Ozempic & Alcohol, The Trap Bar Myth, and A Medical Mystery | Barbell Medicine AMA Teaser

0:28Welcome back to the Barbell Medicine Podcast. deep dive and you want to join the queue for our next AMA, head over to the link in the description to subscribe to our plus feed. All right, let's dig in.

0:43This is going to be interesting to you. I can feel it. The question is, is it normal for my legs to get itchy when starting to run? What do you think about that? If we frame this as a mystery case, I would start to have a lot of follow-up questions, but I do think that there's this phenomenon known as quote unquote runner's itch that is probably what this person's getting at. Again, there are some other possibilities that we can get to in a little bit, but the thought has to do with changes in basically blood flow. So the way capillaries deliver blood throughout our bodies, when we start exercising, you know, our peripheral vasculature tends to vasodilate to deliver oxygenated blood to our tissues.

1:20And there's a bunch of different changes that happen in the cardiovascular system. And so the thinking is that these changes in in what we call hemodynamics, the changes in the vascular system, our heart rate, our blood flow, our blood pressure, especially when somebody is not habitually adapted to this, might lead to kind of mechanical stimulation in the local tissues, like in the skin and things like that, that can be experienced as a sensation of itch. There are some other mechanisms of itch. And so just broadly speaking, again, if this were a mystery case, I would actually start by thinking about the different types of mechanisms of itch.

1:55There's neurologically mediated itch, There's itch that's mediated by histamine release. There can be itch mediated by other things. For example, I see patients get itchy when they have a lot of bilirubin and they're like jaundiced and turning yellow when they have elevated blood urea levels, things like that. So there's a lengthy list of substances and mechanisms by which people can itch. So I've talked about cardiovascular, neurological. Histamine is another one that you might think of as being kind of associated with allergies, but that's also involved in this kind of like blood flow regulation, vascular regulation.

2:25That's why, for example, when people are having an allergic reaction, you might see them develop what are called like wheels on the skin or what we call urticaria as the medical term. That's kind of like raised light red to pink area. A lot of that tends to be histamine related as blood flow increases to an area and then it kind of leaks out into the tissues leading to a little bit of swelling. And it makes the nerve endings in the area a bit more sensitive. And again, the sensitivity of nerve endings can play into the experience of something like itch. Again, I mentioned neurologic. There's this phenomenon called cholinergic urticaria.

2:56And there's also other forms as well. If you just look up exercise-induced urticaria that people can experience or when they sweat, that can also trigger some of these kind of itching responses, again, also impacted by environmental conditions. I experienced this briefly during a time in my swimming career, and I suspect it was multifactorial, some combination of like sweat and like chlorine exposure and maybe something else about the environment that I was in at the time. It wasn't something that I experienced indefinitely or always or reliably, but I just distinctly remember a period of time where I would get kind of red and splotchy on my skin and itchy.

3:26Um, and that might've been some due to some exposure, um, in that, in that context. Um, so I've experienced it, but what about you? Yeah, I have not, uh, at least not to my conscious knowledge. Sure. Perhaps I just attributed to something else, but you mentioned it perfectly a couple handful of mechanisms likely involved in this runner's itch, the vasodilation, right? Um, some histamine release that is normal with particularly exercise can sensitize skin nerve endings. And so people can feel an itch. And that obviously varies between individuals. It typically goes away in a few weeks. And then that cholinergic urticaria is far less common, but pretty interesting.

4:03All of those are relatively benign. However, things can get weird when it comes to itching during exercise. So So Dr. Baraki, imagine this 24 year old fit Marine. He went for a run. He got itchy and then he got hives and his blood pressure dropped to 60 over barely palpable. He didn't know that he didn't have like a blood pressure cuff on him, but he did become lightheaded, thought he was going to pass out. So he sat down to rest for several minutes and when he attempted to stand, he became even more lightheaded and felt like he was going to black out. So he called 911 and went to the emergency room.

4:39Now, he was subsequently diagnosed with exercise-induced anaphylaxis, which is a rare, life-threatening syndrome where the immune system reacts to physical exertion, often combined with food triggers like wheat, shellfish, etc., but not in this specific case. Now, the lesson here is that there's a difference between this case and normal, like, itchy legs or runner's itch. It's the progression and the symptoms. He didn't just itch. He developed hives and hemodynamic instability. dizziness, low blood pressure. So this case highlights the critical difference between itchy skin or runner's itch and exercise-induced anaphylaxis.

5:18Pretty interesting case. Now, we can't use that for an upcoming mystery case now because I gave you the answer. Yeah, I've actually heard of one, a mystery case that I listened to somebody else discuss. I have heard of this once before. It was in the context of some wheat exposure and then subsequent exercise. And yeah, this is a classic story for anaphylaxis. The skin itching, you know, potentially a rash, and then you combine it with some other form, other systems that get involved, either respiratory, people start wheezing, their gastrointestinal system, nausea, vomiting, abdominal pain, or cardiovascular complications like low blood pressure.

5:46Some combination of those are kind of part of the diagnostic criteria for anaphylaxis. This person gets an epinephrine and then you probably have to get assessed by an allergist, immunologist to figure out like, because I don't actually know, aside from avoidance, if there's any sort of treatment for this that can mitigate it, if they use some kind of, you know, mast cell stabilizer or something like that. because it'd be nice so that you don't have to like you know worry about if i exert myself am i going to anaphylax and die and have to epi pen myself bring an epi pen movie like in in crank uh that old that old movie or something like that but yeah interesting and unfortunate condition to have yeah so to summarize normal runner's itch you just get itching on the legs and thighs no visible rash uh you feel fine you're just annoyed because you're itchy yeah capillary wake-up call it should resolve in a couple weeks with consistent training keep training it'll typically resolve uh that's different than cholinergic urticaria so you got the itching and the pinpoint hives or wheels a little red halo kind of thing usually heat sweat related uh so usually when folks cool down um potentially can be mitigated with some antihistamines although would want to refer to some uh clinical expertise uh for that because just generally taking like a benadryl before you go exercise probably not not the move uh and then that's all different than exercise induced anaphylaxis, which was the case report we talked about, which is itching and large hives plus dizziness, wheezing, nausea, you know, other sort of hemodynamic instability type symptoms, would recommend stopping.

7:11Immediately activate emergency medical services. You need to be seen by a professional.

7:24Alcohol use and GLP-1 receptor agonists. So the question is, How do you view heavy alcohol use alongside GLP-1 medications? Is this cognitive dissonance, whereas someone could be on this medication for treating obesity, for example, while still continuing to drink alcohol? To me, treating the obesity with GLP-1 receptor agonists immediately can improve things like metabolic health, liver function, cardiovascular risk profile. And a patient with treated obesity and excessive alcohol intake is objectively better than a patient with excessive alcohol intake plus untreated obesity. So I think, you know, these things don't have to be like linked together.

8:09There's like a little false dichotomy there. And also I should point out like the original question suggested maybe like a substance use disorder thing, whereas excessive alcohol intake is not necessarily substance use disorder. There's specific DSM-5 criteria for substance use disorder. It does get gray there, but I just wanted to clarify. It doesn't automatically mean pathology. Even though it might not be health-promoting, it might not be an actual pathology, so we don't need to medicalize that. But overall, I kind of think the aggregate health risk is lower even if the alcohol variable remains constant, although the evidence suggests, and I suspect you'll get into it, it often improves.

8:48GLP-1 receptor agonists often seem to improve excessive alcohol intake and maybe even some indication for substance use disorder. But to tie it all together, you know, we don't tell a speeding driver to take off their seatbelt because they don't deserve safety until they stop speeding. We use the seatbelt to keep them alive while we address the speed or the other driving habits. The last part of this before I get into Dr. Baraki's take, it's just like this perfect patient idea, you know, like the patient has to be perfect in order for us to treat them. So like we don't withhold statins from people who eat fast food.

9:24We don't withhold metabolic treatment for those who drink in this particular case. This reminds me of the diary of a CEO kind of review podcast we just did with Dr. Lauren Colenzo Semple, where they're like, we're going to take people off GLP ones if they're not exercising. It's like, well, look, we want people to exercise. We know that exercise, even if you're not on these medications, very health promoting, even independent of any change to your weight. But if somebody doesn't, the idea that they're going to be less healthy without these medications and they're not exercising still, that's unlikely.

9:58So Austin, you want to talk about some of these like additional effects, like health benefits that people get from GLP-1s and also just how you think about this overall? Yeah, I kind of wish, you know, the initial take from the question had me kind of curious as to what exactly the question asker here meant. I wish they would have elaborated a little bit more on their thought process, but I think I can follow your lead here. But yeah, so GLP-1 agonists and the multi-agonists that we have nowadays that are hitting more and more receptors, they aren't drugs that just work via that single hormone like in the stomach, for example.

10:34Like, you know, early on a lot of people and some people still hold these thoughts of, oh, it just slows down your stomach, it makes you feel really sick, and that's why you lose weight. That is definitively not the case for these medications at this point. There can be a bit of an early effect with some GI side effects. Those tend to improve with time, and those are not reliably predictive of people's weight and health-related outcomes. So it is not nearly that simple. And additionally, by working what we call centrally or in the brain, we also observe these impacts on appetite reward pathways that it seems to be extending with early evidence into people's use of alcohol.

11:08Now I have a pretty large, I would say, base of experience working with patients on these medicines over the years and have observed this in my own practice with them as well as with some emerging evidence that alcohol use and other substance use disorders actually tend to improve. People tend to spontaneously consume less in the same way that they tend to spontaneously consume fewer calories and lose weight, which is the main mechanism of benefit for weight loss and a lot of the cardiometabolic downstream consequences. Similarly, they tend to spontaneously end up seeking out and consuming less alcohol.

11:38But getting back to this original question, if the idea is I have a patient who tends to drink alcohol, maybe above recommended limits, and they're on this medicine and they continue to do so, you know, this question of is it cognitive dissonance, like should we take the medicine away from them, quote unquote, or decline to prescribe it because they are drinking? This is a deeply, I would say, problematic, very paternalistic approach to clinical medicine. And I think there's some degree of like baked in moralization just around the alcohol itself, but also the medicines. And so I've talked about this a bunch before where a lot of these sorts of interventions that we have available in practice, I wish that we could propose them in a completely like decontextualized, almost like a like a Mad Lib type way where it's like, here is the intervention that you have available.

12:28just in terms of outcomes. It offers this percent benefit on weight. It delivers this percent benefit on risk of mortality. It provides this degree of benefit on liver fat accumulation and cirrhosis. And here are the potential risks or the downsides in contrast, this like minuscule risk of this, tiny risk of this, tiny risk of this. How do you feel about this intervention without knowing what it is or anything else about it? And most people would look at these data and be like, oh yeah, that seems like a no brainer to do something like that. And then you can like, open door number one and reveal to them what that intervention is.

13:01And if it turns out to be a GLP-1 agonist, everybody starts losing their minds because they're like, it's cheating, it's this or that, the other thing. If the potential benefits outweigh the potential risks, then I think that is a valid basis on which to use these tools. We view them as amoral tools that we have available to us. And then even if there are some potential risks, if the patient goes through a full you know, full conversation, and you can you get them as informed as they can be. And they say, look, I accept that risk in order to gain those potential benefits, then I'm still willing to pursue it.

13:37And so this comes up because I do now a decent amount of like menopausal hormone therapy, for example. And so this came up recently, where I had a woman who was dealing with pretty significant perimenopausal slash postmenopausal symptoms. And she for her own personal reasons, was declining to get mammographic screening for breast cancer. And yet she was stating a clear preference to have her menopausal symptoms treated. Now, I think in the past, and even in the present, many people would say, oh, you're unwilling to get screened for breast cancer? I'm never, ever going to give you any kind of hormone therapy to address your symptoms.

14:13But if you walk through this with them and you try to understand where they're coming from, what risks they're willing to accept, maybe their reasoning for declining, that kind of thing, it might be the case that, hey, I'm willing to prescribe it to you because we've had this whole conversation and you understand this potential risk in order to gain this potential benefit, and it's not my job to withhold this from you. Now, if alternatively the intervention is clearly more harmful than it is potentially beneficial, then things get a little bit more tricky. But that clearly to date, based on the available evidence, is not the case for GLP-1 receptor agonists, whether the person drinks too much, whether they are not eating the preferred dietary pattern that we might recommend, even in some cases, if they're not exercising in the exact ways that we might recommend.

14:55Now, there is a certain limit where, okay, this person's BMI is like, you know, 20 or something, or it's cracking, 19, they're getting cachectic, frail. It's like, yeah, the medicine probably should have been stopped a while ago, or they should have been advised to stop the medicine a while ago, maybe because now you're starting to reach a point where, okay, we're starting to go up on the other side of that U-shaped mortality curve as your BMI gets too low. And I'm like, actually concerned that I'm harming you more than I'm helping you. And so that's why there's a conversation to be had with people.

15:22But I really shy away from this like aggressive paternalistic style of care, but rather try to make as many decisions jointly as possible with people and not really moralizing any of this. If the intervention has the potential to benefit, here it is, you know, and then we can work through it together. Yeah. Shared decision making is the key phrase here. You know, I think there's another way to look at this question and perhaps the question askers original intent was with cognitive dissonance from like maybe the patient standpoint whereas they're you know taking this personal responsibility to seek out treatment for uh presumably obesity but not doing that for what the question asker views as excessive alcohol intake and you know is that cognitive dissonance at the level of the patient and it's like well not really you know you don't have to check all of the boxes for health promotion to make a healthy you know, choice.

16:16It's like a person who starts exercise, but doesn't necessarily change their dietary pattern or vice versa. And it's like, look, there are so many ways that we can influence health and performance and fit, you know, all these things, you don't have to do all of them, you know, to do one of them. That's kind of like this perfectionist, uh, idea. So I don't know. I agree that, uh, from the physician patient, that sort of thing, you, you summarize that perfectly just, you know, when it comes down to the individual level, behavior changes is challenging. And like you can pick a single target for behavior change or multiple targets.

16:50And that's really up to the individual and the sort of bandwidth they have to do that. Does that square with your understanding? Yeah, I agree. You can have you can be, you know, in a different stage of behavior change for all sorts of different potential outcomes. And maybe with the GLP one use, if somebody does, you know, drink above recommended limits, that'll start to improve. And maybe they get super motivated based on that early progress that they didn't even mean to get. And it leads to a snowballing effect. Or maybe they say, you know, it's helping, but I want to get more. And then maybe then they start to open up the conversation with pursuing some other form of, you know, a clinical care for that use of naltrexone, other sorts of medical therapies, psychotherapies, things like that.

17:25But, you know, I think that getting the ball rolling in a positive direction with the meds here is would be my intent in this type of situation and not, you know, withholding it for that kind of a reason. Yeah, it's like a backdoor treatment almost to like open up the conversation or other options for managing. Again, if there is excessive alcohol intake and a person doesn't want to change that, yeah, that's a bridge that you're creating there. But if you want to go deeper on this, we did just drop a podcast, a GLP One update with Dr. Nadolsky and Dr. Baraki. It's also on our YouTube channel if you prefer to watch rather than listen and a bunch of references also in the show notes there.

18:02I've linked that in the description here.

18:09this podcast is brought to you by bigs 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 now over the last six years an incredible team of health care professionals did something that most people thought was impossible they helped rebuild the body of legendary olympian lindsey vaughn after a series of devastating injuries and now she's actually headed back to the 2026 Winter Games in Milan, and she's ready to break records once again. This February, Lindsey's team and the entire USA medical team will be wearing figs, and you can rock their official uniform too.

18:43The new Team USA collection from figs is engineered with Fiber X. It's their most durable fabric yet. It really is setting a new gold standard for high-level performance scrub wear because it's lightweight, it's breathable, and it's ultra-resilient for those long shifts. And of course, the style comes in red, white, and blue. Now, if you want the gear that the medical team behind the world's best athletes are wearing, check out the limited edition Team USA collection. You get 15 % off your first order at wearfigs.com with code FIGSRX. That's wearfigs.com, code FIGSRX. All right, on to the next question.

19:16We're talking about training now. This is basically a religious war. All right. Am I missing critical gains by using the trap bar to save my lower back? Does the handle height matter? So this is about the debate between a trap bar and a straight bar deadlift. All right. Now, to me, people argue about this like it is a religious war, like it's a theological discussion. But physiologically, it's like arguing Coke versus Pepsi. You know, when you look at biomechanical studies comparing the two lifts, sure, there are distinct differences about where the training load goes, where the muscular tension is created.

19:55uh so for a straight bar deadlift particularly conventional that's been the comparator bars in front of the legs there's tends to be a longer moment arm the distance between the center of the barbell to the hip and back so you get more hamstring and more erector sort of loading the the same weight is uh distributed differently more on the hamstrings uh and the erectors for the trap bar this tends to be a little bit closer to the ankles the center mass does so you have a more upright torso so you get a little more quadriceps involvement and more glutes less lower back the result is just that the training load is distributed differently you're not really missing any quote gains that are generally applied they just tend to get a little bit more uh training load on the quadriceps and glutes versus uh the glutes and are there the hamstrings and the erectors it's just slightly different and to be clear all of the studies to date on this are focused on emgs uh with this emg data which is just a study of electrical activity at the levels of the muscle we don't have like longitudinal outcomes like group one did trap bar deadlifts group two uh did straight you know conventional deadlifts at the end we tested their leg press one rep max or their erector hypertrophy or their hamstrings hypertrophy if we had that data we could say with confidence like here look these are the differences in training outcomes that you can expect if you fit into that population that was studied.

21:21But so far, it's just EMG stuff. And EMG data to date does not really correlate well with those outcomes. It's a signal on some level, like if somebody did a lift and there was, you know, 90 % voluntary activation of a particular muscle group versus another exercise that had 0%, you know, activation of a particular muscle or muscle group. Well, sure. At that point, you're like, yeah, I can, my brain still works. I have than one synapse that functions, you're going to get more gains out of the first exercise where the muscle or muscle group of interest is actually being, you know, electrically active.

21:55But other than that, when someone's like, well, this is 60 % versus 50%, I'm like, dude, I don't care. To date, that's just, we have a lot of EMG data out there. It just is not really instructive as far as what you should prescribe. Overall, I would predict similar strength gains in unrelated low skill strength tests, whether that's a leg press, whether it's an isometric leg extension or leg curl, something like that. But yeah, at the end of, you know, 12 weeks of trap bar deadlifts versus conventional deadlifts with a straight bar, the biggest differences I would predict are the performance in those individual exercises, but not really outside of that.

22:33And then further, I would like to explicitly reject the idea that conventional or straight bar deadlifts are more dangerous or risky on the lower back compared to the trap bar deadlift. Instead, I think that both are safe when loaded appropriately. Just between the two, the training loads distributed slightly differently, though to what degree and like that that matters depends on what outcomes are being tested and how. You know, you can't say that a regular straight bar deadlift makes you stronger than a trap bar deadlift. It's like, well, in what specific context or a conventional deadlift drives more hypertrophy than a trap bar deadlift.

23:08Like, well, what specific muscle group? And then where's the proof? Because to date that doesn't really exist. So I could not say that confidently. Austin, what do you think about this trap bar deadlift or straight bar deadlift debate? Is it missing? Is the trap bar deadlift missing anything compared to just a regular straight, you know, conventional deadlift? Or is there ever a time that you would specifically prefer a trap bar deadlift over a conventional deadlift? Yeah. I mean, there are, to your point, slightly different exercises that distribute loads slightly differently. And that leads to the expected slight differences in the adaptations that you get as a result.

23:43I just generally struggle to care about this in general. I think that if the person asking this question, or if you're trying to answer this question for yourself, like, do I have a non-negotiable reason that I must conventional deadlift from the floor? Like I'm entering a barbell strength related competition where that is the, you know, the task that I must complete. If that is not the case, as we've talked about before, you have every possible exercise in the world at your, you know, that you can, that you can use to facilitate your, your training towards whatever desired outcomes and goals are, are important to you.

24:16And so if somebody is not a competitor in a sport that requires it, then it's like, okay, is this just for health? Then I extra don't care about the difference between the two, because, you know, if you, if you told me, Hey, I'm going to have somebody who starts training at pick your age and then a decade, two decades, three decades, however many years later between trap bar and conventional deadlift, and then I'm going to measure their resting blood pressure or their hemoglobin A1C or their blood lipids. Would I expect to see a difference? Obviously, no, I wouldn't. Might there end up being over a long enough time frame, some differences in their abilities if you were to do a focused analysis of their hamstring versus quadriceps hypertrophy?