Episode #373: Deadlift Data- The Truth About Sumo vs. Conventional, New Study Finds Hard Cardio 9x Better, and Ozempic's Muscle Secret

28:56And when you get to the halfway point before you take your first breath, that's a positive test, which basically means, oh, you're probably around this ventilatory threshold one, which signifies, yeah, you're probably getting into definitively this is exercise. And to me, that's a more practically applicable way to measure like, am I exercising or is this physical activity? The last thing I'll say here, I'm not hating on walking or light intensity physical activity or just generally being active. I think all that stuff is useful. It certainly is beneficial, just being more active, generally speaking, it displaces sedentary behavior, displaces other behaviors, like eating, for example, for some folks.

29:39But I don't know that it actually contributes to fitness that much unless it's at the correct intensity to drive those adaptations. Fortunately, the intensity range that works is quite wide. You just have to get to that threshold, which is probably around 60 % of your max heart rate on the low end. And like, I don't know that METS act, you know, captures that well. I think that's a reasonable argument. My only counter, I guess, not based on tons of evidence or data, but the low level activity, I think, can plausibly contribute to fitness, depending, of course, on how you're testing fitness. But it's just that the dose in terms of volume has to be massive.

30:20Yeah, right. And so I mean, historically, if you go back through the history of endurance training, there are people in the olden days, who their main training for marathon was hours and hours and hours and hours and hours of walking. And so it is possible to build fitness through that way, through those methods, but that's kind of the scale knob is volume versus intensity, which is obviously debates that's been going on forever. And we can stand to benefit from both. A little bit of both. There you go. Well, overall, I think maybe the bigger takeaway outside of all of that is, hey, we just need some better definitions and ways to communicate exercise intensity.

30:53So fortunately, the American College of Sports Medicine just put out a new consensus statement on definitions for exercise intensity. They basically cited that there's inconsistency with jargon with terms like light, moderate and vigorous are used in public health. But sometimes these are interchanged with low, moderate and high. And the definitions for both are not always the same and cutoffs for both. So, for example, light physical activity is said to be less than three metabolic equivalents, whereas low intensity cardio is often said to be less than 60 percent of max heart rate. And sometimes these things don't match up.

31:29So, like, where does exercise start? You know, how do you how do you communicate this? So this ambiguity is not only a problem for public health, but also in research. Right. Because you'll see a paper says high intensity cardio works better than low intensity. You're like, well, what does that mean? It's not immediately understood. And so then you have to go into the methods and you're like, well, why did you define it this way? People just kind of choose their own adventure here. So they came out with a new set of recommendations. First off, the intensity domains, there's five of them, according to this new consensus statement, very low, low, moderate, high, and very high.

32:03And so what they tried to do was apply this to both cardio and resistance training. So for cardio, they said a very low. Well, look, we admit there's no current measure for this. So just go with God. We don't know. For low-intensity cardio, they say this has to be below the first metabolic threshold. We'll get to this metabolic threshold thing here in a second. For moderate-intensity cardio, it's between the first and second metabolic thresholds. Again, we'll come back to the metabolic threshold. For high-intensity cardio, it's between your second metabolic threshold and maximal work rate. So it's basically like you're exercising at maximum intensity, but you can sustain it for a little bit, so not a sprint because you can't sustain that.

32:48And then very high intensity cardio is above your maximum work rate. So it'd be like a sprint basically. And then they tie this to resistance training where very low intensity resistance training is greater than eight repetitions in reserve. Low intensity resistance training is between seven to eight repetitions in reserve. Moderate intensity resistance training is between four to six reps in reserve. High intensity resistance training is between two to three repetitions in reserve. and then very high intensity is less than two repetitions in reserve. On the one hand, this does seem to unify everything.

33:22It is neat and tidy, but I got some problems with this. Let's go. First, the resistance training thing is interesting because like, wow, this is almost the first time that this has ever tried to be like tied together. But without a rep range or like some sort of measurement of relative intensity, I think it lacks specificity. So, for example, somebody could do a set of 30 with RIR less than two, but that's not very high intensity. It's hard, but it's just not heavy enough, right? And I go back to that Schoenfeld meta-analysis. It's a seminal paper basically showing that strength improvements are greater with higher intensity weights, higher intensity loads.

34:08And the cut point here is like 60%, 65 % of a one-rep max. And so if the assumption is with the scale that nobody's doing sets greater than like 15 reps or 20 reps, then sure, it holds. Right. But that's not always the case. And I think that that wasn't anywhere in the paper. Yeah. Failing to differentiate proximity to failure from intensity as actually different concepts that get conflated a ton by by people because they envision even a low intensity set. So a relatively lightweight, but if you take it close to failure, man, if you look at the person's face on those last few reps, it looks super intense.

34:45And so intensity can be just a confusing term when these two concepts that are actually distinct are conflated because they lead to different outcomes and different adaptations. Yeah. So I don't, I don't have a suggestion for this other than like, you would probably want to say, look, this is really for sets less than 20 reps or less. Like that's the cap, right. Or a 15 rep max load or more or 60 % of one RM. But ultimately, like, I think that's fine for a research setting, maybe not great for public health. I don't know. No one asked me. Then this concept of a metabolic threshold. So if you start your consensus statement out saying, look, definitions and words and nomenclature, these are all highly variable in the exercise science world.

35:32And we need to come up with a consensus. And then you introduce a new term, metabolic threshold. It's not really new because the concept has been discussed for decades and decades, but just no one uses this word, this phrase. This term is used to describe an exercise intensity that results in an apparent change in metabolism. That's why it's called a metabolic threshold. So changes in oxygen uptake, carbon dioxide production, ventilation, blood lactate levels, so on and so forth. So from that definition standpoint, it seems fine, but like what are we really talking about for metabolic threshold one, metabolic threshold two?

36:07They're equating metabolic threshold one with the first lactate threshold, which represents the initial increase in blood lactate above resting levels, also called the aerobic threshold or ventilatory threshold one. Okay. And then the second metabolic threshold is approximately the second lactate threshold. This is where lactate accumulation rapidly outpaces the body's ability to clear it, also called the anaerobic threshold, the respiratory compensation point or ventilatory threshold too. These things don't all line up perfectly, but they're close enough for this type of work. So I don't know.

36:41Maybe I'm just being a jerk and pedantic and whatever, but I'm just annoyed that they picked metabolic threshold. Why introduce a new term that's not commonly used? yeah it is i guess maybe helpfully or appropriately drawing a ton of attention i don't know away from lactate i don't know if that's something that we feel was necessary but there's some potential benefits to making people worry about lactate a little bit less although there's certainly you know validity to it as a as a concept on its own in exercise physiology and metabolism and so making it a little bit more of a general thing i don't know we're just kind of spitballing here but is what it is i doubt that this is going to have any meaningful impacts on anything in the near or medium term.

37:24Well, that's the thing. Like, so with the, if this new thing is adopted, right, this new, these new intensity domains are adopted, like in the research space, maybe that's helpful. But then when you look back at historical data, then you have to kind of like reverse engineer what they did. And hopefully all these things were reported. So I don't know that this is helpful, but maybe it'll be helpful 50 years from now, if this is widely adopted and like we have a better sense of things outside of maybe the concerns about resistance training that we talked about. But then now, if you're trying to compare like high intensity or very high intensity cardio to moderate or low intensity cardio based on these five intensity domains, do you have to measure their blood lactate to like make sure they're above a metabolic threshold?

38:08Sure. Yeah. I don't know. So, okay. So what do you're listening to this? If you're listening to this podcast and you're like, what the heck, how does this affect me. It doesn't. Just broadly speaking, it doesn't. I think, you know, with our previous discussion that we're vigorous intensity, physical activity did better than moderate intensity, physical activity as measured by METS, and the confusion around maybe these metabolic thresholds, and you're like, well, look, how hard should my cardio be? Just like, can you tell me? Well, we want the majority of it to be right around metabolic threshold one, that you'd call that zone two, All right.

38:45And if you're exercising at that level of intensity, where, again, you're becoming breathless when you try to say a phrase like the Pledge of Allegiance, for example, it's hard enough. But it's not so hard where you can only do a little bit of it or I start worrying about fatigue. Now, that the main concern there is if you're actually doing a ton of conditioning throughout the week, like more than three hours or so in a given week, if you're doing less than that, I honestly don't care. The only thing I would really care if someone is doing less than three hours and like, oh, Jordan said I could just do as high intensity as I want.

39:17I'm just doing all sprints. I'm like, well, that's probably not a good idea either just from a fatigue standpoint. So I do think that the talk test, making sure you're kind of around that metabolic threshold one, which we can identify with the talk test, that seems reasonable. If you're at or slightly above that, I feel fine. And if you want to do some sprints on top of that, that's all well and good. it really starts to matter how you distribute your intensity far more when you're doing an actual large volume of conditioning. Does that seem reasonable to you? Yeah, I think the only other caveat that I would add is that your level of training advancement has a significant impact on how these things are distributed.

39:56And it's kind of baked into your advice there to where you said that the way you distribute it matters more when you're doing high volumes. And most people are only ever doing high volumes when they're at later stages of advancement, but that might not always be the case. I think that when you are newer to training, you can often get away with dipping into higher intensity more often. And actually, that is the case for both aerobic and strength training as well. We see people who, you know, push their, you know, rep max effort sets multiple times a week in beginner programs all the time, where you're just adding weight to the bar all the time, and you can get away with it for a bit of time, but that's not even a medium to longer term training strategy to be able to do that.

40:36So the more your level of training advancement progresses, you definitely need to distribute your intensity much more differently. And so I tend to put fewer limits and recommendations and things like that in. In other words, giving beginners more options to explore and experiment. And then if somebody gets motivated, if they start to have specific goals crystallize as they get more advanced and they need to be able to do more, then definitely those details become more and more significant over time. But a lot of people could do with trying a bit harder a lot of the time. Yeah. Dr. Derek Miles has said something that I do think happens to be true, that generally speaking, when people are trying to do this, you know, modern intensity steady state stuff, zone two, whatever, it's usually not easy enough.

41:21And then when they're doing sprints or the high intensity stuff, it's usually not high intensity enough. Yes. Yeah. I think that it sounds truthy anyway. Sure. Yeah. Yeah. Sounds truthy. Anyway, this is an open access paper. So all these resources are linked in the show notes below. You guys can read it. And if you disagree with me vehemently and you want to argue about it on the internet. This podcast is brought to you by Biggs. At Barbell Medicine, we spend a lot of time talking about what it takes to build a body that can handle high level performance. But the recovery and health side is just as critical.

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43:01I know you're a big regulatory T cell guy, but it wasn't just the discovery of that, but this genetic switch, which is FOXP3, that controls at least some of the regulatory T cell activity. Now, regulatory T cells are an immune system cell, and this FOXP3 genetics switch is heavily involved in a lot of autoimmune diseases. So in 1995, Shimon Sakaguchi discovered this previously unknown class of immune cells that usually protect the body from autoimmune diseases. These are named regulatory T cells. In 2001, Mary Brunknow and Fred Ramsdell identified a gene that they called FOXP3, and they demonstrated that mutations in this gene are the cause of serious autoimmune disease known as IPEX syndrome.

43:50Have you ever heard of this? I have not heard of IPEX syndrome. I mean, when you go down the road of autoimmunity and autoinflammatory diseases and things like that, this is an insanely complex space. A lot of genetic and molecular signaling and cytokine mediated things that, you know, is complex, even for subspecialists in that field. Yeah. Look, if you're a rheumatologist and it's actually IPEX syndrome? My apologies. I'm unsure. So it stands for, it's an acronym, it stands for immune dysregulation, polyendocrinopathy, enteropathy, and X-linked syndrome. So IPEX, IPEX, seems reasonable. So this is caused by mutations in that FOXP3 gene, which is located on the X chromosome, and it makes the gene non-functional.

44:32So under normal conditions, the functional gene helps regulatory T cells not attack our own body. But if it's not functioning, the system runs amok. So this leads to early onset type 1 diabetes, thyroid disease, malabsorption, failure to thrive. Yeah, usually caught pretty early and some severe long-term problems here. In 2003, Sagaguchi connected the findings of, you know, hey, previously discovered regulatory T cells and this FOXP3 gene. He connected these findings showing that the FOXP3 gene governs the development and function of regulatory T cells. All right. So they won this Nobel Prize.

45:06What's the relevance? You're listening to Barbell Medicine Podcast. What the heck? Is just like a Nobel Prize thing? Well, these FOXP3 expressing T-cells are also involved in recruiting satellite cells for muscle tissue generation. So their function is obviously impaired when people have this non-functioning genetic mutation, and it's involved in inflammatory myopathies like poly and dermatomyositis, which they have less satellite cell recruitment. So that failure, there's a failure to put the brakes on the immune systems repair process. You get uncontrolled inflammation at the level of the muscle.

45:44You get fiber necrosis of the muscle fibers. You get muscular atrophy and fibrotic replacement of muscle fibers. And so, yeah, weakness and such can appear. Now, I went down the rabbit hole here and I know neither of us are rheumatologists and whatever. And so there is a link between the amount of disease control and the amount of fiber necrosis and weakness that's seen here, which is kind of what you would expect. But I thought that was interesting. There's some muscle biopsy studies where they actually look at the amount of satellite cell and myonuclei per muscle fiber, and they can kind of correlate that with the level of disease severity, which I thought was interesting.

46:21So congrats on the Nobel Prize. uh now we need to do the final step figure out how to fix this thing so yeah yeah it's an interesting topic and and to to your point the immediate applicability to the audience is is going to be limited here but here's kind of another angle on this there was another paper in the newland journal that came out within the past week or two um it's not actually formally part of our uh outline or our topics for discussion today but what they basically looked at was large cohorts of patients who had been diagnosed with certain medical conditions, essentially clinically, meaning the patient had what looked like a prototypical syndrome that looked like maybe celiac disease or maybe looked like some other kind of known diagnosis.

47:07And they did further genetic analysis on these folks. And in a significant proportion of these patients, what they found was that they actually had distinct different genetic syndromes that led to that similar kind of overall clinical phenotype or made it look like a condition, but it was actually a misdiagnosis of an underlying genetic syndrome that hadn't been recognized, which I can totally, as a clinician, I can totally see how this happens. If a patient looks like they have a particular diagnosis and I'm confident enough to, you know, rubber stamp that as their final diagnosis, I'm unlikely to go a ton further and do a bunch of advanced genetic testing, at least based on the, you know, standards of practice today and the technology that we have readily available to look for these types of underlying things.

47:52But recognizing that these things are possible has led to a lot of changes in how diseases are recognized and diagnosed and how they're associated. Even since we were in medical school and training, a lot of this stuff has evolved and additionally leads to more disease specific and more targeted therapies towards the specific genetics that a person, you know, is manifesting. And this in the most obvious example is like targeted chemotherapy type drugs for certain types of cancers based on the specific genes that they're expressing. But following this for me is useful, even though I'm not a rheumatologist who's going to be routinely doing this type of advanced genetic testing, but I do see and diagnose polymyositis and dermatomyositis and thinking about, is this just run of the mill that condition?

48:37Or could it be part of one of these broader syndromes, for example? I'll give you one last example, something else that came up for me recently with a patient, and this also reflects this evolution over time, is I had a guy in his 70s, and he had a history of atrial fibrillation, super common condition. When I went through school and training, this was like, oh, yep, atrial fibrillation, it happens. We'll put you on a blood thinner, we'll control your heart rate, and that kind of is what it is. And then he also had some chronic back pain, and he ended up undergoing some imaging, and it showed some evidence of spinal stenosis.

49:09And in my mind, that was an immediate trigger of, oh, well, we have now increasingly recognized over the past decade or so that there's this other condition called amyloidosis that can lead to both atrial fibrillation and spinal stenosis. It can also lead to things like carpal tunnel syndrome. It can lead to tendon ruptures. It can lead to neuropathy. It can lead to a lot of other manifestations. And if you catch and diagnose that treatment early enough, we now actually have targeted treatments for this particular type of amyloidosis that can delay the progression and prevent you from developing advanced heart failure and needing pacemakers and all sorts of things in the long run.

49:45So whereas this guy a decade ago would have been like, yes, you have AFib, take these meds, you have spinal stenosis, go see the spine surgeon. Now I am guiding this evaluation for systemic amyloidosis, which hopefully rules it out completely. But if I catch it, will definitely alter the trajectory of this patient's life. And so that's why for me, keeping up with this stuff as it evolves is actually super useful because it does actually end up impacting practice at some point, even if the immediate clinical relevance, like the same year that they won the Nobel prize, like I'm not going to be doing this gene testing, but if we find some implications or some treatments or some novel genetic syndromes that I can look for when a patient checks certain boxes, yeah, that changes how I do things.

50:22And that changes patients' lives. It's very a root cause of you. There you go. Yeah. All right. Moving on to semaglutide. Once again, talking about semaglutide GLP-1 agonists. So everybody knows that obesity is a major public health concern, although I believe the last three years were the first three consecutive years on record that we have that obesity rates have actually declined, which... Winning. Winning. There you go. So GLP-1 receptor agonists like semaglutide, so Ozampic, Wigovi, these have emerged as effective pharmacological treatments for weight management, demonstrating significant weight loss in clinical trials, often exceeding 15%.

51:02However, there has been limited data on these medications, particularly at the highest doses, on their impact on body composition, specifically muscle mass, muscle function, and the risk of developing sarcopenia. In fact, there's been a lot of kind of not only public discourse amongst lay people like, oh, you're going to lose all your muscle mass, but even some professional discourse where very intelligent people whom I respect are like the risk of sarcopenia from these drugs is incredibly high. So this was an interesting study. It's called the Semilene study. Great name. This is a prospective longitudinal trial conducted in France to investigate the effects of once-weekly semaglutide on body composition, lean mass, and muscle function over a year in adults with obesity and at least one related medical condition.

51:45So there's 106 patients here. 68 % were women. The mean BMI was 46.3, so pretty significant. They all received semaglutide with a progressive dose escalation up to the max dose. Key measurements were taken at both seven months and 12 months, including in baseline. So they got DEXA scan to look at, like lean mass loss versus fat mass loss to assess body composition. They also did hand grip strength for muscle function and some other tests. notably 49 percent so nearly half of the patient population exhibited sarcopenia at baseline which they assessed with uh the appendicular uh appendicular skeletal muscle mass uh test and hand grip strength so those are the two measures which is a reasonable definition for sarcopenia although the european working group would be like we could do better need more functional assessment yeah indeed so the results first as expected significant weight loss was observed averaging about 10 % at seven months and 12.7 % at month 12, which pretty good.

52:46That's kind of what we expect from semaglutide, generally speaking. 60 % of the subjects achieved at least 10 % of weight loss, and 26 % of the patients achieved 15 % weight loss or more. Lean mass decreased significantly in absolute terms during the first seven months of treatment. The average amount of lean mass loss was three kilograms, which then stabilized and further and didn't decrease after that. To be clear, this is not just straight up skeletal muscle tissue. This is everything that's not fat mass. So this can be water, glycogen, certainly muscle tissue, but also other things, anything that's not fat.

53:24Based on the values provided in the article, they didn't actually report this, but I did some calculations here. The calculated proportion of fat mass loss to lean mass loss at one year, it was approximately 80 % was fat mass and 20 % was lean mass. Hand grip strength also improved at seven months and continue to improve at the 12-month mark despite not exercising. So first question to you, like, is there some sort of preservation effect of GLP-1 receptor agonist on lean muscle mass? because the predicted sort of proportion of fat to lean mass loss with like diet only interventions is 75-25. Now, this isn't that different, but it's not zero either.

54:15So like, should we all be taking GLP-1 agonists to start preserving muscle mass or what? Yeah, I have historically found the kind of hysteria around muscle loss with these agents to be really irritating and And also short-sighted in a lot of different ways. So many of the health complications that are among the leading killers worldwide, namely cardiovascular disease, cancer, things like that, are more often related to the consequences of excess body fat and things like that than they are directly attributable to having insufficient muscle mass and muscle function. But even if we were to focus the lens a bit more on sarcopenia as a problem in itself, which, hey, both of us also, we are quite concerned with that as well for a variety of reasons.

55:07Recognizing that the assessment and measurement of it is complex, it is both muscle mass and, more importantly, muscle function actually has been shown to be the more important variable here. And additionally, we know that measuring muscle mass is complex depending on the tool, the instrument that you use to measure it. But also when people have excess body fat adiposity, there's also fat deposition within and around muscle fibers and all sorts of things like that, right? And so that can lead to certain measurement artifacts. And so you can have a situation where you are actually, while losing body fat, the overall maybe cross-sectional area of a muscle might be declining, but the muscle quality is improving.

55:55And muscle quality, which is the stronger variable related to muscle function, is what I care more about than what is the absolute just mass. Or if I, you know, take a CT cross-sectional image and I just outline it and I measure the area. So muscle quality and muscle function are the things that I'm more concerned with. And so to the extent that I see that improving, I'm content. Now, we also know that it doesn't have to be one or the other with the use of medicines or the use of exercise. We see the best results, including people gaining and building muscle mass, muscle strength, muscle function, while losing substantial amounts of weight on these medicines.

56:31If we can just get them to lift a little bit of weights here and there, which doesn't even have to be a full on, you know, six day a week powerlifting template. It could be, you know, two, three times a week with sets that are a couple sets that are just hard enough, you know, a beginner will respond to that. And so that's kind of my perspective on this is my interest in the overall muscle mass question. It has declined over time, I would say. And my interest and focus on muscle quality and muscle function has continued to increase. And that is more so my emphasis when I look at these types of results or when I'm working with patients.

57:04What can we do? Yeah, I think there's just a misunderstanding of the disproportionate risk at both ends of body composition. So what I mean by that is at the higher end where you're thinking that somebody has a lot of excess body fat, adipose tissue, effectively that becomes a much higher risk than the potential benefit of a lot of muscle mass. Individuals with obesity tend to carry more lean body mass than lean counterparts just generally speaking. But they're not really absolved of the risk from excess body fat just because they're carrying extra muscle. So there's a kind of a misunderstanding on that side.

57:45And then with respect to GLP-1 agonist, anti-obesia medications at large, there's also a misunderstanding of like the risk of developing sarcopenia because the thought is like we lose any muscle mass that's sarcopenia. Well, no, that's not what sarcopenia is because it specifically requires a decrease in muscle function that is large enough to cause functional decline and a lot of other problems. And so at the lower end, which is way on the other side of the pole, the other side of this continuum, we're really talking about there's been such significant muscle loss that the person is now – they can't function, which is not what we see.

58:23Not happening. Yeah. It's not what we see. Like if – because there's a concern, there was a concern with people with sarcopenic obesity. So they had already poor muscle function and they had obesity. It's like, well, should these people be on GLP-1 agonists? And like that's still a clinical question that's out there, right? Because you're worried like, well, they already have poor muscle function. And so the thought is if they lost additional muscle mass, that would reduce function further. But to my mind, that's mostly like a muscle training, muscle quality kind of thing rather than like absolute amounts of muscle mass.

58:52Like they got muscle mass already. It just doesn't function very well. And so that's like an activity thing. So anyway, in this particular study, they actually did assess muscle function. Now, it was hand grip strength, and we talked about hand grip strength for a while. But despite not exercising, at least they were not told to exercise. But most of these folks have tried to lose weight a number of times before, and some of them had been in previous trials. Their average BMI was 46.3. The idea that these folks had not been encouraged to exercise for their entire life seems unlikely. So unclear how many actually were exercising.

59:25They did not assess that. But there was an average increase of 4.1 kilograms at 12 months in hand grip strength performance. Now, this does exceed the minimal detectable change, which is 2.9 kilos. So it does appear to be real and not just like a statistical aberration. But it does not exceed the minimal clinically important difference for hand grip strength, which is estimated to be between five to six and a half kilos. So I don't know. I don't have a good explanation for this. I guess is what I'm saying. I don't know that – and in fact, I don't think that excess body fat necessarily itself has a deleterious effect on muscle function whereby losing body fat now unlocks your muscles' ability to actually produce more force.

1:00:11If I had to rationalize this, I'd say, well, look, if they hadn't done a hand grip strength test before, right, familiarization with the test could have led to some of this. and that's why it didn't exceed the minimal clinically important difference. It's basically like, oh, you figured out how to do a hand grip strength test better. And so that's part of the increase. But it is reassuring that at least these people didn't – their hand grip strength didn't go down. 100 percent, yes. Oh, cool. And so with the definition they use for sarcopenia, which is reduced grip strength coupled with reduced appendicular skeletal muscle mass, the sarcopenia rate, which started at 49 percent, was 33 percent at 12 months.

1:00:50And so, yeah, we can hem and haw about how they define sarcopenia and the validity of a hand grip strength to monitor muscle function over this time period. But like I think it's time for some people to eat a little bit of crow. I hope so. I don't know that they will, but we can hope. Yeah, we'll see. We'll see. All right. We've got two more topics here. We'll wrap this up first off. And I know this is your favorite topic. We're talking politics, baby. So look, effective in October of 2025, this year, the Cyberspace Administration of China will require influencers who create content about sensitive topics, specifically medicine, law, education, or finance, to certify that they have formal training and expertise in those fields.

1:01:32They basically have two months to submit degrees, certifications, or verified credentials to demonstrate their expertise. And all content on these topics must clearly cite the sources used and specify whether it includes dramatizations or AI-generated elements. And it's actually the government apparently of China is putting a major onus on social networks like TikTok and some of the other ones that are used in that country to verify the influencers' credentials and remind their users of their own legal and scientific responsibilities regarding information dissemination. So they also are banning the advertising of medical services or products, including medications, supplements, or health foods.

1:02:15And they're ordering the removal of accounts using educational formats to promote products or impersonating professional identities. And so they're basically saying, look, if you're a social network, you've got to train your algorithms to block this stuff. Also, if it includes sexualized content disguised as educational. Thoughts? Like, do you think this actually protects the public from misinformation or is it setting a concerning precedent for government control over online discourse like freedom of speech? Like, what do you think? Obviously, it's different countries. They don't have the same.

1:02:48Totally. Yeah. I mean, I am I don't love it. I think that there's some good but mostly bad here, to be honest. Just, you know, China's level of control over everything in their society is, I think, pretty counter to a lot of the ways that we think and live in the States and the things that we value, not just in the States, but I guess in the West, more broadly speaking, although there's some variation, say, between the US or Australia, you know, EU, things like that. But with that said, you know, banning advertising of medications, for example, like we're, I think, in the camp of, yeah, not preferring to see pharmaceutical advertising direct to consumer.

1:03:28Wish that would go away. But other things about this requiring that these platforms verify communicators degrees or certifications to be able to post things on the platform. I think that that is, A, quite onerous, B, also potentially problematic for a lot of ways in terms of what credentials count, which ones don't, who decides from what institutions. Is that itself going to have some, you know, unintended second order effects of like, you know, obviously there's probably some level of control over that too. But like who can open an institution that then becomes accredited or can what credentials are allowed?

1:04:08Do they accept any sort of international, you know, credential? It gets such a complex web. And I don't think that that is something that I would be in favor of requiring. I think I tend to lean more on the side of people being able to speak. You and I interact regularly with people on the internet who are fools and make all sorts of inaccurate, non-educated, even in many cases, potentially harmful comments and things like that. I still don't know that I am likely to fall down on the side of, well, just because I, you know, had the fortune and the resources and everything to go through this schooling, only I can speak about this, about this thing in any meaningful way.

1:04:50because, man, I train junior doctors, I train medical students. Many of them, would I like for them to go out and start opining about things on the internet? It's like, no, they're also likely to say wrong things, particularly if they veer outside their scope of expertise. And so I think physicians and experts, they are more likely to be correct on a topic than a non-expert. That I'm in agreement with that idea. But are they necessarily correct? Is it possible? You know, are they fallible? Also very true. But their fallibility does not mean that we throw the relevance of expertise out the window and make it so that everyone's opinion is equal, because I don't actually think it is in most areas.

1:05:33But it's almost like this. I hesitate to use like some sort of bell curve, you know, metaphor or something like that here, but some sort of like probability distribution of who is more likely to be correct. the person with more formalized education and training and expertise, but I wouldn't use those as legal arbiters or limits on who can speak about something. At least that's my take. Yeah. Yeah. I mean, I agree with, obviously, big shocker. I agree with what you said. I don't like the idea of the government telling me what to do. I mean, if this came to fruition in the United States, for example.

1:06:09On the other hand, I do recognize that there is a huge misinformation problem. And I do think it needs to be addressed in some sort of like equitable yet effective and ideally evidence-based manner. I just don't know how to do it. I don't think it's this way, but I can understand why this was like done in that particular society. And there's likely cultural differences as far as like deference to actual experts. And so maybe that works in a culture like China, but I don't think it would work in the United States. In fact, I think it actually have like the opposite effect where it's like another social platform would pop up like black market sort of thing.

1:06:47It's like, no, this is where you get the real truth. Ironically, I think that is a social platform. So, you know, so I don't know. Like we'd be arguing with less people. Maybe. I think. Maybe not. Maybe. I don't know. Like, yeah. Yeah. Does you get to talk? Because like he says dumb stuff all the time. Does Rhonda Patrick get to talk? She says dumb stuff all the time. Like we go down the list. Like we were just this morning, you know, this misinterpretation of a mouse study that, you know, these people with large platforms are just promoting. And it's like they have credentials. But are just not smart.

1:07:24I think I almost sent you most recently. I think Huberman's last episode had something to do with like his his his expert commentary on the lymphatic system and how to improve your lymphatic systems health. And I'm like, bro. Wow. You're like a neuro ophthalmology Ph.D. Yeah, look, you know stuff about the optic track and rodent models. Respect. Defer to all your expertise on that. On that. I'm not thinking about that. Pretty much anything else outside of that, I would probably just stay quiet. All right, last topic. We're talking about protein powder and lead. Obviously, there's been recent headlines with the Consumer Reports article that's gone viral that found that a lot of protein powders have significant amounts of lead in each serving.

1:08:07Now, it should be noted lead is this naturally occurring element that's present in our environment. It's in the soils, in the water, it's in the air. So virtually all food products from vegetables to grains and obviously protein powders that are made from stuff of the earth, they contain trace amounts of lead. It's an unavoidable part of our food supply, not necessarily an indication of contamination or unsafe practices. And so I just want to clarify that there's got to be some incidental lead in pretty much all food, right? And depending on the soil that the stuff is grown in, like vegetables that we consume or should be consuming on a daily basis will actually have a significant amount of lead per serving.

1:08:43But there's also the risk of contamination. And so I think differentiating between those two things, that's a fair – that is a fair sort of thing to do. Incidental lead you really can't get away from, but contamination and high levels of lead, that is a problem. So there are multiple sort of cutoffs here, and that's where I think the real problem with this article came out. came from. So the FDA right now recommends that if you're an infant or child, 2.2 micrograms per day of lead, that's max. If you're a woman who's pregnant, 8.8 micrograms per day. And if you're an adult, otherwise 12 micrograms per day, that's daily sort of threshold.

1:09:21And those are based on clinical outcomes. It's far below the threshold still of like where lead toxicity actually occurs, but they're like, you can get this high and you're probably going to be fine. It doesn't I mean you go to 12.1 and it's like, oh, no, I have heavy metal toxicity. Collate me. Collate me. Collate me. No, no, no. Not that. The EU has a different sort of threshold, and this is mainly for legal enforcement of stuff on the market. They say you have to have less than 3 ,000 parts per billion of lead in something that you're putting on the market. So that's their enforceable exposure.

1:09:54But the article didn't use either of those. Those two targets have been around for a while. They used what was in Proposition 65. This was in some legislation that's passed in California in 1986, I believe, that said, look, if you've got a food, you've got a supplement, whatever, it's on the market. It's got more than 0.5 micrograms per serving. You've got to warn people about it. Now, this is 1 ,000 times lower than levels shown to cause no reproductive harm. So this is not a clinically derived health risk limit like the FDA or the EU, but this is more like right-to-know labeling. It reminds me of when I think I first bought some like iron plates from my first garage gym and they came with stickers on it.

1:10:36The standard California stickers that said this may contain substances known to cause cancer by the state of California. It's like that type of legislation leading to that public messaging. And so, yeah, just way, way, way more conservative, I guess, kind of cutoffs here, way lower than they would need to be to ascertain actual risk of harm in humans. Yeah. To me, like the FDA limits and the EU's exposure limit, like those two things are – they're still very low to be clear. But I also think they're reasonable because if you raise them higher, now you're getting closer to the threshold where clinical badness can occur.

1:11:17Prop 65, to me, I'm like if this label is everywhere, then how useful is it, right? People just – yeah, they get desensitized. They're like, well, OK. Yeah, everything could potentially cause cancer, I guess. Whatever. So as far as how does this apply to supplements? Well, look, some supplements are contaminated. And I think the article does a reasonable job at highlighting some of the unregulated supplements, some from very popular manufacturers that do actually have a decent amount of lead in every serving or other heavy metals. And so I think it's reasonable to avoid those. Like, look, if your supplement, right, is not third party tested, already I have concerns about contamination.

1:11:59And with respect to lead specifically, plant-based proteins, because that's where you're getting the protein from, that accumulates more lead, so more incidental lead already. And then if it's not third-party tested, right, for this stuff, batch tested, by the way, not just like once a year, I suspect that risk gets even higher. And so you have somebody who's maybe taking a very popular, but I'm not going to name them, plant-based protein that's got almost seven micrograms of lead per serving. They take two scoops a day. Well, now you're at 14. Yeah. I don't like that. And just by comparison, WheyRx, our protein, has 0.823 micrograms of lead per serving.

1:12:36It's less than spinach. All right. I'm not saying our whey protein is a better vegetable source than spinach. But as far as whey proteins go, we definitely have one of the lowest lead content. It's just the incidental stuff. You can't get away from it. And we're at 31 parts per billion. So we're way under both of these targets. So look, we third-party tested. Every batch is third-party tested. If you need a protein supplement and you're good with whey, I would recommend our whey protein. There are other whey proteins and other non-whey protein supplements that also fit this. But just make sure that they're manufactured in a GMP-accredited facility.

1:13:10They're third-party tested, batch tested, again, not just once a year. And you can ask these manufacturers for their laboratory analysis. We were recently asked for ours, and we provided it. Generally, manufacturers are happy to do so, especially if they have good results. But if they're not testing their stuff, don't buy their stuff. Like it's not worth saving a few bucks. People are like, oh, look, I can go to some big box commercial store and I can get 100 pounds. They send me a vat of protein and it's this expensive. It's so cheap. Look, I'm saving all this money. I'm like, yeah, but it's probably not worth – like again, it's not that big of savings for this potential risk from not only just lead but cadmium, arsenic, et cetera.

1:13:52Like it's just not worth it to me. I don't know. Does that make sense to you? Yeah, I agree. I think that we're fortunate to live in a time when toxicity from these things is not terribly common. But if you are buying these supplements with potentially more concentrated sources of them, and if you are using them a lot as a part of your diet, yeah, you're going to be at a higher risk compared to somebody who's using either a different product or not using them. So do with that what you will. There you go. Should we play System of a Down toxicity to take us out? Oh, great choice. All right. Well, that is a wrap here on the fifth episode of The Rundown here on the Barbell Medicine Podcast, where we bring modern medicine to strength and conditioning and strength and conditioning to modern medicine.

1:14:29Again, I'm your host, Dr. Jordan Feigenbaum. Special shout-out to Dr. Austin Baraki for joining me on the podcast. Before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast so we can keep bringing you all the latest nuance in health and fitness. From everyone here at Barbell Medicine, we'll catch you next week and every week right here on the Barbell Medicine Podcast.

1:14:55Thank you.