot of women will follow their mother's trends as far as the age of menopause. Um, but there's also a lot of environmental factors that dictate when a woman will go through menopause. Um, smokers tend to go through menopause a little earlier. Um, so you know, it definitely environment can play a role in when a woman will go through menopause, but there is definitely a connection there.
A lot of women will follow their mother's trend.
[00:06:42] Frankye Myers: Okay. Okay. And I know for me, you know, as I. Was enduring this. I talked to my mother and I, you know, kind of processed doing needle hormone therapy and she was adamant because there's this mindset that that's associated with cancer. So would you talk a little bit about hormone replacement and um, Some of the risk factors related to that, and I know that women are struggling with symptoms but are afraid to, to use hormone replacement.
I know I struggled with that myself. Sure.
[00:07:21] Diane Maddela, D.O.: So, hormone replacement therapy is currently indicated for severe hot flashes and night sweats. Um, Back in the eighties, I mean, every woman was on a hormone replacement therapy. 'cause back then the idea was that it was cardioprotective, right? So every postmenopausal woman was, b was placed on hormone replacement therapy because of this.
Um, and, and, and to also alleviate their vasomotor symptoms, I think. The big trial that everyone knows about. Um, the W H I trial that came out in, in, um, I believe it was 2002, um, was the big clinical trial that proved that this was incorrect. That, um, putting women on hormone replacement therapy for primary and secondary prevention of, uh, coronary heart disease, um, is not effective.
And if anything, it showed increased rates of heart attack, stroke, blood clots, breast cancer, dementia. When that study came out, of course it made national news and all these women were taken off their hormone replacement therapy, um, because of this. Okay. The problem with that clinical trial was the population that, that was utilized for this clinical trial.
Um, these women, over thousands of women in this trial were between ages of 50 and 79. Um, and about 73% of these women had never even been on hormone replacement therapy. Had potentially even been outta menopause for over 10 years at this point. Okay? 67% of these women were greater than 60 years old. The average age of menopause is about 51, 52.
Um, the, they tested women. Deemed safe from a cardiac perspective for the clinical trial as long as they had a normal E K G. Um, and we all know that that's not the greatest screen for preexisting, um, coronary artery disease or, um, cardiovascular disease. Some of these women were also already taking, taking statins for high cholesterol, taking anti-hypertensives for high blood pressure.
So it, it was a, a bit of a skewed population. I mean, they were giving hormone replacement therapy, estrogen and progesterone to women who have been in menopause for potentially decades. Who also potentially already had preexisting cardiovascular disease. So now looking back, I mean many, many years later, they've taken the same data that they've accumulated from W H I and they've also looked at demographics and have looked at the data for women between ages 15 and 59 that received the hormone replacement therapy.
And these were women typically that transitioned into, into menopause within 10 years. They had no significant, significant cardiovascular risks. Um, so I mean, that's a big difference. Absolutely. And more newer clinical trials have, have showed the same thing that women have started on hormone replacement therapy within the, within 10 years of menopause, or even in the perimenopausal period, could potentially have, um, cardio cardiovascular, uh, benefits, um, cardio protection.
Um, it definitely shows decreased risk for dementia if started within that timeframe. Of course, it still has the benefit of, um, relief of vasomotor symptoms and it still has the benefit of prevention of osteoporosis. Um, the breast cancer risk, depending on the trial, has been, you know, plus or minus, um, synthetic versus, um, bioidentical hormones have been.
You know, uh, clinical trials have been going on with comparing both of those. They're showing less risk, less risk with bioidentical um, hormones than with synthetic. So, but this is still data that, you know, needs to be, uh, continually studied before we start making those recommendations.
[00:11:00] Frankye Myers: That is really great information.
Thank you. Thank you. I know one of the symptoms that I know I struggle with and continue to struggle with is the weight. Specifically belly. Yes. Belly adipose tissue. I'm gonna use the, the medical terminology for that. Um, well, the hormone replacement helped with some of that. I know there are things that we have to do as far as exercise and get a good regimen and Yeah.
And a healthy diet and lifestyle. But there was a time when I literally could eat whatever I wanted. Yeah, fairly active. But those days have, have, have,
[00:11:42] Diane Maddela, D.O.: so that, that's, I think every woman feels what you're feeling right now, especially women that are in their, their menopause and perimenopausal states. So there's, you know, metabolism is a, a big player in, um, menopause.
Um, and one of the biggest complaints women have as they make this transition. So, you know, the three key hormones that we deal with as far as ovarian hormones, which also. These hormones also come from the adrenal gland, but estrogen, progesterone, testosterone. All three of these hormones are secreted by the ovaries.
They're also made by the adrenal glands. These are the primary hormones that drop in perimenopause. Okay? Okay. With dropping. Believe it or not, women need testosterone. Um, you know, there, there's a reason why men can lose weight really fast, okay? They have raging testosterone for most of their life. Women have peak testosterone levels typically in their adolescents and in their twenties, and that's why at that time you can eat whatever you want and not even gain a single pound.
Okay? Testosterone levels will start to steadily decline in your late twenties and early thirties. Exponentially decline in perimenopause and menopause. Um, that loss of testosterone is real. I mean, that really puts a hit on your metabolism, your ability, ability to maintain lean muscle mass. Um, it's also another reason why women have decreased libido.
I mean, you lose your testosterone, you lose your libido. Um, and it, and it contributes. All of that contributes to weight gain. You know, your inability to maintain muscle mass unless you're doing something proactive about it. Um, Estrogen also in the declining estrogen levels also play a role in the meta, in the decreased metabolism too.
So when all these hormones, I mean these are just three of many hormones in the body, but they all are inter interdependent on each other. Um, they will affect your overall metabolism, including growth hormone insulin. So as we go through menopause, we become. Less insulin sensitive and more insulin resistant.
Okay? We're not able to mobilize and utilize glucose as efficiently. So if you're not changing your diet and you're eating the same amount of carbohydrates you did in your thirties, all that sugar that used to be, um, mobilized and utilized for energy tends to get stored. And that's where this abdominal fat comes in.
You know, women are trying to eat the way they did in their thirties. But the problem is the metabolism is not letting them do that, and instead of utilizing those blood sugars, they're getting stored straight to fat. So Dr.
[00:14:07] Frankye Myers: Cordell, are you telling me I can't blame it all on age? It, i, it it is related to stuff that I'm putting in my mouth.
Well, it, it,
[00:14:15] Diane Maddela, D.O.: it's related to age a hundred percent. Um, but what happens is what you used to do in your twenties and thirties is no longer going to work for you in your forties and fifties. Okay? And that's the burden of, of women is that we have to evolve with our changing hormones. And if you don't evolve and change with that, you're going to see.
Repercussions and usually they're not good ones. Um, such as weight gain, increased risk for diabetes, increased risk for coronary, um, artery disease, cardiovascular disease, dementia. I mean, these are all things that are linked to menopause in the aging process for women. Um, so if you're not making those lifestyle changes, those dietary changes, um, you are gonna have the burden of those, um, comorbidities.
[00:15:01] Frankye Myers: Okay. Good, good information. Another problem area as I hear women talk about is hair growth. Mm-hmm. Um, specifically chin and lip. Um, is that all related to the shift in the hormones as well?
[00:15:20] Diane Maddela, D.O.: It can be some, a lot of it is also genetics. Um, you know, so if you have a, um, a mother or you know, sister that you know have either.
Thinning hair age-related, you know, thinning of the hair or age-related hair growth. Some of that can be genetics. Um, thinning hair. Absolutely. I mean, our estrogen is what gives us the, you know, beautiful, healthy hair. So when you lose that estrogen, you will notice that you, you know, you, you lose the luster in the locks.
Okay. Um, so some of it is hormone, but some of it is also genetics. Of course, there's also also pathologic causes that need to be ruled out. But I mean, it is, you know, Potentially can be part of the menopausal, uh, transition too.
[00:16:04] Frankye Myers: Okay. Are there some, you know, and I know you can't really prescribe on this podcast, but as we age, are there some specific vitamins that we should be mindful of mm-hmm.
Um, that we may become deficient of? Um, one that I hear about all the time is your vitamin D. Yes. Can you,
[00:16:25] Diane Maddela, D.O.: so vitamin D is so important I. The reality is, is um, most of us are vitamin D deficient. I mean, you just can't get enough of it, enough of it in the diet. Um, there's just not enough supplementation going on in the diet for it.
We're not out in the sun or we shouldn't be out in the sun all day long. 'cause our, our body can make vitamin D. It is one of those vitamins that can be synthesized internally in the body. Um, the problem is, is we're not out in the sun enough and we shouldn't be. Um, Vitamin D is a vitamin, but it actually functions as a precursor for a lot of hormones.
So when you're vitamin D deficient, it can also affect hormone production. So it's so important that women have, um, normal or optimal vitamin D levels. And optimal really for a woman is gonna be greater than 50 to 60. You know, normal is greater than 30. Ideally women should have it higher. Um, 50 to 60 should be the goal of, uh, above that range.
Um, and then of course for bone health, I mean, we all know that vitamin D, um, dietary calcium, I, I tend to promote over supplemental calcium, but you know, calcium and vitamin D is so important for bone health as women make that transition into menopause because that's when bone deterioration will occur due to declining estrogen levels.
Okay. Um, I think fish oil is fantastic. More and more data is supporting fish oil for postmenopausal women. You know, the brain fog is real. Okay? You walk in the room and you can't remember why you're, you were there or why you even stepped into that room. I mean, that is a true symptom of perimenopause and menopause, and once again, it's related to declining estrogen and progesterone levels because we have receptors in the brain.
So when those levels decline, cognitively we decline. Uh, this also is what puts us at increased risk for, for dementia. You know, Alzheimer's tends to be more common in females. Um, so, um, menopause is considered a state of low grade chronic inflammation. So fish oil is anti-inflammatory. Okay? So fish oil, um, you know, one to two grams of D H A E P A, preferably organic, um, you know, um, Seafood fish, um, is ideal I think for every post-menopausal woman.
[00:18:37] Frankye Myers: That's some really good information. Thank you. Um, I have my vitamins in my purse. Hmm. I haven't taken, but you have inspired me just by really understanding the impact that they have on some of the symptoms that I'm having. I'm gonna do better about taking my vitamins. We should all be on some kind of micronutrition.
[00:18:59] Diane Maddela, D.O.: Extremely important in menopause. We need all the help we can get, right? So, um, those supplements are very important because diet, I mean, unless we all eat a perfect diet, which, you know, none, none of us do. Um, the supple, the micronutrition and the supplementation is very important. Vitamin C is another excellent anti-inflammatory.
Um, great for immune system. 'cause once again, in menopause we see, um, decreased immune response. Lower T cells, lower B cells, so boost up your vitamin C to help that immune system stay strong. Okay.
[00:19:30] Frankye Myers: Okay. Very, very good. Um, are there any other therapies, um, available to manage, um, menopause or perimenopause that we haven't discussed?
DR. Maddela,
[00:19:42] Diane Maddela, D.O.: so I mean, I'm a huge advocate for hormone replacement therapy for severe hot flashes, night sweats, and you get the extra benefits of obviously protection against osteoporosis. But the reality is lifestyle matters and when you're going through perimenopause, if you can figure out how to navigate through your diet, your exercise, your sleep, It all will come together easier when you transition into menopause.
So what you eat matters when you eat matters, you know? Um, There's a lot of data right now out on time, restricted eating and intermittent fasting. Um, and that's basically when you either have 12, 14, or 16 hour windows of fasting and then you have a, a smaller window for eating. Okay. Um, you know, on a cellular level, this induces.
What we call autophagy, where your body actually heals and cleans out, um, cancer cells and cells that your body no longer needs, um, increases insulin resistance, which most perimenopausal and menopausal women start to have problems with. So, you know, when you eat, what you eat matters, you know, whole foods.
Um, with high nutrient density, I mean, staying away from processed foods. Women in perimenopause and menopause have to be careful with their carbohydrates because once again, you know, we're impaired with glucose, meab metabolism, um, and exercise. I mean, I, you know, it's, it's hard to incorporate. We all know we have to do it, but you should do it.
As we go through perimenopause and menopause, we lose our muscle mass. Muscle mass is what gives you metabolism. You have to maintain that muscle mass in order to stay vital, in order to keep your metabolism either where you want it at or higher. I mean, it's so important. I mean, your muscles. Play a huge role in how you age and whether or not you're gonna age gracefully through menopause or not.
So I think women tend to focus more on the cardio, which cardio is great, but they, perimenopause and menopausal women really need to focus on their, their, uh, strength training and, and maintaining and rebuilding their muscle.
[00:21:57] Frankye Myers: Alright, that's, that's, that's good. Any quick tips to help with the carbohydrate piece that I know that is a challenge for me?
You hit some key things that I know are, are an issue timing of eating. You know, it's almost like for me at, after about seven 30, at eight o'clock at night, you really wanna start snacking. Um, doesn't really give you much time before you go to bed. And are there some quick tips to help with kind of managing and just.
Begin looking at the amount of carbs you're taking. And we always talk about calories, right? But you know, I know for me, I had to educate myself on reading labels, and so I don't think, oh, yeah, absolutely. Talk much about the carbohydrate intake. Yeah.
[00:22:47] Diane Maddela, D.O.: So carbs aren't the enemy. I mean, I don't want everyone to stop, you know?
You know, not everyone should, and this is the thing every woman is so, Unique in bio individuals. So what works for you may not work for me and what works for someone else may not work for, you know, her girlfriend. So it's really figuring out what your body responds to and what your body doesn't do well with, or, you know, um, gains weight with and stuff like that.
But, The thing with carbohydrates, we all love carbohydrates because they, the simple sugar stimulate our dopamine receptors. There was a study that, um, where these scientists put cocaine in one center and sugar in the other center, and every time the rat went to it, they would get shocked. These rats went to the sugar over and over and over, over the cocaine.
[00:23:39] Frankye Myers: That tells you how powerful sugar is then. Right?
[00:23:41] Diane Maddela, D.O.: It's so powerful. It, it is. It's a drug. It's almost worse than any other drug out there because of the dependency, the comorbidities that are associated with it. Um, so it's retraining the brain, right? So things that are gonna keep you full are fiber. So think mainly, you know, fresh vegetables, um, complex carbohydrates, whole grains and protein.
It takes longer for your body to digest protein and fiber than it does sugar. Um, so you know, kind of. Making your meals a little bulkier in those macronutrients, the protein and the fiber less in carbohydrates, but your body still needs carbohydrates, but think more complex carbohydrates that way it takes longer for the body to break down and digest and you're feeling less hungry.
I. People, I think, eat too much fruit because they think it's healthy. The problem is fruit is a simple sugar, simple carbohydrate with fiber. So even though you get the fiber, you're still getting that simple sugar. So you just gotta be careful with fruit. I mean, you can have, you know, an occasional fruit, but don't load up on it because it's not as healthy as you think it is.
Right. Um, so really kind of changing your macro nutrient, um, you know, leaning more towards protein and fiber. That way you're not hungry because if you consume too much sugar and less protein, less fiber, you're gonna be hungry, you know, in, in the next couple hours. And that's
[00:25:04] Frankye Myers: that overeating, correct? That comes in.
Uh, that, that's, that's a good way to think about it. Okay. And, and women are creatures of
[00:25:12] Diane Maddela, D.O.: comfort. You know, they, they, um, they like to emotionally eat. So, you know, whether that be outta boredom, whether that be outta depression, um, you have to figure out why you're eating what you're eating, and. Try to turn that around, you know?
So instead of eating because you're bored, go out and take a walk. You know? I mean, these are little things that I think people turn into habits and they don't realize it. Okay. Um, and they just need to make the healthier choice. And it's not always easy, but it's something that you need to be aware of so that you know you can make the necessary changes once you figure out that that's what you're doing.
[00:25:50] Frankye Myers: That's great information from a timing perspective, you know, some people say, Hey, it's better to have that carb up in the day because then you're more active than at, than at night. Any tips around that, or, I think it's
[00:26:02] Diane Maddela, D.O.: based on your activity. I mean, so if you're doing, if you're exercising or doing high interval training in the morning, you absolutely need to give yourself some carbohydrate.
I mean, you, you know, you're, you're. You're depriving yourself if you're not, because your body needs those extra calories because you burn those extra calories. The problem is a lot of people overdo it. I worked out, so I'm gonna go, you know, give myself a milkshake, you know,
[00:26:28] Frankye Myers: to treat myself. You're kinda
[00:26:30] Diane Maddela, D.O.: negating your exercise.
The benefits of the exercise routine, you just finished so you know, I can speak for myself because I'm, I'm, I know my body and I know what my body needs. Every woman's different. And that's the thing, I think women want an a quick fix, you know? But the, the, the reality is, is that, you know, we aren't square boxes.
[00:26:53] Frankye Myers: We're, you know, hexagons and, you know, pentagons and everybody's roadmap is different, right? Everybody, exactly.
[00:27:00] Diane Maddela, D.O.: Every individual, every woman is a bio individual, has different needs. Um, different physical, physiologic, emotional, spiritual. The goal for every woman is to figure out your own body. And once you kind of tune inward and figure out what works for your body, you can start to navigate through what you need and what you don't need, um, to make you feel your optimal health.
[00:27:24] Frankye Myers: Okay. Dr. Maddela, you have shared some great information. I'm so passionate about women's health and health promotion and disease prevention, and I can just. Glean that and feel that from you. So thank you so much for what you do. I definitely wanna have you back on the podcast again. I think there's more that we can continue to talk about and keep things top of mind as it relates to women health and um, menopause and perimenopause, and then other things that are specifically related to women's health.
[00:27:59] Diane Maddela, D.O.: Oh, thank you so much. I, I think this is a, you know, a very important topic that, um, a lot of women don't wanna talk about or are scared to talk about, but we need to talk about it because, you know, when women. Are afraid or, or they don't wanna do anything to change. This is when, you know, unfortunately, you know, your health goes the the wrong direction.
So, absolutely.
[00:28:21] Frankye Myers: Absolutely. And next time, maybe we can talk on another subject that is dear to me. I, I had a very, um, trying time getting pregnant. I had a, a history of fibroids and incompetent cervix and so it was a tumultuous journey. But I do have two, um, adult children, so, I just wanna continue to educate women to, to take care of those things early.
Yeah. Um, I waited late and so that, that can cause a lot of problems. Yeah.
[00:28:50] Diane Maddela, D.O.: Women tend to put themselves last, you know, for everything because you're too busy taking care of everybody else. Absolutely. Um, but the reality is, is you can't pour from the, you can't pour from the pot if the pot is empty.
Absolutely. Then you should always consider yourself the first priority and, and that way you have more to give to everybody else around you.
[00:29:09] Frankye Myers: Unfortunately sometime that that takes getting some seasoning.
[00:29:15] Diane Maddela, D.O.: You know,
[00:29:16] Frankye Myers: we get up in eight sometimes before we realize that. So yeah, I'm really glad that we're talking about that. Yeah. If someone wants to connect with you or maybe schedule an appointment, can you give them information on how they can contact you and the practice? Yeah,
[00:29:30] Diane Maddela, D.O.: absolutely. You know, so actually I am.
I am an OB G Y N, but I will be stopping obstetrics at the end of the month. Oh, good. I'm still doing outpatient G y n though. Um, and I'm really trying to, uh, to make a focus of my practice in perimenopause and menopausal health. Um, Hormone health, metabolism, metabolic health in the perimenopausal, menopausal women.
So I am open arms to these women. I want you guys to come in. I wanna sit down and talk. Um, I'm with Partners in Women's Health on the Oyster Point location at the Oyster Point location. Okay. Um, So, um, you know, I, I am accepting new patients. Eventually I will have a clinic day specifically for perimenopause and menopausal women.
Okay. Um, so yeah, I mean, I, uh, that's great.
[00:30:18] Frankye Myers: Will you please send me the information because I am going to schedule an appointment. You know, I'm the one in the meeting that always keeps a piece of paper close by. And I blamed it on the vent. So I think it's time I get formally evaluated for these hot flashes.
[00:30:36] Diane Maddela, D.O.: Absolutely. I'd be more than happy to help you.
[00:30:39] Frankye Myers: Alright, thank you so much. Have a wonderful All right, thank you, Frankye. Thank you. Thank you for listening to this episode of Healthy Youth. We're so glad you were able to join us today and learn more about this topic. If you would like to explore more, go to riversideonline.com.
