Episode #371: Q/A- Optimal Fitness Standards, GLP-1s, "Race-Based" health metrics, and More!

0:00This is our first seminar in about a year and a half. We held it at Sal's gym, Watchdog Strength here in San Antonio, Texas. Thank you guys so much for joining us. This is our Q &A. Obviously, you guys submitted the questions. Austin picked out his personal favorites, so if yours wasn't picked, it's his fault. DM him. I can also give his address. You can send him personal mail for that. Some of them will actually receive direct responses because they might have needed more information or they might be something that you just need a consult for, not something that would be appropriate to discuss here, depending on the depths of medical aspects.

0:35All right, so you'll read the questions. I'll read the questions. And I will just sit here like a wart. Okay, good. Number one, is there any evidence that looks at the optimum balance of strength, cardiovascular capacity, and body composition? For example, squat one and a half times body weight or deadlift double body weight, VO2 max over 50, body fat 13 to 15%, et cetera. I'm interested in what metrics you guys would use as measures in each of these as goals for quote-unquote all-around or optimal fitness? Woof. You've looked into this a bit. Yeah. If I'm understanding the question, it'd be like what sort of metrics for each individual parameter, and I think that's more, I mean, this is an answerable question, just whether or not we actually have the technology and have the data to answer it as desired.

1:19So if we break all those things apart, like what's optimal for strength and how do I think about either measuring and then categorizing somebody as, oh, you're strong enough, you need to gain more strength, or you need to gain a lot more strength. Yeah, the evidence on a particular strength threshold, we wrote about this on our up-to-date article on strength training in primary care. It looks like somewhere between 1.5 to 2x body weight for one rep max leg press for men. We extrapolated some data out on how strong women tend to be relative to men, and that looks like it's like 1.2 to 1.5x body weight leg press for women.

2:00For bench press, it's close to 1.5x body weight, the machine chest press. So we think it's like 1 to 1.1x for women. That's like a strength to strength cutoffs. As far as how confident I feel in those, not confident. But I think it does highlight a broader point that actual improvements in strength, while important, we probably need to get less strong than most strength training enthusiasts think you should be in order to like optimize your health trajectory as far from a strength perspective so i'm thinking like if a if a guy can squat his body weight on the bar that may actually be strong enough like lower body wise to be like yeah you're checking you're checking the box i don't know that to be true.

2:46Maybe that's a little light, but I think there are both like direct benefits of continuing to engage in resistance training, even if you're not really gaining much strength much longer, but you need to get us to a certain level of strength. We just, I just don't really know what that is. I think those leg press and chest press parameters are reasonable targets. And just to be on the safe side, I'd probably go a little bit more than that. From a cardiorespiratory standpoint, VO2 max, this is going to vary based on age and gender over time. But yeah, VO2 max greater than 50 for a guy that's, you know, 35 to 55 would be great.

3:26But I think higher would be better still. And I don't know that there's an upper limit to that. You just kind of run out of VO2 max improvement that's going to happen. So yeah, for women, it's going to be about five to ten less less than that but I just don't think there's an upper limit. The average VO2 max in the United States right now I think is like for adults is like 35 or 36 for dudes which is relatively untrained so if we could get most people to above 40 or mid 40s I'd be stoked and then higher than that obviously takes more training to get there but I'd be a big fan of that as well and then for body fat that gets even more challenging mainly because there's these individual fat thresholds that where I think disease tends to become a higher and higher probability of occurring.

4:15And I don't feel confident being like, dude, stay under 20 % body fat. You'll avoid that most of the time. Women stay under 28 or 30 % body fat. You'll avoid that most of the time. It just seems to be a little bit more variable than that. So I think actually the waist circumferences are kind of where I would default to if I had to make a population-wide sort of checklist like make sure you can leg press twice your body weight or thereabouts make sure you can machine chest press your body weight if you're a woman or about one and a half times body weight if you're a dude make sure that you have less than a you know 37 inch waist circumference if you're a guy less than 31 inches if you're a woman and that your vo2 max is as high as you're willing to get it as high as you're willing to get yeah do you find any of that like terribly not objectionable i mean i think that in practice day to day i see the negative effects of insufficient muscular strength every day but that's also the bias of my practice setting being mainly in like inpatient care in a hospital where it's like this person is not strong enough to get out of bed so i am constantly faced with insufficient physical strength and the and the complications and consequences and poor physical reserve when people get ill and things like that But at the other end of the spectrum, it's harder to observe, for example, the benefits of higher and higher and higher strength levels for me to feel confident that, oh, because this person can bench 315 instead of 290, that their health status is markedly better.

5:43And the reason I'm talking about just observation here is because we don't have great research onto this. There's so much more historical evidence base in the realm of cardiorespiratory fitness and aerobic adaptations and things like that than we do with strength and muscle mass and power. We have tons of this cross-sectional correlational data where it's like, yeah, we know higher hand grip strength associates with less disease mortality, more appendicular lean mass, more muscle mass associates. And there's so many other reasons why somebody at the low end of that spectrum is going to die more.

6:11And somebody who can maintain higher levels might survive longer, even outside of the muscle itself or the strength itself. So interpreting that stuff is challenging. But where we do have more evidence and more data is in this realm of cardiorespiratory fitness and things like VO2 max. Caveats of interpreting VO2 max notwithstanding, we can feel more confident that pushing that up higher will provide an ongoing benefit. although like everything else, diminishing benefits over time. Whereas we suspect that the benefits of further strength improvements plateau probably earlier and certainly earlier than we would like, given how much time we've spent training.

6:49The idea, you know, not that we did it all for health, certainly to reach the levels that we did, but knowing that it probably got tapped out pretty early on as far as health outcomes go, assuming you're able to sustain that long term. So that's why we feel that a lot of folks who are inculcated in the strength and power community are probably under conditioned when it comes to health outcomes, or at least we try to make sure they're not under any illusions that just continuing to add more and more and more strength is going to add more and more health indefinitely for them, even if it would be cool for them if that were true.

7:22Not as confident. You know why we out of this cardio stuff and none of this resistance training stuff? What is that? Dr. Kenneth Cooper of the Cooper Institute. comes up in the 80s. Big cardio focus. Aerobics hits the scene. Nobody's interested in getting jacked anymore. Yeah. No, shout out to Kenneth Cooper. His stuff is great. All right. Number two. Yeah, you want to read this? I got it. Yeah. Can older adults reverse bone loss with exercise alone after being diagnosed with osteoporosis? You want me to start? Yeah. Sure. I want to point out just one thing up front here that osteoporosis, while it is a diagnosis, it is a variable condition.

8:05It's heterogeneous. There's a variety of different degrees of it, severity, and there's also a variety of different underlying causes and contributors to it. So for example, you can have a parathyroid-related disease that if we just treat that, which can involve a simple surgery in some cases, boom, your bone loss will bounce back, sometimes even so quick that there's other complications that can happen with your blood calcium levels and things like that because of how fast you can bounce back from that kind of thing. So there's the upfront point I want to make here is not all osteoporosis is the same.

8:39And so I don't want to overgeneralize and say, oh yeah, everybody with osteoporosis can build bone mass and restore it because each situation, while it might have the same diagnostic label based on a bone density measurement, there might be different causes, contributors, things like that, that might respond differently, for example, to a diet intervention or a training intervention. Athlete. Yep. If we are dealing with quote unquote common kind of postmenopausal osteoporosis that's not due to one of these other underlying causes, the degree to which the bone loss can be reversed is, I would say, two things.

9:12One, relatively modest, if it is going to be possible, but B, also variable between people. There are some folks who I have seen or worked with or are even members of my family who might have been diagnosed with osteopenia, for example, and they train and they train and they train, and maybe their numbers don't tend to look much better over time. And they get very frustrated by this until I have a much more empathic and detailed conversation with this person to point out that the number on your report is not the problem here. The number on the report is a component of your overall risk, and we care about preventing the bad things from happening.

9:54You don't feel your bone density, but you feel if you have a fracture. We hope not. And if you are training and improving your general health and your function and your ability to control your body and reducing your risk of a fall and likely also reducing your risk of a fracture, even independent of the bone density measurement, that's a win. That's preventing the thing that I mainly care about. If I can get a little bone density increase on a reliable measurement over time, that's awesome. If it's staying relatively stable in that postmenopausal osteoporosis situation, sometimes that's also a win because it's not declining precipitously, right?

10:30So I often end up kind of like our pain and rehab conversation, end up reframing that discussion to put the emphasis on the thing that matters, that I'm trying to prevent falls and fractures and things like that, and trying to shift a little bit of focus away from over fixation on the number itself, right? Because the number itself is not the disease, right? It's part of the diagnostic criteria, but what we care about is the complication, right? So that's kind of where I put my emphasis. And then, of course, this question specified with exercise alone, but it doesn't have to be with exercise alone.

11:01We also have various medications of different classes that can further support those efforts to either mitigate, forestall the decline as time goes on, or potentially there are some anabolic agents that can actually help build bone mass. But that's kind of how I end up framing it, is anything that is mitigating our risk of falls and fractures and the actual bad things is the most important. And if I can slow down the rate of decline, that's also a win. If it keeps it stable, that's also a win. And if it goes up, that's also a win. That would be the way I would have this conversation. All right, I have a question for you.

11:332A, if you will. Okay. Because we know that bone mineral density, bone mass tends to peak, particularly in women, 30-ish, right? So the idea is start early, get that peak real, real high, and then, you know, don't fall off. You get a 30-year training period, all right? And it's either from 20 to 50 or it's from 40 to 70. All right. In women, which group would you predict to have less falls and fractures in their sixth decade? That's an interesting hypothetical. If I could choose which are going to train, probably the latter would be the one that I would prefer. Oh, really? Yeah. Just because they're more actively training at that time, so likely to have better functional scores despite perhaps a lower bone mineral density.

12:22If they were going to stop after 30 years? Yeah. That would probably be my preference, and that I think is heavily informed by my bias of most of the patients that I end up seeing are in those older demographics and are not active and are not functional. And the decline ends up being super rapid, whereas it would be pretty responsive to training. Yeah. So there's the debate between you want the higher peak of bone mass early in life, and you want to keep training to keep it as high as you can, even if it's going to gradually decline. So the essence of your question is, would you rather have the highest peak possible, even if you let it decay later on, or would you rather maybe not reach quite as high a peak, but do everything you can to try to forestall the decline?

12:56That's an interesting hypothetical. But fortunately, we don't have to choose between those two things. Por que no los dos? Yeah, no, that's a good one. Okay. Right. Number three, with respect to dietary patterns, why is grazing bad? Which I'll let you define as well. Does it interfere with muscle protein synthesis or what's the problem with grazing? Yeah, grazing, if we can define it as just instead of having discrete meals where there are periods of you're actually eating food and then longer periods where you're fasting in between meals. So if you're grazing and that you never get any prolonged period of fasting between meals, which I would define as greater than about three hours or so between meals.

13:36Yes, it does compromise muscle protein synthesis. Generally speaking, the machinery that drives muscle protein synthesis needs to be reset between bouts of being elevated or periods of being elevated. So when you eat a meal, muscle protein synthesis rates go up. They peak, depending on the protein source, about an hour to an hour and a half after you have finished your meal, and they go back down to baseline. And then you can do that again about three hours after you've finished a meal. Now, if you never finish a meal because you're always eating, you never get to reset that machinery. So we think there's less muscle protein synthesis.

14:17This is also known as like a muscle full effect. Atherton, I believe, described this. And so, yeah, we think there's less muscle protein synthesis. The muscles become a little more anabolically resistant with persistent grazing, especially if it's in an environment where you're getting, like, food through a tube and you're sitting, hanging around. There's also some evidence that increases rates of insulin resistance as well. You want these periods of fasting in between without food so your body can kind of use, store, and get that energy out of the bloodstream such that you're ready for the next meal.

14:51And so the problem with this evidence is that we don't have a ton in a free-living society where you would control the total amount of energy intake and the macronutrient intake and say, look, these people ate pretty continuously throughout the day over a 12-hour, 16-hour window. And these people had three discrete meals separated by five hours at a time. Same calories, same macronutrient, same dietary pattern overall except for the frequency. You would want to see that study just to feel super confident in this. But when it comes to dietary patterns with respect to meal frequency, I don't think grazing is the best choice.

15:29Yeah. My concerns with grazing, though, to be clear, are not at all related to concerns over muscle protein synthesis. That's not where I'm worried about it. My bigger concern with grazing is that, yep, we're not meant to be constantly postprandial, which means always in a fed state for a variety of reasons. and my concerns relate more to the insulin resistance aspect that can happen with being continuously fed and also that with cardiovascular risk because it depends on what you're eating. So if you're eating things that contribute to basically what are circulating particles in our blood, like blood lipids and some cholesterol related things and triglycerides and things like that, we always have these post-meal remnants that are circulating around all the time.

16:11We never clear that from our bloodstream. All of that increases the risk of cardiovascular disease and things like that as well. So these things that we eat, we absorb, go into our blood. Ideally, they get cleared, spend a bunch of time cleared from our blood before the next meal rather than constantly being around all the time, which I think is probably the bigger problem with grazing than people not getting jacked as enough from their muscle protein responses. Yeah, I think it's just more points to the body's general response to always being fed. So not only is it not good for like the majority of your organ systems by way of insulin resistance, but yeah, the muscles become a little resistant to.

16:46Interestingly, that sort of data may be one of the impetuses or driving forces behind the popularity of intermittent fasting, kind of making a big push where, like, look, if you eat all the time, bad stuff's going to happen to you. So let's do it intermittently. Let's have extended periods of fasting, which would be a fine way to eat. Time-restricted feeding can be a viable option for folks. I don't think that people get better results from using that particular approach, save for folks who already have some demonstrable insulin resistance. They have type two diabetes, metabolic syndrome. In those individuals, it does seem like matching up their meal intake with the daylight hours tends to be a little bit better than eating most of the calories at night.

17:35So it's kind of intermittent fasting, but in reverse. Eat most in the morning, in the afternoon, and early evening and then be fasting when it's darker outside and have a prolonged fasting period overnight. Other than that though, yeah, I'm more worried about grazing from the insulin resistance thing and also just from over-resumption. All right, number four, how do the effects of GLP-1 agonist medicines change when they are combined with diet and exercise compared with when they are not combined with diet and exercise? We talked about this a little bit on our podcast. I think was the lean mass loss in dieting.

18:09I think it was 223 or 233. I forget which episode, which is crazy. That's like 130 episodes ago. Also crazy that it's still in my brain. Anyway, yeah, there's a few studies out there on this. I know one of them with loraglutide, which is not typically used or favored for a GLP-1 for weight loss. And I forget what the other one has been used. But either way, the results are the same. And it's exactly how you would predict. Individuals who are using diet and exercise with the addition of a GLP-1, they tend to lose more fat mass than those who are taking the placebo. That said, the individuals who are taking the GLP-1 receptor agonist also seem to be able to gain strength, and there's no difference in strength gains between the placebo group and the GLP-1 group, and there are no changes in the amount of lean mass that is either gained or lost in this application, which is interesting because you would expect, well, if they lost more fat mass, they would also lose more lean mass, but it's liraglutide, so it's not quite...

19:11Not the most potent. Not the most potent. So what I would predict, if you set up a trial where people were using Zep bound, so terzepatide, manjaro, which is probably one of the better agents that we have right now, one group was getting that at max dose, the other group was getting a placebo, and both were getting dietary and exercise interventions on top of that. I wouldn't predict any sort of strength change outcomes differences. They would both gain strength in response to exercise. I would predict more lean mass accumulation in the lifestyle only group with the placebo, mainly because they won't have lost as much fat mass as the Zep bound group.

19:45But I would predict way more fat mass loss in the Zep bound group and total weight loss as well. Yeah, I think they're powerful. The other thing I want to mention here is that the existing data we have here on people who get prescribed GLP-1 receptor agonists and their physical activity habits is that they actually tend to increase compared to placebo. Now whether or not that's because people feel like it's working, I'm losing weight, and it's like a positive feedback loop, or somehow they figured out they were actually in the study arm and they were like, well I should add some exercise to this to get the most out of my time here.

20:18I can't speak to that, but I do find it interesting when people say, oh yeah, people are just taking these drugs so they don't have to exercise. I'm like, well, it actually makes them on average exercise more every week. And to that point, do you care how these people achieve the end goal or do you simply care that they get better? Because I fall in that latter category. Yes, I would prefer everyone to exercise. Yes, I prefer everyone who is able to eat a health-promoting dietary pattern. But I care more about that than people being lessening a risk factor for a lot of different diseases that are a burden to effectively everyone, including the person.

20:55Yeah, I've talked about this with you. I've talked about it on the podcast with several people who are here this weekend that I wish maybe we'll, you know, at some point spend the time to sit down and pull the best data we have, which we do have in some of our lectures on the effectiveness of the diet and exercise alone for various outcomes and its impact on health, then the effectiveness of the GLP-1s maybe without necessitating or requiring some lifestyle intervention, and then maybe with. and then blinding people to what is what and saying, which would you pick? The one that gives you this chance of sustaining clinically significant weight loss at 20 years.

21:31The one that gives you this chance of sustaining clinically significant weight loss at 20 years. And then the one that causes you to have less heart attacks, GLP-1s. The one that causes you to have less heart failure, GLP-1s. The one that causes you to have less chronic kidney disease progression. Less and less and less of all these bad things that we're discovering now. and then using the tools that we have available to us to get people the best health outcomes if they're willing and able to do diet and exercise in addition to that that's great but if they're not should we be gatekeeping this and say well you don't deserve these benefits from these things or do i just care that you know i would encourage you and i'm going to do the motivational interviewing and i would also prefer that you die less yeah by using these types of things you can't cheat bro the outcomes are more what we care about no you can't use tools to help.

22:18In fact, we should ban fitness coaches until someone has failed trying it on their own multiple times and only then can you get a fitness coach. And if you fail fitness coaching, then you can get drugs. Okay, number five. Given that the best way to learn motivational interviewing is to practice motivational interviewing, like specificity of adaptation to the imposed demands, how would you try to teach a coach or provider how to do motivational interviewing. That's question 1A, 5A. We'll come back to the second one. Outside of practicing it, how would you try to teach somebody how to do it? Maybe just telling them to practice, maybe they don't know where to start or how to go about it, what to do.

23:00I think that's more of like self-inventory. What is your general approach to getting somebody to change their diet now? Because if it's just an assessment, you take that assessment and then you come up with a plan in isolation and then you deliver it to them, That'd be one strategy. But I'd also be wondering about, like, well, what are your success rates with that? Because if it's great with your population, like, yeah, learning motivational interviewing is a great skill, but, like, I don't know that you need me to tell you, like, what to do if you're already getting great success. So I think looking at what somebody, an individual is doing and then figuring out where does the conversation go when it comes to actually developing the plan?

23:41Because I think most coaches that I've interfaced with, they tend to ask a person, what would they like to do? What are they willing to do? And what they're currently doing right now. And that's all some form of motivational interviewing, whether or not it's effective or not. Yeah, I don't even know that most coaches are doing that. Yeah. I think a lot of them are just like, here's the plan. Yeah. Yeah. So, I mean, if that is, in fact, the case, then I think maybe changing from this more like patriarchal relationship where it's like, you ask me what to do, I will tell you what to do. That is a way to go about giving someone recommendations, but I think having a more collaborative approach would be the idea.

24:19So asking a person, okay, great. So you're up for change. Love that. What would you like to do? What are your preferences? What obstacles do you feel like you're going to be facing? How do you think you're going to navigate them? I mean, now you're just opening the door to have these conversations about tailoring the plan so you don't have to project your own preferences onto the person. And I feel like it's likely to be more successful because you don't run into anything like, oh, why did you tell me to go buy a bunch of brown rice? I told you I hate brown rice. And you're like, well, actually, I never asked you if you like brown rice or not, for example.

24:53So I think that kind of intermediate step between assessment and the plan is a perfect time to start practicing, asking about preferences, what somebody's willing to do, what their perceived barriers are. And then whatever, once you do that a few times, you'll kind of run into a few awkward moments. And those would be the points I would focus on. Okay, why did I run out of things to say? Like I don't know the phrasing or did I get surprised by the answer or something like that? I think those are good teaching points. But yeah, I don't know. I'd be really interested to know what coaches are doing if they're not asking any sort of questions to the individual.

25:31You could do mock interviews with another coach, another person, but if you're actively coaching somebody, I do wonder how you end up coming up with the plan without actually talking to the individual. Yeah, as someone who does teach clinicians how to do this kind of thing, a lot of it comes down to some combination of modeling and mentorship. And if that is not something that's easily accessible to you, then pursuing formal training, I think, would be the best strategies. Self-teaching this in the absence of any like resources is going to be quite challenging because you're going to be sitting there.

26:07You're going to be like, am I doing it? Is this motivation? When did it, when did I start doing the motivational interviewing part? And there's not a discreet, you're doing it now. It is ultimately, you know, I don't go into like, oh, I'm in like motivational interviewing mode. It's just in, you know, imbued in my conversation with the patient throughout and it's just a back and forth. And so a lot of times I will, like if I'm happening to do it in the hospital setting, I'll bring one or more of my learners with me, might be a student or an intern, come watch this, hang out in the corner if they've never seen it before, or I might have them pull up a chair and introduce them to the patient just so that they can be present and potentially involved in the conversation.