Episode #368: The Rundown (4)

24:16Dr. Austin Baraki:So it takes a little bit of like loading time to get up to the right levels in the system. That's not as big of a concern, but it's just something that we recognize. The other though, is that depending on the dose that you start with, if you end up starting too high and the person experiences side effects on too high of a dose that they get up front, you cannot easily adjust the dose as quickly, right? And so the extreme version of this is like where I tend to work, be it in a hospital or an ICU type setting where I have a medicine that if I stop it, it's out of your system in like two minutes.

24:48Dr. Austin Baraki:And so I can tweak the dose very fine tuned to get exactly what I want. Whereas if it's a medicine that's going to last in your system for three months, and I load you up with way too much up front, it's like, well, this is going to suck for a little while and before we're able to adjust things. This is also, for example, why in throwing back to some toxicology, when patients develop vitamin D toxicity, if they take way too much vitamin D and it accumulates in their body fat and they have super high vitamin D levels that lead to the consequences of high calcium and all sorts of other things, it can take months for that to get better because it's all accumulated and it's long lasting and it's stored up in their body fat and it's slowly being released that way.

25:28Dr. Austin Baraki:And so my, you know, questions, concern, if, you know, if I were initiating a patient on a medicine like this, because we know that up front at the time of dose initiation of GLP-1 agonists and with dose adjustments going up in dose, for example, at that time, patients might have a little bit more of the gastrointestinal side effects, particularly among patients who are a little bit more sensitive to them and before they fully adapted to these meds. So they might have a little bit of GI stomach, you know, discomfort or some nausea or some constipation as somewhat common effects, depending on the dose, the person, the frequency of dose escalation and things like that.

26:04Dr. Austin Baraki:And so I would want to be extra careful with a medicine like this, not to start out too high too soon or escalate too rapidly. Because again, I suspect that the effects might linger longer compared with if I were giving you a medicine that's once a week, where patients still might have issues for a few days, or if I wanted to go way back to, you know, liraglutide, which is once daily, I could adjust the dose once a day. But at At the same time, the tradeoff is that those medicines are way less effective. So I think that the dose finding, dose ranging, adjusting, tweaking, titration with patients is going to require a little bit more careful strategy in these medicines that are longer and longer acting.

26:39Dr. Austin Baraki:On the other hand, we have experience with other meds in this space. There have been long-acting formulations of insulin even, which is a much higher risk drug to be using with patients in terms of risk of low blood sugars that can be dangerous. And yeah, a couple of years ago, they came out with a once weekly long acting insulin, which scared me as somebody who act who uses mainly short acting stuff in a hospital setting. But when it's been researched, it's actually like pretty effective and not that much higher risk of low blood sugars in patients. I suspect, of course, you have to know what you're doing when you're dosing this stuff.

27:11Dr. Austin Baraki:But yeah, so more research, more practical experience will lead to proper dose finding and titration strategies. So those are some of the pros and some of the cons with medicines like this that are much longer acting.

27:22Dr. Jordan Feigenbaum:All right, two questions, and we'll move on to the next one. So you mentioned, yes, if you overdose, you know, the dose is too high, then you're kind of like up a creek because it lasts so long. But what if that is actually a feature and not a bug, not to overdose people, but say, for example, people routinely around the time of injection for whatever reason have with like semaglutide or terzapatide, they have nausea for a day or two, right? But then the rest of the week, they're fine. But I imagine if that happens enough times, they might start skipping doses because they're like, I really don't want to do this.

27:54Dr. Jordan Feigenbaum:And so there's less coverage, right? And so now, okay, look, you're still going to get maybe a couple of days of nausea, but then the rest of the month, you're killing it. It's great. So maybe that's a feature. You think that's plausible?

28:06Dr. Austin Baraki:Plausible. I think the factor that would differentiate it as well, because it's a longer-acting medicine, do those side effects last longer up front? And that would be the, we'll just have to see based on experience once we start using this stuff. Assuming this makes it, I mean, this was, I believe, a phase two, and so it still has a little bit more to go before we might be able to use something like this. But if it gets there, we'll see. Yeah. All right. Second question.

28:25Dr. Jordan Feigenbaum:What side of the GIP coin are you on? You want to stimulate or you want to block it or maybe both? Can you – look, at some point there's going to be a medication. It's going to have multiple GLP-1s attached to something that blocks GIP and the other one that some of the time stimulates it because we've refined this physiology enough. But yeah, curious, do you have a, you're going to put your money on one side or the other on this GIP situation?

28:48Dr. Austin Baraki:No, I'm not. Because I don't know. I'm a clinician and not a basic scientist. There are a few other medicines out there that have this interesting kind of partial agonist or like mixed agonist antagonist type activity. But that's getting a little bit further down into the weeds of pharmacology and things like that that are both outside the scope of this podcast and outside the scope of my my expertise so i don't really know what we want to do with gip but i trust that the people who are most incentivized to figure that out are going to yeah i just think we need to tickle it that's

29:24Dr. Jordan Feigenbaum:sure that we just tickle gip do something to it and it's like great we got a benefit for you yeah

29:29Dr. Austin Baraki:sure nice all right next lebron james does a silly exercise do you see this video uh i've seen i think it was him doing some kind of deadlift if i recall the video that you're talking about yeah so this

29:42Dr. Jordan Feigenbaum:is none other than four-time nba champion lebron james and in this video i'll put it in the show notes if you haven't seen it he's in a gym performing what can only be described as a snatch grip sumo stance romanian deadlift with about 165 pounds uh you should know that the weight is light enough for him to actually swing the bar away from himself at the top of each rep by a few feet Yeah, no, a few feet, not inches, like feet. OK. And speaking of feet, he's wearing vibram or vibram five fingers, which are only good for like chastity purposes. So interesting that he's wearing those. And more interesting than that is a Lyco felt compelled to repost this because he's using an a Lyco barbell and weights.

30:24Dr. Jordan Feigenbaum:So the controversy that kind of erupted from this is not just about his form, though. it's the fact that his you know lebron james who has access to the best trainers presumably nutritionist physical therapist whatever on the he has access to all this stuff why would he do this specific lift like who taught him this there's no way you go into the gym and you're like i'm gonna adopt this wide stance and an even wider grip and then do a partial deadlift with the weight that's light enough that you can like hip thrust it away from you while standing uh but on the other hand, you know, he's been in the league for like 20 years.

31:00Dr. Jordan Feigenbaum:So maybe we should all just shut up and not, you know, just move on by this video. So I don't know. What do you think about this? How did LeBron get here to this particular exercise? Do you think that he just came up with it, you know, and because he saw somebody else doing it or somebody told them to do it? How do you think this happened?

31:17Dr. Austin Baraki:I would be surprised if he is making his own lifting decisions with the resources that he has access to in terms of his coaching and strength and conditioning and, you know, physical therapy and all the other things that he presumably has as part of his general routine for strength and for conditioning and for kind of rehab and maintenance and performance and sports psychology. Like I bet that he, you know, has access to resources in all those realms. So I don't think that he necessarily arrived at this at all. I, it would be interesting to hear what the coach who prescribed this was, was thinking, but at the same time, you know, I, I know all the we've seen all the usual arguments around this kind of thing over the years.

31:57There's on one hand going to be folks who are like, this is the dumbest thing I've ever seen.

32:01Dr. Austin Baraki:This is more so coming from, you know, lifters, I suppose, oftentimes like us. Yeah, powerless. This isn't the way to do deadlifts. Right. You should. Here's a more effective way to do this exercise. He or the pushing that to I think the more egregious level would be like he would be so much better if he did it my way. Right. Which we see that kind of thing. on on the other hand there's people who might argue well you know over the course of a couple decades doing this uh kind of thing maybe they have gravitated and figured out something that quote-unquote works for him and then i think there's an in-between position where it's like this is probably neither helping him that much nor is it likely harming him that much and he is such a freak athlete in so many other ways that he is able to perform well and this is like fine this is like not substantially moving the needle in in other words if he were to change and maybe you know instead of doing this weird squatty snatch grip rdl type thing but he actually did an rdl or he actually did a squat or a deadlift would it would we see a difference in his performance on the court would he score more points right to to use like you know when we talk about mechanisms versus outcomes and things like that it's not about like is this putting the right amount of muscular hypertrophy or strength stimulus on his hamstrings or his quads or his adductors or something like that but rather like is there some relationship between this and his points or his rebounds or his wins or some statistic that actually matters for the sport and for somebody who is as freaky as him I suspect that there are probably a whole lot of things that you could do in the gym that uh that would maybe not move the needle as much as maybe lifters like us would like to think because we want us we want it to be like a lifting is so critically important but man freaks are freaks are going to freak at a higher level i remember seeing this back in you know my my swimming days um there were some swimmer lifting was not a big part of swimming kind of training and then gradually over time we saw it grow and we started to see uh lifters uh swimmers like ryan lochte for example started to get a little more popular there were videos of him doing you know pulling chains around and doing tire flips and things like that in the gym and then you know hang cleans which was like radical for the sport super super different mike boyle just took his shirt off.

34:10Dr. Austin Baraki:Yeah. But these guys were already at the top of the sport seemingly. Um, of course, some of the strength I do think helped them in, in certain ways, but there's a lot of ways to develop strength, including using lifts that are not traditional. And so I just don't really, uh, I don't know the value in, in hyper analyzing the precise things that the absolute, like people in the stratosphere of sport are, are doing as a, as a way to draw any sort of conclusions about what anyone else should do. I think that once you have defined your individual training goals, then we can talk about the pros and cons of different ways to get there.

34:47Dr. Austin Baraki:But I just almost see like no external validity from what LeBron James does to what you or I or anyone else listening to this might be inclined to do as part of their own training.

34:58Dr. Jordan Feigenbaum:Yeah, yeah, I'm inclined to agree with you. I mean, I think if you're a sports scientist, if you're a coach, right, you have to have some sort of method and central like paradigm to organize your thoughts It's about how you go about choosing an exercise. And so, you know, you can – there are basically two poles here. One is like specificity and the other one is like a generalized exercise. And so depending on how you approach, okay, where are we at in the season? What are we looking to develop? What are the goals of this program? You would pick, you know, something on that continuum. This is kind of like none of those things, you know.

35:31Dr. Jordan Feigenbaum:I mean it would – if you had to, you know, place it on that continuum, it's definitely towards that generalized type approach. And I guess if I had to, you know, confabulate to throw back to that term, a reason for why this quote unquote works for him, it's kind of like maintenance, muscular force production. He's like applying some force against an external resistance that is whatever, preventing him from otherwise detraining with no exposure. Right. Compared comparatively, although it is very light for him. So, like, I don't know, man, the weighted stretching. We could call this. Sure. Right.

36:06Dr. Jordan Feigenbaum:Yeah, exactly. But to your point, somebody definitely told him to do this, which is maybe more concerning because it's like that person either has no familiarity with a deadlift or any really hinge pattern or like – or the Olympic lifts or apparently footwear. So I'm like, how did this person get into this position, right? Because, yeah, very, very interesting. Yeah, as always, success leaves clues some of the times. but often freaks do well in spite of the stuff that they do. So like, I don't, to your point, I don't, I don't think that anybody who's aspiring to be in the NBA should be like, that's the deadlift variation that I need.

36:45Dr. Jordan Feigenbaum:If I had to pick a deadlift variation, it would, yeah, an RDL would be fine. A rack pull would be fine. A trap bar deadlift would be fine, you know, and some of that stuff should be done at high velocity. Alternatively, and maybe this is a hot take. If you are not a barbell sport athlete, you don't have to deadlift. Like if I saw LeBron James doing like hip thrusts and like, yeah, and the caption in my perfect world is like, this is the hinge pattern that I do a few times a week. I'd be like, great, great. You're loading the body or, you know, whatever. But he doesn't need a deadlift. So, yeah.

37:16Dr. Austin Baraki:Yeah. You know, you mentioned that success leaves clues and it makes me think about a little bit of our approach in say clinical practice or in coaching practice to the extent that we want to rely on any degree of evidence. And there's almost no situation where a single piece of evidence or a single example or even like a case report of one person experienced this thing medically or in the coaching, training, performance, where one single example is going to change how we do things. It's much more so an accumulation of evidence, a larger body of evidence. And so this is the same thing here. To the extent that success leaves clues, I think that we tend to see it more often in larger cohorts of high-level competitors, right recognizing uh the the general you know these papers that look at for example olympic level endurance athletes and their general training that what are the patterns in their training setup their intensity distribution their volume tendencies things like that of course there's always going to be outliers and those are maybe the freaks who either have some aspect of their physiology that has not been defined or some genetic mutation that makes it so that some particular way works best for them maybe they're really good in spite of what they do theoretically although unlikely at the highest levels of sport or maybe it's just good enough for them to to be the rest right you know i think back for example you see pictures of mark spitz in his original olympic swimming the swimming the fly race and it is like the most horrendous butterfly technique you've ever seen and then you fast forward a few decades right you fast forward a few decades and you see how sport has evolved and how swimmers are executing it you know so much better and more efficiently and lower to the water and propelling forward and not up and down and things like that but if you had looked back at the time and critiqued his technique people be like well clearly it works.

38:56Dr. Austin Baraki:Well, this stuff is always in a state of evolution and flux, right? One way or another. And so that idea of success leave includes, it's not one person doing something a particular way, but just the general evolution of sport as competitors, who are those who are most incentivized to figure out the best way to do things, uh, actually do that.

39:12Dr. Jordan Feigenbaum:Imagine if you're Steph Curry and you, whatever you're doom scrolling. Cause like he probably does. And he sees this and he goes, Oh man, I gotta be doing this exercise. Yes, that's the trick. Yeah. Shoot. Yeah. Anyway, so I thought it was funny. If you haven't seen this video, it's in the show notes. All right. Next topic, when chat GPT goes wrong. So this story is a cautionary tale. It's making waves across the medical community and beyond. So what happens when you ask an AI chatbot for health advice? The answer, in one man's case, was a three-week stay in the hospital with hallucinations and paranoia.

39:49Dr. Jordan Feigenbaum:So in August of this year, a 60-year-old man who was looking to cut out table salt, cut down a salt intake, from his diet, he asked ChatGPT for an alternative. ChatGPT reportedly suggested sodium bromide, which is still used in veterinary applications for epilepsy in dogs and cats. It's also used for some water treatments as well as processing film and by the oil and gas industry to stabilize wells. Now, in medicine, sodium bromide was originally used as a sedative and an anticonvulsant in the late 19th and early 20th centuries. However, its use in human medicine has declined due to concerns about toxicity.

40:26Dr. Jordan Feigenbaum:We actually have a podcast, a medical mystery case, which is no longer going to be a mystery to you if you listen to this. So maybe like episode 299. It's a good one. Just go back 15 seconds and like neuralize yourself and then you can go listen to that episode. So in any case, the chatbot's response may have been intended for other uses, but the man took it to mean that he could use sodium bromide as a salt substitute, which he did for three months. He was admitted to the hospital with a variety of symptoms, including hallucinations, paranoia, and a claim that his neighbor was poisoning him. Doctors initially considered a psychiatric cause but eventually diagnosed him with bromism after consulting the poison control.

41:06Dr. Jordan Feigenbaum:I mean honestly the fact that this took three months to get bromism was – is pretty impressive to me because normally it's like, oh, you started doing this. You started taking in sodium bromide at any sort of significant quantity and you're like, oh, shoot. You got the bromism. So the question to you, Dr. Baraki, the convenience of AI and chat GPT, stuff like that, it's undeniable especially for answering some questions that can be – have already been written about on the internet. But at what point does it become a liability? Like specifically, if people are using this for like self-diagnosis, what are the dangers surrounding that?

41:40Dr. Jordan Feigenbaum:In addition to the benefits, right? Like you can imagine somebody is just on a fact-finding mission that may be beneficial, but I don't know. Do you see some harms here?

41:48Dr. Austin Baraki:Absolutely. There's no easy answer to this. It is both a convenience and a liability. And it is not – there's no simple heuristic by which you can differentiate when it is which. So part of the issue, for example, is I could take a hard line and say, absolutely not. patients, people should never use these tools. You should only see a doctor, a human doctor like me, whatever the case is. But then there's going to be people who are like, well, I have this condition that nobody could really figure out after, you know, seeing multiple doctors and specialists and a lot of testing. And, you know, I spent some time reading and researching and putting stuff in and I managed to come across this diagnosis that they hadn't heard of.

42:21Dr. Austin Baraki:And when I presented it, it ended up being the correct diagnosis. And it's like, yeah, I can't argue with that. Like doctors are humans too. We have limited human brains. They have the benefit of, you know, a lot of dedicated training and experience with things. But that also means we also have biases and blind spots and things like that. And that's why medical education takes a long time. And, you know, my style of medical education also draws attention to things like, you know, the ways we think and biases and where there can be these types of blind spots and also figuring out ways to use these tools to enhance our skills and our performance and our accuracy and reduce the amount of harm that we might cause.

43:01Dr. Austin Baraki:So using these tools kind of responsibly is actually something, I mean, I've done some formal training in the past year in the use of these tools in the context of medical education and as well as in practice. So there's not an easy answer here. There is obvious risk with a patient kind of on their own using these tools without any maybe requisite background knowledge or understanding or training and then acting upon it, right? So I think that there's a big difference between doing this kind of research, say you come across some diagnosis or some health strategy, and then you just, you know, send it and you go all in on the strategy that the large language model suggested to you, compared with if he had, for example, done this, and then he also had a backup of, okay, next time he chats with his doctor and he's like, look, I've been looking for strategies to improve my health.

43:48Dr. Austin Baraki:I feel like, you know, maybe for this reason or whatever that some reducing my total daily sodium intake may be beneficial. First of all, is that true? Second of all, is this a wise substitute for that? Because there are sodium substitutes for those who want to reduce or replace their sodium intake with more healthful options. This has been studied. There's some randomized trials of potassium-based salt substitutes, light salt, reducing the risk of stroke and some other things like that. Not to say that everyone listening to this should go and substitute with potassium because there's some potential risks to that that need to be kind of dealt with on an individual basis.

44:21Dr. Austin Baraki:But any any doctor who was, let's say, worth their worth their salt. That was that was that was painful to say. But he goes and talks to somebody, consults with them on this. They'd be like, no, dude, don't do that. That's not a good idea. Here's a safer alternative. And he could have avoided all of this. So, yeah, I think they are both a benefit and a liability. And on a individual, unilateral basis for, you know, untrained folks using these to make active health management decisions. I feel like that probably falls slightly more on the risk side of the spectrum than the benefit outside of very obvious, you know, issues of like asking your large language model whether losing some body fat or improving your sleep would be good for you.

45:02Dr. Austin Baraki:But these sorts of kind of higher stakes decisions, I don't love people doing this unilaterally without some additional input. All right.

45:09Dr. Jordan Feigenbaum:So a couple of follow-up questions before we move on to the next part. thing one, if this is a large language model, then presumably it's just scouring the internet, crawling the internet for stuff that people have written about related to this question. Yeah. So does that mean that somebody out there or multiple people out there have published this idea like, hey, stop using table salt, use sodium bromide, right? Like where does it come from?

45:32Dr. Austin Baraki:Exactly. Yeah. Hallucination or is this real? That's kind of what I'm wondering is, you know, these things are known to hallucinate. And if this was more of a hallucination than anything. Cause you know, a lot of these will spit out linked references or like, where, where did this come from? And so I'd be curious where to go down that rabbit hole and see how it came about this, if that's identifiable, but these hallucinations

45:50Dr. Jordan Feigenbaum:are definitely, definitely dangerous.

45:55Dr. Austin Baraki:I've had patients already, you know, that I, that I work with who take their labs and they punch them into one of these things and it gives, it might give, you know, correct interpretations or it might give interpretations that are problematic. And And when I read the chat, the chat models interpretation, I'm like, I can totally see how it got here. But that is actually incorrect for this patient situation based on what I know about them. It might be that I know more about the person. I have more context. I know more of their background. This just happened to me pretty recently. And I read the output of it.

46:26Dr. Austin Baraki:And I was like, yeah, I see how it did, how it arrived at all these conclusions. But this is like, this is like, you know, first year, second year medical student level interpretation of these labs to the point where it's actually incorrect. and it takes a bit more experience and knowledge of this person to know how it does and doesn't apply to them. But it had already, it was like too late because it had already freaked the patient out. And so these things do need some expertise to work through. I'm sure these models will get better with time, but I don't know. It's a little scary sometimes. Although in other areas of my practice, I have made some use of these tools as well.

46:57Dr. Austin Baraki:So that's why it's such a messy area. There's not a clean answer of like, yes, we should be going all in on these things or no, we should never touch them and just stick with human doctors. It's like, no, I don't think that that's a realistic future.

47:07Dr. Jordan Feigenbaum:So the second thing, last thing, I swear to you. So this is the last thing I'm going to say. If a patient asked you, Dr. Baraki, I want to cut down my salt intake. I think I'm going to take like a sodium bromide instead. And you were like, sure, send it. That would be grounds for some sort of malpractice suit. Totally. So is Chatty G going to get sued here? Sam Altman. Yeah. Yeah. I mean, what do you think about that? Or like the person, the people who published this stuff that the language model like interpreted if it wasn't a hallucination, right? Imagine if Mercola had posted this on his website or DeNicolantonio, you know, idiot surrounding sodium intake, just generally speak, maybe just idiot in general.

47:50Dr. Jordan Feigenbaum:Full hate, sending hate from California. uh like if you put this out there and it does cause harm like what sort of you know recourse

47:59Dr. Austin Baraki:is there yeah i i'm not having any uh legal uh knowledge knowledge or background uh i i don't know i think it is a question that will at some time point going to need to be addressed it reminds me of you know some of the legal uh concerns in the social media space i believe it's called like section 230 having to do with like, are these social media platforms, are they just a platform for people to put things up or are they the publisher of the information? And so as a result, what sort of liability do they have? For example, if somebody decides to act on some information on there, be it, you know, some sort of attack or violence or something like that, do they have any liability or responsibility for that?

48:41Dr. Austin Baraki:Or are they just serving as a platform for people to put up whatever they want and the liability there falls on the individual? In this chatbot, realm, there isn't really a clear individual that we can lay such blame at the feet of. And so it'd be, not that it would be, I think it will be interesting to see when this almost inevitably gets tested in the courts, if something like this happens. And I suspect that there would be just absolutely gargantuan, aggressive legal tactics and lobbying tactics and things like that on behalf of the companies to more strongly limit their liability, because if they were deemed liable, then that almost shuts down the whole enterprise because there's no way that they can realistically exert control over what these things tell people.

49:26Dr. Austin Baraki:And so that's, you know, in our, I don't know, maybe approaching dystopian internet society, that may be the way that it ends up playing out. But you're right that it's a question that ought to be answered. I just don't know that it's going to be answered satisfactorily for like patient safety and things like that.

49:43Dr. Jordan Feigenbaum:I wonder if people will support, you know, the companies that have these large language models and like, hey, look, they can't be held liable, you know, and how many of those people do not feel the same way around vaccine manufacturers. Totally. Yeah. Interesting. Okay, next topic. This is on plant-based diets and blood pressure. The American Heart Association has been in the news recently with new studies linking plant-based protein to lower blood pressure. The MESA study, which just came out, analyzed data from about 2 ,300 participants who were between the ages of 45 and 84 from a diverse background.

50:19Dr. Jordan Feigenbaum:It's probably one of the strengths of this study, the diversity of the individuals. All participants were free of high blood pressure or hypertension at the beginning of the study. And they completed this 120-item food frequency questionnaire at the start of the study to assess their usual dietary intake or dietary pattern. And they were followed for a median of nine years. Incident hypertension or high blood pressure was defined as a blood pressure reading of greater than 130 over 80. millimeters of mercury, or the new use of a antihypertensive medication. As far as the findings, the researchers found a clear inverse relationship between plant protein consumption and hypertension, meaning that the greater amount of minimally processed plant protein sources were associated with a lower risk of developing high blood pressure.

51:06Dr. Jordan Feigenbaum:The researchers did mention the potential for a, quote, threshold effect where the benefits plateaued after a certain amount of consumption. But there was no statistically significant association between the quantity or variety of minimally processed animal protein intake and the risk of high blood pressure as well. So I thought that was an interesting finding. And finally, they also found that highly processed plant-based options were linked to a higher risk of high blood pressure. So question to you, what do you think the mechanism, the mediating mechanism is here? Do we think there's something in the plant proteins themselves that's causing this unique antihypertensive effect?

51:45Dr. Jordan Feigenbaum:Do we think this is just a reduced energy intake because people who follow a vegetarian or vegan diet tend to eat less calories by quite a substantial margin? Is there other confounding variables like, oh, you're more likely to eat – if you eat plant-based proteins, you're more likely to exercise or something like that? Is it the level of processing since they found those relationships? What do you think the mechanism is here?

52:06Dr. Austin Baraki:Yeah, I'm going to give a maybe unsatisfying answer and say it's very likely to be a combination of all of these things because the way that the study was designed doesn't really let you identify a particular mechanism. All of these, like, in other words, the results observed in this study would seem to be compatible with any or some combination of all of those mechanisms that you just described, right? So on one hand, you could say, well, people who, you know, this whole like healthy user bias, those who tend to eat plant-based diets tend to be healthier on average. But that does not mean that it is impossible to have a generally healthful dietary pattern that does include animal products.

52:42Dr. Austin Baraki:And I think that that's a position that we would mostly sign on to, depending on some more details in a matter of degree. But we also know that there are plant-specific compounds like what are the general category of phytochemicals that have a whole bunch of health benefits, both defined and as yet undetermined, on things like systemic inflammation and vascular health and function and insulin sensitivity and all sorts of other factors. So there's a plausible mechanism of benefit there as well. You mentioned the energy relationship. That's probably the easiest one to figure out just by looking at if that was data that was collected in the study of did those who were on the plant-based diet, did they have, say, lower levels of body fat, lower waist circumference?

53:21Dr. Austin Baraki:Did they tend to lose weight if they switched their dietary patterns, etc.? So that may or may not be as much of a factor depending on what the actual data set looked like. So there's some plausible evidence of some plausible mechanism of confounding some plausible mechanism for overall energy. I do buy that having a more plant predominant dietary pattern is just generally more healthful in a variety of ways compared to many commonly consumed diets that include higher amounts of animal derived food sources. Again, I don't think it's impossible for somebody to have a health promoting dietary pattern that includes some degree of animal derived products.

53:58Dr. Austin Baraki:Now, if that is the entirety of their diet, the most extreme example being like carnivore or something like that, I think that both of us are going to stick by our position that that is not the most healthful dietary pattern. And those folks would stand to benefit greatly by introducing more and more plant-derived food sources, both plant-derived proteins as well as other plant sources of foods. So that's my take. Like I, you know, in general, when I'm assessing a patient who has concerns over their blood pressure, who has newly elevated blood pressure, I'm taking a general dietary history on them, like 100 % of the time, and then really getting a sense based on their level of self-efficacy, their readiness for behavior change, their motivation, and what are the highest yield targets that I can attack.

54:41Dr. Austin Baraki:And so, you know, it's typically going to be like, does this person consume a high amount of sugar-sweetened beverages? Do they consume a lot of alcohol? As a couple things that I'm going to target right away. How's their sleep? What's their waist measurement? And then from there, going down the dietary quality piece and seeing what things I can substitute, not specifically because I might have evidence that like if you substitute this food for that food, it'll lower your blood pressure, but rather we have good enough evidence to say that if we substitute this food for that food, we're going to improve the overall quality of your dietary pattern.

55:09Dr. Austin Baraki:And as a result of that, as well as many other things, we can expect some improvement in blood pressure and many other important health parameters over time.

55:16Dr. Jordan Feigenbaum:Yeah. Yeah. The biggest takeaways for me on this, The finding that a higher amount of minimally processed plant protein is generally beneficial for this particular metric is not surprising. You could replace this metric with like lipid levels, blood sugar control, whatever. I'd be like, yeah, we kind of already knew that. The main interesting points here was that there was not a relationship between the intake of minimally processed animal protein, which is kind of nice to – again, another little – that fits my bias. I like that. And then also that highly processed plant proteins were associated with an increased risk of high blood pressure, which I think when people consider vegetarian or vegan options, just most folks would say, yeah, this is healthier than this other option, which is probably not true if it is highly processed, especially if there's like added sugars, added sodium, stuff like that.

56:06Dr. Jordan Feigenbaum:That would be the main point. And we'll come back to that specific question about processing in just a few questions. All right. Next question. We're really doing some trigger warning type stuff here. We're talking about sex testing in sports yet again. So gender eligibility in elite sports has been a contentious and complex issue for years, but a major shift is underway. World athletics and world boxing are leading the charge by implementing mandatory one-time genetic testing for female athletes to detect the presence of the SRY gene. Now, the SRY gene, which stands for sex-determining region Y gene, is a specific gene on the Y chromosome.

56:50Dr. Jordan Feigenbaum:It is a critical factor for male sex development. In a developing embryo while you're in utero, if you've got XY chromosomes, typically the SRY gene triggers the formation of testes. The testes then go on to produce hormones like testosterone, which lead to the development of male characteristics such as increased muscle mass and strength later on when people go through puberty. So this move is being hailed by some as necessary, a necessary step to protect the female category despite it being called the women's category in most sports. But that's an aside. While others warn of the potential for discrimination and harm.

57:24So the question is, is this like a good fit to determine eligibility for the women's divisions?

57:33Dr. Jordan Feigenbaum:Just a brief history before I get you to weigh in because I am interested in your take on this. And we did this before, not we like you and I like went around testing all the athletes, but like in sport, this was done 1996 to 2000. The IAAF, which is now the World Athletics and the IOC, the International Olympic Committee, decided to use a genetic test for the SRY gene. They would swab people's cheeks to distinguish them from male from female. And this was used at the 1996 Summer Olympics in Atlanta, Georgia, where eight of the 3 ,300 female athletes failed the test. So they were found to have an SRY portion, although all were allowed to compete as women.

58:18Now, in the year 2000, the IOC decided to abandon this testing, this universal testing, in favor of a, quote, suspicion-based approach where athletes suspected of being men competing in the women's division would be tested.

58:31Dr. Jordan Feigenbaum:This was mostly done by like the physical appearance like, oh, your shoulders are too broad or breast development isn't what we would expect, stuff like that. So this suspicion-based approach ultimately led to officials subjecting athletes like South Africa's Castor Semenya to testing and public scrutiny. Now, she's a South African runner who dominated the 800-meter distance on the track, and she was born with what's known as DSD or Difference in Sexual Development, Disorders of Sexual Development, which means that she's got an XY genotype but was legally registered and identifies as female. Basically, this intensified after the 2016 Olympics in Rio where the World Athletics introduced a rule requiring DSD athletes to reduce their testosterone levels in order to compete in certain events, which required Semenya to basically take a medication to lower her testosterone levels.

59:26Dr. Jordan Feigenbaum:And she refused to follow that, arguing it was a human rights infringement and it was discriminatory. There's a long legal battle including a challenge at the Court of Arbitration for Sport, which she ultimately was barred from competing. So she effectively missed her entire – most of her career due to this. So with this new policy, if an athlete's test is negative, meaning they don't have an SRY gene, they're eligible to compete in the female category. However, a positive test indicates the presence of an SRY gene, which basically means that they cannot compete in the female division. So what do you think about this?

1:00:05Dr. Jordan Feigenbaum:Is this like a good move, bad move, just, you know, one or the other, binary?

1:00:11Dr. Austin Baraki:Few things are. I truly don't – I don't think I've ever arrived at a point where I would say I feel very confident and have very strongly held opinions on this. And this is for a lot of reasons. But, you know, we've talked a little bit about this before as far as how sports are arbitrary. They are made up. And every sporting organization gets to decide how it wants to set up its rules and its policies and its divisions and things like that. And so if a sporting organization says, here is going to be the way that we divide competitors up, we put them head to head in this way versus that way, the organizations can do that.

1:00:52Dr. Austin Baraki:I am not sure that this is a fundamental human rights issue. And I'm not saying that to say that it isn't. I just, I don't have expertise in this realm of like, you know, human ethics and human rights and things like that. and so you like for example in powerlifting if one federation did this you can go compete in another of course that's probably less of an option at the highest level of sport on a international level for track and field and things like that which is probably the counter argument to that is where else would this would this individual go i also find it interesting from the more kind of biological standpoint at how much we fixate on particular deterministic variables here And that's also because in the same way that sports can set up divisions arbitrarily, these choices are also to some extent arbitrary in the sense that there are a lot of different biological variables that have impact on human performance.

1:01:53Dr. Austin Baraki:And we are choosing to stratify or divide people along very particular ones, like, for example, their blood testosterone levels. We don't have different Olympic endurance events stratified by what is your baseline hemoglobin level, which is also something that is going to be heavily influenced by all sorts of biological variables. Like we don't have the hemoglobin over 15 grams per liter division, the like 10 to 15 grams per liter division, and then the race for those who are naturally or for whatever reason more anemic, just as an example, or stratifying people based on their pulmonary function test performance or something like that.

1:02:30Dr. Jordan Feigenbaum:Just not to push back because you are correct. We no longer do that. However, prior to the introduction of the biological passport in 2002, there actually was in some sports an upper level on hemoglobin. Like the UCI previously had a limit on this. They were like, look, you cannot compete if your hemoglobin levels are higher than this. But anyway, we no longer do that. And you're exactly right. We don't have like, oh, if your arm's this long, you can't, you know, be a thrower or pole vault, something like that. You know, just we're making these arbitrary distinctions.

1:03:01Dr. Austin Baraki:That's the point. It's not actually shocking to me that a sporting organization did that. And it's also illustrating how arbitrary this is, that it could have been hemoglobin. It could have been testosterone. It could have been pulmonary function testing. It could be arm length, limb length, mobility, you know, metrics for certain other sports, whatever the case is. And so that's why I'm like, you know, I think that it's almost like we have this ecosystem of sports that are going to try trial a whole bunch of different strategies and see which ones, quote unquote, work to achieve whatever aims they have, which ones end up being more trouble than they're worth, which ones have unintended consequences, which ones are a disaster.

1:03:38Dr. Austin Baraki:and it's kind of like this continuous process of evolution over time. I don't know, again, I'd be curious as to maybe your thoughts or if there are experts in this room. I think you interviewed Roger Pikey before on this, who he has a lot more kind of knowledge of this space, but is it generally thought of that this level of participation, is it a human right to be able to do this thing? I'm like, I'm not so sure about that, Even though it doesn't feel great to exclude people or potentially to recategorize people based on these things. But again, we're choosing to participate in a kind of a made-up endeavor here.

1:04:17Dr. Austin Baraki:So I'm not sure where the right answer lies.

1:04:19Dr. Jordan Feigenbaum:Yeah, I definitely don't know what the right answer is. So I have a few thoughts on this. thing one on the on one hand i kind of want to applaud world athletics for actually making some sort of policy relating to eligibility in particular divisions because most sports if you look at their you know rule book they do not have these which presents a problem when you run into these you know you could call this like a fringe case because look just in the wide world of you know sports in the women's division in particular this is a very small proportion of athletes, although it is overrepresented compared to the general population as far as individuals with DSD, disorders of sexual development.

1:05:01Dr. Jordan Feigenbaum:So but having a policy, even if it's the wrong one, you need to have something there. It can't just be like, yeah, we'll sign up. You sign up for whatever division you want and it will shake it out later. Like that's probably not going to work. But I do. On the other hand, I do have concerns about using this SRY gene. I think it's fine for determining genotype. I think that's pretty good at that. But as far as eliminating women with DSD from participating, period, I don't know that that's the right policy, mainly because the connection between performance in women with DSD who do happen to have a Y chromosome or at least a portion, the SRY portion, that's not been well established.

1:05:48Dr. Jordan Feigenbaum:It's not like, look, if you've got this SRY gene and you are a woman with DSD, your performance level is on average 15 percent higher or, you know, 50 percent higher. If that were true, OK, well, look, I kind of see your point now. Like we have good evidence, robust evidence. And from a fairness standpoint, I kind of understand that. That said, you know, if you look at the charter, the Olympic charter, they do say that, look, everybody should be able to participate in sports. But so maybe then we need a third division, for example. That's an alternative policy. I think the reason why this was chosen is because there's a presumed connection between the SRY gene, testosterone levels, and then subsequent performance.

1:06:26Dr. Jordan Feigenbaum:But even the relationship between testosterone levels and performance in both women and men is not super clear cut. Yeah. And in fact, I thought it was interesting that the guy who discovered the SRY gene, Dr. Andrew Sinclair, I believe he's out of Australia. He said, mate, this is overly simplistic. That's my worst Australian accent. Yeah, not great. But he said that and I'm like, look, the dude who discovered this gene is telling you like, hey, maybe this isn't the best policy. So I don't know. I think they could have released this in a different manner and said like, look, we're trying this.

1:07:01Dr. Jordan Feigenbaum:We're going to collect data. We're workshopping this. Yes, we did this before and it was unsatisfactory, but we're going to do it differently this time. We promise. And to your point earlier, there were some methods that were very bad. the naked parades previously just hey look if you're a woman you got a stripped down naked you got to walk in front of this panel of male physicians and they're going to inspect your genitalia as you walk by to make sure you're a chick yikes yeah we've done we the you know again sports science community medical community has done some things in the past that don't make make sense so i'm not sure this policy uh it was not worse than that but i also don't know that it's the right policy my second concern is that resource allocation like these tests on average run 100 bucks,$150 US, you could argue the money is better spent on fighting doping, increasing access to sport for participation, things or like coach abuse, that sort of stuff, mental health.

1:07:56Dr. Jordan Feigenbaum:Like there's a bunch of places you could spend this money. So kind of like an opportunity cost consideration. And then there's like an ethical consideration as well about outing athletes with DSD. Like why do we know anything about Castro Semenya's genotype and testosterone levels? It's like we shouldn't know that. Anyway, no easy answers here. And so when people say it's very simple, just do this. I'm like, I don't think you've thought deeply about this, which maybe ask ChatGPT for some thoughts here. All right, a couple of questions left here or a couple of topics left. The surprising role of body weight and mortality.

1:08:37Dr. Jordan Feigenbaum:So we've been told for a long time that being overweight is a significant risk factor for early death. But a new large-scale study out of Denmark is challenging this long-held belief, suggesting that being too thin might actually be deadlier than being overweight. That's the headline, all right? Researchers used health data to examine the relationship between BMI and mortality in about 85 ,000 individuals. This population was about 81 percent female. And the median age at baseline was 66 years old. During the follow-up, 8 % of the subjects or about 7 ,555 individuals died. And the underweight category, so those with a BMI less than 18.5, were almost three times more likely to have died than individuals with the reference range BMI.

1:09:24Dr. Jordan Feigenbaum:And that reference range was 22.5 to 25 for a BMI. Uh, the, uh, those with a BMI of 40 or above had about a twice, uh, a two times increased risk of death compared to that reference population. So overall, this is like a U shaped curve when plotting BMI against mortality, meaning those with the lowest and highest BMIs were at the highest risk of death. So the question to you, Dr. Baraki, is it really true that being too thin, you know, having an underweight BMI is actually more risky than carrying too much body fat?

1:09:56Dr. Austin Baraki:Yeah, uh, this is not new. It's unclear to me how this is groundbreaking here. I think that if you speak with anyone who sees patients, in general, my level of concern over somebody whose BMI is less than 18 is always greater than that of somebody whose BMI is 40. I see lots of both categories, and it's something that I don't even consciously think through anymore. It's like I walk in the room and I see the person whose BMI is 18 or less. And even if I didn't know their BMI, I'm like immediately much more concerned that this person is going to have a bad outcome from whatever I might be seeing them for or outside of that context.

1:10:39Dr. Austin Baraki:Whereas people with a BMI of 40, 45, 50, they might be ill in their own ways or maybe don't yet have any diagnosed medical conditions or complications. And I don't feel great about their general health status and prognosis, but it still intuitively is oftentimes not as high a degree of concern as the person who is, you know, what we'll call cachectic or super, super, super thin skin and bones wasted away. And I think that's the point of this is that it is most likely at these extremes, not the BMI itself, but rather how they got there and why they got there. And so the reasons why somebody gets to a BMI of 16 are often more ominous, dangerous, life-threatening compared with the reasons and mechanisms that a person might get their BMI up to 35 or to 40 or to 45.

1:11:27Dr. Austin Baraki:Patients with advanced cancer, tuberculosis, chronic inflammatory diseases, wasting syndromes, HIV, AIDS, heart failure, chronic kidney disease, all the kinds of things that I see on a day-to-day basis in their most advanced stages lead to this chronic wasting syndrome. There's a lot of oftentimes chronic inflammation going on that can lead to appetite suppression. These patients have no interest or desire to eat. And in a tiny fraction of people who are this thin, they might have eating disorders, anorexia, which is actually one of the most dangerous, highest risk, highest mortality psychiatric conditions in existence is anorexia nervosa, as an example.

1:12:00Dr. Austin Baraki:Not to say that that's the most common reason why I might see somebody with a BMI in that range, but that's kind of like on the differential, so to speak, for a BMI that low. So it's much like many other conditions where we've talked about their relationships and how we interpret them. It matters to some extent how you got there rather than the finding itself. We see similar findings, for example, when you stratify people's blood creatinine levels, their blood levels of how their kidneys are functioning. You know, a lot of people fixate on very, very high creatinine levels as an indicator that your kidneys are not working very well.

1:12:30Dr. Austin Baraki:Maybe you have advanced chronic kidney disease. Maybe you have end-stage kidney disease and you need dialysis. Those are all very, you know, dangerous conditions and high risk of death associated with those. Even if you get put on dialysis, your prognosis is not like miraculously better. It's still a concerning condition. Fewer people recognize the risk, health risks and mortality risk associated with very, very low creatinine levels. So a creatinine level of 0.1, for example, gets my attention of like this person has almost no muscle mass as indicated by this blood creatinine level. And I'm generally more concerned that they have a higher risk here.

1:13:03Dr. Austin Baraki:Now, what's the solution? Is the solution to give them creatinine to make the creatinine higher? That's what you do. Right? Just like, you know, these other patients who have a very low BMI, is the solution just to, like, force feed them to get their BMI up? That will probably not return their risk of death back to baseline, but rather it is more likely to be related to whatever underlying condition they have. So treating their tuberculosis or their cancer or their AIDS is more likely to benefit their risk of death in the same way that the person with a very low blood creatinine level, making the creatinine look pretty isn't going to be what helps them, but rather improving their, you know, level of lean body mass is more likely to help them to the extent that that's realistic or possible for the person.

1:13:43Dr. Jordan Feigenbaum:Yeah, you don't need to buff the chart. But I look at this a similar way that like, on the in the long term, right? Having too low of a BMI is not really a concern, because that's not a long term problem. It's a short term problem, because just because the mortality does increase so rapidly, mainly due to, as you said, the process by which people got there, right? It's mostly some sort of underlying condition that has moved a person from a, quote, normal BMI or even overweight or obese BMI into this underweight category. So that short-term change, that, yes, is very, very scary. It gets my attention.

1:14:19Dr. Jordan Feigenbaum:Compared to somebody who's had an elevated BMI for a long period of time, that's more of a chronic risk of exposure to excess body fat. And so, yeah, I don't think that's like a, I don't think it's likely to improve somebody's lifespan having too much body fat. But in the short term, yes, somebody moving down into that underweight category is very, very concerning, mostly due to the underlying process that got them there. Yeah, I don't think that having like too much body fat is now suddenly like a protective factor. It's more just an association that you see because you're not picking up how people got to these various endpoints.

1:14:54Dr. Austin Baraki:Yeah, totally. Yeah. I would hesitate to make a ton out of this because a lot of folks maybe whose BMI is elevated because they legitimately are carrying a bit of excess body fat, they might, you know, look at this and say, oh, well, I'm in the optimal, optimal range. Meanwhile, my waist measurement is, you know, 40 inches or something like that. And there's actually room for improvement on that. No, but I got all this muscle mass,

1:15:16Dr. Jordan Feigenbaum:dude come on yeah probably not yeah uh okay two questions two topics left one is about the impact of ultra processed foods we're back to this yet again uh the fda and usda are making headlines with a request for information on a for a federally recognized definition for ultra processed foods on september 9th the maha commission released the make our children healthy again strategy report which outlines a broad set of proposed updates to federal nutrition and food safety policy, one of these policies to come up with a definition for ultra-processed foods. Now, to date, most studies, most researchers, most public health organizations use the NOVA food classification system.

1:15:58Dr. Jordan Feigenbaum:It's a name. It's not an acronym. And this separates food into four different groups. Group one is unprocessed or minimally processed foods like fruit, vegetables, eggs, meat, milk, water, et cetera, Whereas group four, these are termed ultra-processed foods, the ones that use many ingredients, including food additives, ingredients rarely used in home food preparation and industrialized processing to improve palatability. So how the food tastes and shelf life for the food. So cereals and a number of other sweets, desserts, et cetera, would all classify as ultra-processed foods. Although you would also lump in whey protein powder in there or some versions of Greek yogurt, for example.

1:16:37Dr. Jordan Feigenbaum:So the question to you, Dr. Baraki, is, is coming up with a federally recognized definition for ultra-processed foods important? And if so, why? Yes.

1:16:50Dr. Austin Baraki:Oh, okay, cool. I think it's super important because, you know, we've talked about this a ton before as it relates to our options for addressing, you know, the general prevalence and increasing rates of obesity in the population, both ranging among children all the way through adulthood. that we have this interaction between people, all the things that make them individual, including their genetics and their surrounding environment. And those are fundamentally our two levers that we can work on. And at the level of the person, we can work on behavior change and lifestyle habits. And then we can also use individual targeted medical treatments, be it GLP-1 agonists, other anti-obesity medicines, metabolic bariatric surgery, et cetera, to try to address things at the level of the individual.

1:17:33Dr. Austin Baraki:but they are still living in an environment. And that environment is increasingly toxic, shall we say, as it relates to promoting or setting the person up for behaviors that are more likely to lead to the development of obesity and its complications. And so in an ideal situation, we would be working on both levers. I think historically, there has been much more reluctance to work on the environment because what does that even mean? Who works on the environment? Do we expect companies, food companies, restaurants to voluntarily make their food less palatable or less appealing to people so that they will naturally consume less, obviously that's never going to happen.

1:18:11Dr. Austin Baraki:And so to the extent that we want the food industry to reform in some way, if we want food reformulation, if we want changes in the food environment, the only way that happens is from the state. And so if we're looking at government level regulation and things like that. And so the – and then obviously any form or attempt at government-led regulation is going to be immediately steeped in legal battles because that's how we do things in the United States is tons and tons and tons of lawyering and legal battles back and forth. And so that relies, that necessitates clear, distinct definitions on which we can attach our laws and regulations and things like that if we're going to go down that road.

1:18:56Dr. Austin Baraki:And so absent a definition, to the extent that you want to modify anything about the food environment with respect to these quote-unquote ultra-processed foods, yeah, having a very clear, distinct definition is going to be absolutely essential. That's going to be a lot harder to do than it might initially seem. A lot of people might just take like, I know it when I see it type definition, but that's not good enough to survive the legal battles that are going to happen. So it needs to be something that is very clearly and distinctly defined. And I don't think it's going to be a perfect fit. I think there are going to be gaps, there are going to be things missed, there's going to be what we'll call false positives and false negatives, very likely in these types of definitions, and there's very likely to be unintended consequences.

1:19:34Dr. Austin Baraki:So this is going to be a messy process, it's going to take a long time, if it even happens at all. I also have my share of questions or skepticism about the kind of overall interest of this administration in carrying this through. I think that you described this particular commission that has its own thoughts and agenda, which oftentimes are not entirely based on evidence, but a lot of times based on a lot of deeply held beliefs and convictions that may not entirely be supported. And then that is situated within a broader administrative context of not being terribly in favor of aggressive regulation.

1:20:11Dr. Austin Baraki:And so how that ends up playing out, you know, I struggle to be super optimistic that we're going to like overhaul the nation's nutrition, food system, children's health and obesity trajectory during this administration. But, you know, I'm open to seeing what happens, starting with needing a definition and then going from there to see like what steps are realistic or feasible from a from a governmental standpoint.

1:20:34Dr. Jordan Feigenbaum:Yeah, I think the way I view having this definition, how it would work is that it would – look, if you buy this criteria or producing an ultra-processed food and putting it on the market, that maybe there's either some sort of tax associated with that or some sort of – you're incentivized to not do that, right? If the idea is like we reduce intake of ultra-processed foods, we'll improve health of the community. Fine hypothesis. But then you have to come up with, all right, well, what is the definition of an ultra-processed food? And so now you're like, is it just foods with added sugar or is it foods with added sugar, added sodium, added fats?

1:21:08Dr. Jordan Feigenbaum:Or is it all of those things plus some sort of manipulation of the mouthfeel of the – right? You could like go down. You could come up with as little as one criteria all the way to like hundreds of criteria. And then like food manufacturers are then going to like weave around that ultimately to probably increase profits under the current model. So, yeah, I think it's important, but it's going to be challenging to come up with a satisfactory definition, especially now that Kevin Hall is no longer on the case. Yes. That's going to be a problem. So we'll see what happens here. I did have this idea.

1:21:41Dr. Jordan Feigenbaum:All right. So you're familiar in health care with the idea of a capitation model, right? So if you're not familiar with this, instead of a fee-for-service model, most of healthcare uses that. There's this alternative model where, look, the provider, the physician in this particular case would receive like some sort of set payment. And effectively, if there are issues with them providing high-quality care, right, they end up using way more resources than would be predicted or whatever. Some of that can get docked or deducted or whatever. What if that was the case for food manufacturers? the government identified look you're the top 20 food manufacturers for the food supply in the united states we're going to pay you x every year right provided you do these things for you improve the quality of the food and whatever but you can't raise prices so food insecurity potentially goes up and you know whatever you got to make these things tasty so people actually eat like whatever and until you start doing weird stuff at that point we're going to start finding you.

1:22:40Dr. Jordan Feigenbaum:Is that any, I don't think it would be very popular. I don't think anyone would go for it, but I thought like, what an interesting model that would be because then they're not incentivized to just sell more product. They're incentivized to put the best product on the market and have people actually consume it. So they don't get dinged throughout the year. I don't know. What do you think about that? Is that crazy? Am I, my, yeah, yeah, dude, that's crazy.

1:23:01Dr. Austin Baraki:Fair enough. I think there's, I think there's some fundamental kind of American sociopolitical, you know, understanding here that's kind of leading to some deep down discomfort at that idea. I think the number of unintended consequences from a strategy like that would be massive. And it might be both unintended, but might be like very predictable consequences from people with more economics expertise. But yeah, that sounds crazy.

1:23:26Dr. Jordan Feigenbaum:All right. Capitation model, barbell medicine template win. Yeah. All right. Last topic we're going to talk about. We're talking about the rock. There's been some recent controversy surrounding Dwayne The Rock Johnson's weight loss. With speculation flying around on social media and in the news, the conversation was sparked after he appeared at recent film festivals with a noticeably leaner physique for his upcoming role as MMA fighter Mark Kerr in the movie The Smashing Machine. Great title. Cool. By the way, yeah. Johnson has since addressed the weight loss, explaining that it was a deliberate transformation for his role in The Smashing Machine and a new role where he'll play a whimsical and eccentric 70-something-year-old.

1:24:09Dr. Jordan Feigenbaum:He attributes the change to a new diet and more endurance-focused workout regimen to embody the character of Mark Kerr. He says he lost about 60 pounds. So the question to you, Dr. Baraki, how did he do it? Did he just stop using the pharmaceutical enhancements that are likely resulting in his previous physique? Although he has denied that he's taken anything since as an adult. He said, oh, in my previous years, sure, but no longer. Was he taking Wegovy or Zempic or Zepbound or just training alone, just endurance stuff?

1:24:45Dr. Austin Baraki:Obviously, neither of us really know. I think that this harkens back to some extreme examples of like movie transformations. Of course, the one that comes to mind most immediately is Christian Bale's transformation from when he was on one hand, like in The Machinist and he weighed like 120 pounds and lived on like a can of tuna and an apple a day. And that must have been absolutely horrendous and miserable at the time, all the way up to the other end of the spectrum when he's played roles where he actually carried like a lot of body fat for various things. I think one memorable one, I think, was when he played Dick Cheney in Vice.

1:25:17Dr. Austin Baraki:That was also an excellent, excellent movie as well as a couple others. and so I'm thinking about like if you or I were in that scenario if we happen to be actors and we needed to be able to manipulate uh our body composition a ton and you had access to really any of these things for the rock's prior roles where he needed to be a behemoth of a man and needed to be lean and muscular and things like that pretty tough to argue that there that there were no anabolics involved in that in that process um which you know I don't particularly care about as it relates to somebody doing acting for movies.

1:25:51Dr. Austin Baraki:That's a different world than in competitive sports where things are tested, for example, and things like that, setting aside the legality or illegality of these things. The more interesting idea is with respect to the GLP-1 aspect, because I suspect that Christian Bale was living in absolute misery that whole time when he was preparing for the machinist role. You must be ravenously hungry, and that's something that can just erase that. It can markedly reduce the suffering associated with something like that. And so, you know, on a very individual kind of physiologic level, it depends on his response to energy deficits and how much the hunger and the appetite end up being an issue.

1:26:32Dr. Austin Baraki:Like if I were in his shoes and you had the means and the resources and you needed to get down to a certain weight or certain degree of leanness, you could do it without these meds and be potentially miserable and, and, you know, hungry all the time, which for me would be particularly tough because I have a very difficult time falling asleep if I have like an inkling of hunger, much less like ravenously hungry. So yeah, I would totally do it. Use these tools at my disposal to achieve the necessary, you know, target physique and body composition for the movie role. And training certainly is going to play a role, but I don't think that that's particularly difficult for someone like him who's been training for his whole life at this point.

1:27:09Dr. Austin Baraki:And then the rest is just bonus. What do you think? Yeah.

1:27:11Dr. Jordan Feigenbaum:Yeah. I mean, so the idea that this was just a training alone endurance focus workouts, I'm like, nah, because you think of the size of Dwayne Johnson, the size of The Rock compared to like an IFBB pro, you know, bodybuilder or whatever and like how they get in shape for a show. And it's like, well, look, if you switch to doing a lot more cardio, less lifting, would you lose some muscle mass during that process as you lose weight? Sure. But not 60 pounds, my friend. So that seems unlikely, potentially contributory. Sure, from like an energy expenditure standpoint, but definitely not the main factor here.

1:27:48Dr. Jordan Feigenbaum:And similarly, when people like, oh, he just came off the anabolics, off the steroids. And I'm like, you're telling me that this man with an incredibly busy schedule is somehow immune to all of the side effects of coming off of all anabolics, the insomnia, the fatigue, lots of muscle mass loss, increase in body fat, you know, So potentially psychiatric conditions that are associated with that lull when you come off before your body hopefully kicks back into gear. Seems highly unlikely. The doses might have gone down. The regimen might have changed. But the idea that he – oh, I just stopped and this is what happens, particularly in short order, unlikely.

1:28:25Dr. Jordan Feigenbaum:I would suspect, again, given the access, it wouldn't be – I wouldn't be surprised if he was on a particular dose of a GLP-1 receptor agonist combination medication just to deal with the hunger and make things more palatable, to use another terrible pun, mainly because it's like, why do you need to suffer?

1:28:44Dr. Austin Baraki:Yeah.

1:28:45Dr. Jordan Feigenbaum:Nobody cares. Yeah. And that's kind of something I've been saying recently when asked. I'm like, I don't necessarily care if people want to use these things recreationally to like lose weight. Like you don't get a gold star for like, you know, it being a worse experience for you. Yeah, agreed. But more – the last thing, just quickly, are there any impacts on society from this sort of thing? I mean you got to think he had particular roles that he was selected for due to his size. I think of like all of the action, smash him up, fast and furious, whatever, the rundown, so on and so forth. It's like, yeah, you're supposed to be this big hulking GI Joe type character.

1:29:23Dr. Jordan Feigenbaum:actor uh and so you have a particular body you need to fit into and that has an impact on society and what they expect but now you're going to be considered for more roles as a you know a lighter individual batista same thing yes he's done another one that came to mind in the same way yeah and it's like i actually don't know because you're you've almost been typecast as a particular type of of actor already i mean i don't know anything about you know casting folks otherwise But I'm just thinking I'm like imagine there's like it's like a drama or a love rom-com and the Rockets cast is like a nerdy empath or something like that.

1:30:02Dr. Jordan Feigenbaum:It seems highly unlikely to me. But yeah, I don't know. Does this change the way people view this maybe hyper muscularity sort of thing in your opinion?

1:30:12Dr. Austin Baraki:Yeah, hard to say whether this reflects any sort of more generalized like social trend. But, you know, I remember when we were getting into the lifting world, do you remember what was his name? Justin Lasik's website, 70s Big? 70s Big, yeah. That was a very entertaining resource back then. But there is this kind of more at this point, it does feel a little bit more like historic glorification. And this is outside of like the highest level competitive bodybuilding scene, because still at the highest levels of competitive bodybuilding, you see the freakiest physiques that are looking more and more alien each year that that goes on, it seems.

1:30:44Dr. Austin Baraki:But if that's what is incentivized, then so be it. But that's not necessarily what's reflected in broader society. But this is interesting that things are kind of evolving in this direction. It also feels like there might be some evolution in that just in the training world at this point, outside of people trying to get as huge as possible, again, outside of competitive bodybuilding, that there's a lot more people, I don't know, maybe this is just within our bubble, but, you know, leaning into conditioning a little bit more and not necessarily aiming for those kind of maximalist physiques or really on either end of the spectrum.

1:31:19So I hesitate to speculate

1:31:24Dr. Austin Baraki:on whether this is a general, more broad societal trend, but I do think that people at that level of social popularity like Bautista, like The Rock, things like that, if more of them continue to do that, then that's the kind of thing that does percolate more into society and pop culture and things like that and kind of define the trends and what sorts of physiques and things like that people are seeking with their training and activity, where maybe at one point in the past people were more like, I remember hearing a lot about the Brad Pitt Fight Club look that people were looking for, which is quite skinny in that look, versus massive, like the rock in many of his prior roles or Bautista, and now maybe a little healthier in between, potentially.

1:32:08Dr. Austin Baraki:I don't know.

1:32:09Dr. Jordan Feigenbaum:Yeah. Did you ever watch, what was it, Beer Fest? Gunther is I mean that dude is one of the biggest Bodybuilders ever I think his off season weight pushed into the low 300s And he's still just huge But he's cast there to be this big German Drinking machine And I'm like cool I don't know It wouldn't surprise me if The Rock ends up doing A high rocks just to lean into that Sure that'd be cool Did you have a favorite wrestler like WWE Or at that point WWF wrestler growing up Oh, I was a kid for sure. That's fine. Maybe we'll bleep that out so people don't know. Ric Flair is obviously my guy. Sure, yeah.

1:32:50Dr. Jordan Feigenbaum:Can we get a woo to sign off? You got a woo for me? Woo! That's right. All right. Well, that is a wrap here on the Barbell Medicine Podcast. We bring modern medicine to strength and conditioning and strength and conditioning to modern medicine. Special shout out to Dr. Austin Baraki for joining us on the fourth episode of The Rundown, where we bring you the latest headlines in medicine, fitness, nutrition, and sports. I'm Dr. Jordan Feigenbaum. We'll catch you next week and every week right here on the Barbell Medicine Podcast. You've probably noticed that we're doing more ad reads lately to keep the lights on and the microphones powered up.

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