Lifting and longevity: is 1 hour a week really the limit? Plus GLP1s and mood, training with ME/CFS, and Protein vs. Calories

24:24Jordan Feigenbaum:you know when the mechanism was kind of sussed out a little bit look these drugs act on the brains reward pathway this sort of wiring that creates the urge to want to do something um with less payoff than you would otherwise expect you know then people are like could this be useful or researchers certainly were like, could this be useful for substance abuse? Right. Which on the one hand was like a silver lining. And then other people took that to like, to, to suggest, well, maybe I won't like anything. And there's been some effect, you know, people reporting like flat effect and stuff like that.

24:54Jordan Feigenbaum:Um, there's some interesting data here. You know, researchers have investigated what happens if you give people with alcohol use disorder, a GLP one and see what happens. Well, they, they drink less, uh, for example. Um, so there's a study came out last Last year in JAMA psychiatry, 48 people with alcohol use disorder. They were on low dose semaglutide, so ozempic we go V, or placebo. And they were put in a bar lab, which, can I go? Like it's just a simulated drinking environment. In any case, it cut how much they drank and they craved. And they also cut their cigarette consumption as well. There's a second trial recently published in the Lancet, which was bigger and longer and showed the same thing.

25:36Jordan Feigenbaum:Now, this has never been studied for like gaming. Right. It's never been studied for socializing other hobbies or whatever. So all of like the brain imaging studies and the mechanisms hasn't really been applied here. We do think that these sort of if you want to call them an anti reward type effect, we do think that it reaches past food, but we don't know to what extent. And the hobbies, you know, in this case are pretty much untested. So that's an open question. um yeah sure a few people like as you mentioned a minority can report feeling flat but that's more anecdote than anything else and i don't think there's a huge signal otherwise showing like a lot of people experience this and it's a big problem i would be concerned if there was a big libido effect uh but i suspect if anything it would probably get better mainly because the effect of the drug itself like if you if someone's appropriately prescribed these medications they are carrying excess body fat.

26:31Jordan Feigenbaum:And, you know, in men who are carrying extra body fat, that tends to reduce testosterone, particularly if they have a high amount of visceral adipose tissue, again, surrounding your internal organs. And because these drugs do such a good job at reducing that, testosterone levels actually tend to go up. Now, libido itself is more complex than just testosterone level, but we do think that this would likely improve. I think you can see sort of a confounder though if people are not eating enough generally speaking and they're losing weight very quickly so that fatigue can sort of overwhelm any sort of hormonally mediated improvement in libido but that's like a kind of separate issue but the third question and the one that i think uh uh you know needs to be asked whenever we discuss these sorts of things mainly due to the still fairly prohibitive cost where are people getting these medications from so if somebody's sourcing a GLP-1 through like research chemical or gray, you know, gray market sort of peptide.

27:30Jordan Feigenbaum:I have concerns about that. Maybe not just related to like anhedonia, right? Or like reduced enjoyment of activities, but mostly just like safety, because you don't really know the dose that you're getting. For example, you don't really know if what is marked, you know, labeled on the vials, what you're actually getting. Plus, if you're getting it through those sources, I do wonder about the monitoring. So all of that sort of kind of tilts the risk benefit scale firmly, to me at least, towards the risk sort of situation. But I think overall, the psychiatric risk is relatively low, if anything, likely to be beneficial, as long as somebody's not really taking an unregulated peptide from the gray market here.

28:09So Austin,

28:10Jordan Feigenbaum:you've got patients on these medications. Now, if this individual was your patient, acknowledging this is not medical advice, this is for infotainment purposes only, and they're kind of express these concerns about anhedonia having a sort of flat effect. How would you counsel him on that? Would it be mostly like, hey, we're going to monitor this as we go along? We're starting low, this is minority or anything unique in your sort of counseling here?

28:34Austin Baraki:Yeah, I want to first be clear about what is the goal of therapy? Because one of the things that wasn't listed in the question is like, what is the indication for using a GLP-1 medicine in this situation? Is this somebody with obesity, with metabolic disease, with cardiovascular disease, with fatty liver disease, with chronic kidney disease? All of those things or any combination of them really strengthens the case for benefit outweighing potential risk. That's the first thing. Now, if on the other hand, he says, I'm super lean, jacked, healthy, I'm wanting to use a GLP-1 weather prescription, FDA approved, or gray market, red up, so I can prep for a bodybuilding show.

29:09Austin Baraki:I'm not saying he's saying this, or she is saying this, but that obviously changes the potential benefit to potential risk sort of calculation there. Right. That's that's the first thing, because we're always framing these therapeutic conversations around what are the potential benefits that we are looking for? What is the goal and what are the potential downsides that we should be aware of and kind of take into account? And then once accounting for those things, can we negotiate a mutually acceptable strategy to navigate that path together? And so if this person has clear clinical indications for their use or that if they don't, they are willing to accept potential downsides despite the lack of a clinical indication for its use, then yes, the plan would be, hey, we're going to start at the lowest dose.

29:55Austin Baraki:We will monitor how you're doing, knowing that we have creative dosing strategies, options for combination therapies to address side effects if needed, or we can always go back down in dose, or we can stop and it is a reversible effect, not something that tends to be permanent. And again, I would reiterate that the big picture of observation in practice is that this is infrequent. If it happens, more often at the highest doses that take a while to get to, and it's something that we can mitigate gate by just going back down. And so that that flexibility is quite quite nice about these agents. Yeah.

30:29Jordan Feigenbaum:All right. Well, that's about as new as medicine gets. Now let's tackle one of the oldest questions in the field. Is a calorie really just a calorie? So the question is, can you discuss the nuance around the studies showing weight loss when protein goes up, even at the same or higher calories? There's one you energetic that just means at the same calorie level. There's one you energetic high protein trial in particular. I've also heard people say keto lets them eat more and still lose weight. Yeah. So on its face that, you know, these two scenarios look like they break physics, you know, you're eating more calories, presumably, and still losing weight.

31:06Jordan Feigenbaum:Uh, but if you dig in, it's kind of, uh, it's kind of a farce. Okay. So let's, let's start with the, we'll back up a little bit and start with the phrase that everyone kind of fights about. Is a calorie really a calorie? Just a calorie? Yeah, it is 100 % of the time a calorie is just a calorie because it's a unit, just like a second or a meter or, you know, measures time or distance. A calorie is a unit of measure for energy. um that said you know calories in calories out is a calorie just a calorie i think what people are getting at when they're i mean trying to poke holes in that relationship is that on either side calories in calories out both sides are dynamic and just stating the relationship is not terribly helpful advice for most folks and i think that's fine two things can be true a calorie can just be a calorie but the advice to just eat less move more or it's all just about energy balance may not be great advice.

31:59Jordan Feigenbaum:And I think that's fine. Now with respect to protein, I think it's fair to say that protein pushes both the calories in and calories out. It affects them both in a way that favors weight loss. I think it's fair to say that, but there's some nuance here because effectively the effects are modest. So when you increase dietary protein intake, a few things happen. One, it tends to displace other foods. You know, Americans typically eat quite a lot of protein, about one, 1.1 grams of protein per kilogram body weight per day. But most of that protein is from ultra processed or highly processed sources, tends to have a lot of fat and other things, which increases energy intake.

32:43Jordan Feigenbaum:And so when people make this, quote, conscious choice to eat more lean protein in particular, it can displace some of those higher calorie options and other options that don't have a lot of protein but otherwise do contain a lot of calories so that could reduce energy intake for example increasing dietary protein intake also tends to increase the thermic effect of food because protein costs more to digest than carbs or fat but it's mostly a small effect if any we know that yeah it does take more energy to break down protein but how that affects total daily energy expenditure we don't really know because everything kind of is dynamic.

33:19Jordan Feigenbaum:When you increase one variable that, you know, the system isn't closed, everything else changes too. So I don't know that increasing dietary protein actually increases calorie burn in a way that produces weight loss. I think the main factor here is it reduces intake overall. So the study that was sent here is from 2020, Haggiat in British Journal of Nutrition, it was 12 weeks. And basically they looked at the effect of a high protein diet versus So a standard protein diet in women. Now, the diets that were prescribed to these individuals were the same in calories. There was the prescription, which differs from how they were actually implemented because they actually ate different levels of calories.

33:59Jordan Feigenbaum:In the study, in table one, the high protein group reported that their intake fell over the trial while the standard protein groups actually held the same. So the average in the high protein group, they ate about 90 fewer calories per day, closer to 130 fewer calories by the end of the trial. They also cut carbohydrates, which drags water and glycogen out. And so they were eating less calories. And what do you predict happens when people do that? Well, they lose weight. There was an improvement in body composition here showing increase in lean body mass, decrease in fat mass, unique to the high protein group, which isn't a surprising finding when it's combined with resistance training but it was surprising in this study so you have to look a little deeper and you look in the methodology and how did they assess body composition bioelectrical impedance which is pretty poor a bathroom grade device if i'm being charitable the authors themselves say look this wasn't a gold standard and which begs the question like what why did we use this for that it just is not sensitive enough to discern relatively small changes in lean body mass.

35:06Jordan Feigenbaum:And, you know, in the defense of BIA, bioelectrical impedance, DEXA wouldn't be good either in this short period of time, mainly because you just need large changes in actual muscle tissue and fat mass for it to be picked up on either one of these tests. Bioelectrical impedance is just worse, right? So ultimately the people in the high protein diet ate less, so they lost more weight. and the body composition changes in this relatively short study were mostly a result of a measurement error although again i would expect a higher protein diet up to a certain level probably about 1.6 1.8 grams of protein per kilogram body weight per day to improve lean lean mass if people were resistance training although if people weren't resistance training i don't really think it's going to move much for muscle mass to me the keto version uh dies the same death you know when people say they went keto and they ate more and lost weight, really what happened is they felt like they were eating more, but actually their calorie intake went down.

36:00Jordan Feigenbaum:This has been investigated. You know, people said, hey, you can only eat these types of foods, in this case, a ketogenic diet, and they tend to eat less some of the time. What's more interesting to me about the ketogenic diet data is that that is a relatively short-term effect. When you look at six months, one year, the weight loss, quote, advantage disappears relative to other types of diets. Now, if somebody wanted to follow a ketogenic diet in perpetuity, they hate carbs, war on carbs. Okay. There are ways to do that. That's fine. And that's ultimately fits their preferences, allows them to eat the correct amount of energy.

36:35Jordan Feigenbaum:But the idea that ketogenic diet somehow breaks the law of physics where people can eat more calories and lose weight has never been shown. Never been shown. So Austin, how do you handle this? When a patient swears they're eating more and losing weight, or they're losing on keto without counting their calories. What does the conversation look like? I'm going to kind of guess. You say, nice. But I'm very curious how you address this.

37:04Austin Baraki:Yeah, firstly, it would be nice. Cool. Keep it up. That's great. I think that the other aspect of this conversation, though, is definitely wanting to be on the same team with the patient. And that means that if the ultimate goal of this is for their health, then yes, as long as they are making progress, losing in a way that they prefer, then yes, I'm on their team for that. But I also wanna make sure that they are on my team in the sense of, hey, we wanna make sure there's not detrimental effects happening from this diet. And so the reason I bring that up is depending on the particular food choices, the way that this keto diet is set up, there can be, even if you're losing weight, can be some other detrimental effects.

37:41Austin Baraki:For example, if you are consuming very high amounts of animal-derived saturated fats, as we've talked about many times before, that can have some detrimental effects on your blood lipid profile, for example. There might be some other impacts that are adverse on your insulin sensitivity and things like that. So I definitely wanna make sure, hey, we wanna make sure you're very sufficiently active. And if I can get them to agree that we should aim to make the most progress we can while avoiding objectively detrimental effects, then we can say, hey, if we see that, like say your blood lipid panel goes haywire, like your LDL goes up, your triglycerides go up, your things like that, that would you be open to making some, you know, tweaks, some modifications to this keto diet within the realm of your preferences as much as possible to mitigate that.

38:28Austin Baraki:And I think that there's likely to be a way to, you know, thread that needle. Maybe we swap out some of the, you know, dietary fat sources for more unsaturated sources from, you know, seafood sources, from plant derived sources, things like that. And then aiming to get the dietary fiber intake up to our standard recommended targets for whichever population the patient falls in. So typically, getting them up to say 30, 40 grams of fiber a day, if they're willing to go that high or as high as they're willing to go within the confines of their diet. And then that might confer some beneficial effects on those otherwise detrimental effects.

39:02Austin Baraki:So I think that that's the two big pieces is making sure that we are getting the benefits we're looking for and mitigating the harms. If we can do those two things and the person wants to stay keto, like we go for it.

39:14Jordan Feigenbaum:yeah yeah and further if somebody was like i want to increase my dietary protein and you know what what can i expect what to expect when you're expecting it's like well it depends where you're starting at right now so for example if a person's consuming you know 0.6 to 0.8 grams of protein per kilogram body weight per day and they're like i'm gonna go up to 1.6 i'm like okay well provided that your resistance training right i suspect you're gonna have uh get you know a bigger benefit from your exercise i do suspect that that increase in protein is going to displace other higher calorie foods from your plate.

39:46Jordan Feigenbaum:And so net, I would expect some benefit now going from like 1.6 to 2.2 or, or more. I don't expect that benefit. On the other hand, it could further displace other foods from, from your plate. And so some people may find that approach successful in the short term, but long-term that has not been borne out either, where it's just like, no, just jack your protein up and you're going to lose more weight. It's like, well, at the end of the day, it all comes down to energy balance one way or another. but I think overall you and I are aligned we're not calling this person a liar and and and breaking out the physics for them and saying well look the law of thermodynamics yeah there was no point just like telling people to eat less and move more that is not particularly useful advice telling people that it all comes down to energy balance is probably also not useful advice all right our next question has to do with lifting and chronic fatigue syndrome the question is what's the best weightlifting to do when you have chronic fatigue syndrome?

40:40Jordan Feigenbaum:I go weeks where I barely have the energy to shower. I want to increase my lifting. I sometimes lift weights in bed on my worst days, but my boyfriend says that isn't doing anything. What are some exercises that won't make me need to sleep for two days? All right. So some people are going to say, look, chronic fatigue syndrome, this is made up. It's not a real illness, but it is. And it's often referred to as myalgic encephalomyelitis or MECFS. And in 2015, there was a National Academies of Science panel that laid out formal criteria for diagnosing it. Now, the thing that separates it from just being quote tired is what happens after somebody exerts themselves.

41:20Jordan Feigenbaum:So in this particular instance, she does something, whether it's physical or mental, and instead of being wiped out that same day or being tired that same day, there's a sort of extended sort of crash for multiple days, in some cases, even longer than that. And it's out of proportion to the effort that was it was done. Now, her question says it plainly, basically doing some light lifting, and then I need to sleep for two days. That sort of delayed crash is called post exertional malaise. And it's one of the key features of this particular condition. There's a really interesting case with a pair of identical twins where one has chronic fatigue syndrome, and the other doesn't.

41:55Jordan Feigenbaum:Same genes raised together, so you can't chalk it up to genetics or lifestyle. Now both did a hard exercise test two days in a row. The healthy twin repeated their performance on day two just fine. The twin, though, with chronic fatigue syndrome, dropped about 13 % at the anaerobic threshold test on the second day, basically the point where the effort tips from manageable to much harder. And it's not just a twin curiosity. Run the same two-day test on groups of these patients and the same pattern holds. They show a bigger drop off on day two than healthy people do. You can't really talk yourself out of that.

42:27Jordan Feigenbaum:Unfortunately, there's no real proven program or like exercise routine for this. It hasn't been studied well. And but the one thing that everyone agrees on is basically staying under the sort of limit that sets off a crash. Now, this is a relatively new update, because for a long time, the idea was, look, we just got to push these patients. We just have to like tell them just add a little bit more every week to sort of graded exercise. Unfortunately, that just is like forced progression. And it turned out to be wrong. Now, it's also wrong in others like people without this condition. But that seems to be a little bit more again, disruptive in this in this population.

43:04Jordan Feigenbaum:And there's just lower stakes. If you kind of overdo it in a healthy person, they're like, man, I'm sore for longer, I'm tired for longer, my performance has decreased, but they bounce back relatively quickly, usually, these, these folks can be prolonged. so the guidance has flipped and this happened uh you know in in the last few few years as far as her boyfriend goes he's half right look lifting weights in bed is probably not going to build as much muscle or strength as like going to a gym and doing a quote real training session but that's not really the point it's better than doing nothing thing one and two she's getting something out of it for exercise to really accomplish nothing it has to be so submaximal so light so easy that it does not challenge her or the person at any level, which is pretty hard to do.

43:51Jordan Feigenbaum:You got to, you'd have to like really fabricate something, um, you know, uh, something unnatural, uh, for, for that to happen. Um, ultimately to me, this is like doing what you can, when you can, where you can. And I think that's certainly better than nothing. So the way I would approach this from a practical perspective, I generally think that shorter bouts of exercise are likely a better place to start then longer ones and would do longer rests so instead of having like six exercises on the docket maybe you only have two right and instead of resting you know only two to four minutes maybe it's four to six minutes which you can get away with if you only have two exercises for example i would also generally stick with lower rpe targets you know probably more five six compared to six seven or eight i would also instead of trying to force progression with a fixed rep range, for example, use double progression, wherein you would have a rep range of like six to 10 reps, for example, and only add weight when you could max out all of the sets at 10 reps at a given load.

44:50Jordan Feigenbaum:And so it's going to be a little bit more of a gradual progression, delayed progression that we're sort of constraining with that, that rep range. I would also have a backup plan. If, for example, someone is feeling like, I don't really have it today, you know, not just like, I feel sore, if I don't feel quite as strong as normal, in this case, like my energy levels are really, really low, maybe all they can do are isometrics, you know, where you're creating force and not really moving dynamically, or maybe it's just much lighter. And then the other thing that would add that's kind of unique here, we often talk about monitoring session RP, like how hard was the effort, you know, what was the whole training session, whereas a session RP 10 would be like, that's maximal, it's the most thing, most I've ever done.

45:29Jordan Feigenbaum:And SRPE one is like, that was rest, I didn't do anything. Yeah, we should measure that, right. But also, I'd want to see what happens the next day and two days later and three days later because the sort of disruption and prolonged sort of decrease uh in energy level uh sometimes called an energy envelope happens days later and so you would really want to have you know be kind of like monitoring this post hoc just to see like is the program that we're on right now is it adjustable enough and is it like actually like uh meeting the person where they're at you know and i think that it's harder to do when you have to sort of look at monitoring only directly after the session or during the session.

46:10Jordan Feigenbaum:So it needs to be a little bit longer than that. So Austin, this is where you're better than any study. If this were your patient, someone with chronic fatigue syndrome, who actually wants to lift and is scared of the crash they've been experiencing, how would you go about counseling them? What does the sort of strategy look like day to day? And how do you talk about it without sort of noceboing them, for example?

46:31Austin Baraki:yeah i will be totally up front that this is not an area of a great deal of expertise or experience for me i think that this is a very challenging syndrome number one it is poorly understood it is multifactorial different people experience it in very different ways and they likely have arrived at this kind of like final syndrome probably in different ways as well so that deviates a lot from kind of our more we'll call it more traditional like medical diagnoses if you will, where patients tend to more often present with a kind of more prototypical pattern because so much of diagnosis involves things like pattern recognition, and there might be a relatively common or shared underlying pathophysiology.

47:14Austin Baraki:Here, it might be different pathophysiologies that converge to manifest in a similar way in a diverse set of patients, ultimately not super well understood. Maybe some people have greater or lesser degrees of mitochondrial problems. That's a total hypothesis. And again, I'm not an expert in this area. So as a result, that's why I am both reluctant to sign on to the idea that I'm better than any study here, but also be that, you know, I'm probably not the best person to be giving confident advice on this. I think that a lot of what you proposed is probably reasonable. Although I would also point out that even the best plan that you could propose within those kind of constraints may still fail for a person for reasons that we may understand and may not.

47:55Austin Baraki:And so much more so, I think the idea of individualization, and again, as I alluded to earlier, being on the same team as the person is probably the most useful thing here. So trying to get a sense of like, how do you feel that I can help you best? Are you willing to work together, collaborate on this, iterate on this over time? What are the goals you're trying to achieve? Can we like mutually agree on an acceptable starting point with a plan to modify as we go? because you're right that historically the idea that, oh, these folks, you know, they have this syndrome, but they still are capable of tolerating a stress and adapting to it just like anyone else.

48:28Austin Baraki:It's like might be a little bit of an exception to that rule because when they have been pushed, they tend to do worse. And so there's some other path, some other strategy that's going to need to be worked out. And again, it's going to need to be super individualized to the person and what they're willing to do. I think that both of us would hesitate to sign on to an idea of, well, you're just not going to be able to exert yourself and just like you know bed rest is going to be the move for you that's not something you're likely to ever hear a say for somebody but rather that prospectively without you know meeting with the person working with them got you know collaborating on this over time it's going to be tough to propose something up front that is anything more than like a reasonable guess and that's kind of what you came up with there and with a if then sort of thing so that they have some confidence that hey we got a backup in mind and i like that you included some ideas for backup strategies.

49:18Austin Baraki:But you need to be on the same team. If there's an adversarial sort of relationship, if there is, you know, doubt in the relationship of, oh, well, I don't think that I can tolerate this, but they're making me do it or recommending that I do it. Like you're already kind of on the wrong foot. So you need some rapport, you need some trust, you need some collaboration, you need some iteration, you need a lot of time. If it were me, I would probably be like, hey, can we find somebody with like way more expertise than me in this space who can guide you? Because I've done that for other things that are not necessarily, like I will claim to know a lot about a lot of things, but certainly not everything.

49:50Austin Baraki:And this is one of those areas where unfortunately I do not have a great deal of that expertise. And a lot of that is an artifact or a consequence of my typical practice setting over the years. Working in hospital medicine for a lot of the time and not having like brick and mortar clinic where I'm seeing patients with these sorts of chronic debilitating illnesses limits my degree of experience in working with them. And so then that limits my confidence in giving advice on the internet about it.

50:17Jordan Feigenbaum:Yeah, yeah, well said. And I think if you're a coach working with somebody like this and you've never seen it before, never dealt with it before, I don't wanna scare you off and say, we don't wanna scare you off and say, look, you can't touch this. You know, a little MC Hammer reference, but I would just generally be more conservative and more dynamic with your recommendations, readiness to change, what you're doing. And then further, if you get in a few weeks or a few months and you feel like you really can't get purchased on like, this is where the person should be starting. Generally speaking for the bones of a decent program, you just can't find that entry point.

50:52Jordan Feigenbaum:Then finding somebody with some more specialized expertise would be, would be the move. And I think, you know, we see that all the time in medicine. It's like, look, this looks like something I feel like I can handle. And then, you know, if that doesn't really shake out, okay, cool. We're going to actually call, we're going to get a consultant on board. He's going to help us because they have more expertise. That's a handful of the best questions from this month's direct line. The full episode, every question our members sent in goes out to our Barbell Medicine Plus and premium members every month.

51:18Jordan Feigenbaum:Now, if you want the whole thing each month and you want your own questions to be answered on the show, head over to barbellmedicine.com and jump in. From everyone here at Barbell Medicine, I'm Dr. Jordan Feigenbaum. That's Dr. Austin Baraki. We'll catch you next week and every week right here on the Barbell Medicine Podcast.

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