Building strength and muscle mass: how to optimize training, nutrition, and more for longevity (AMA #71 rebroadcast)

[Music] Hey everyone, welcome to the Drive Podcast. I'm your host Peter Atia. This podcast, my website, and my weekly newsletter, all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. If you want to learn more about the benefits of our premium membership, head over to peteratia-md.com/subscribe. [Music] Welcome to a special episode of the Drive. This week we are re-broadcasting AMA71, which was on the topic of building, strength, and muscle mass. This is a topic that is obviously central to both lifespan and health span, and is probably one of the topics I'm most frequently asked about. This episode was released last year to our subscribers, but we think it's important enough, and we do this occasionally with AMAs that we re-release them to everyone. It's also a great chance for those of you who are not subscribers to hear and experience what the monthly AMAs are all about. While we've covered many aspects of this topic in the past on different podcasts with multiple guests across many years, we find that AMAs like this that are designed to bring all of that knowledge into one streamlined discussion are really helpful, especially as you want to start to operationalize some of these things in your life. We consider this a long TLDR compared to what it would be like to gather all this information everywhere. In this episode we're going to talk about why muscle matters for longevity, metabolic health, and injury prevention from a data standpoint. The difference between muscle mass and strength, because they're not the same, although they travel together, and which one matters more, talk about things like why would grip strength, predict mortality. We discuss how to build muscle and strength effectively, including the important concepts of progressive overload, rep ranges, training intensity, and safe ways to maximize results. Talk about why power training and explosive movements become especially important with age and how to add them into your routine. Talk about the nutrition needed to support muscle growth, including protein intake, timing, and supplements such as creatine. Talk about training stages for different people from beginners and older adults to younger athletes and people focused on maintenance, and including people like seasoned lifters. Talk about how to balance recovery and injury prevention by managing fatigue, training consistency, and making progress slowly over time. So without further delay, I hope you enjoy this special rebroadcast of building strength and muscle mass as an AMA. Peter, welcome to another Ask Me Anything episode with Dr. Peter Atia, Stanford, educated physician. How you doing? Thank you for that incredible introduction I'm doing well, and I appreciate you having me back. I just wanted to make sure you knew it was your show, so I thought more of an introduction would make it feel more like home. Before we start today's topic, how's your day going? Learn anything new today? Have you been educated in any way? Well, you're always learning, Nick. That's the thing. I think we should all try to be learning at all times. Today I had a particularly fun day. I went to my son's school to take him lunch. This is something that I like to do once in a while is take lunch and eat with my kids. He wasn't really in the mood to have lunch with me today, which happens from time to time with seven year olds. So I ended up just in the cafeteria sitting at a table all by myself eating lunch, which in and of itself was pretty funny because I really got a kick out of watching all the kids doing their thing. But eventually a bunch of kids in his class, I think, felt bad for me and they came up and just sat around me and they started asking me a bunch of questions, which of course turned into me asking them more questions like what do they do in P, what are they learning in science, that kind of stuff. But the kids sitting right across from me noticed I was drinking a diet soda and truthfully I don't really drink that many. I'm mostly a topo-cheeko waterloo guy, but this was the first thing I grabbed. And he said, huh, I noticed your drinking, whatever it was, I was drinking a fresco actually. You know that that has a sweetener in it that is 500 times sweeter than sugar. And I said, oh yeah, I think that's how they get away with making it have no calories. He goes, you know, that causes cancer, right? I just decided at that moment, probably not a good time to argue the abundance of the human literature and the animal literature and all that. I let that one go, but I appreciated the conviction and his concern for my health. He also pointed out afterwards that it wasn't going to kill you quickly because you were only ingesting so little of it, which I thought was a very astute comment for a seven year old. But anyway, needless to say, I had a lot of fun doing second grade lunch today and I would be interested in going back. I do love it, especially because you've openly talked about how when you go to parties and events where there are adults there, you usually don't explain what you do because you don't want to have those conversations and I love the fact. You went to the local elementary school and they wrote to you into that. We were talking briefly before this and I think Jessica and our team had a good idea and people in the audience can let us know if they think this is good, which is maybe we do get a panel of these seven year olds together and do a round table on what elementary kids think about health, nutrition, exercise, protein, microplastic, seed oils, you name it. Sounds like you're a local elementary school has a lot of insights on these topics. Honestly, if our audience wants to hear the seven year old round table, I am totally game to get a group of three or four or seven year olds around the table and really go deep on the health issues that mean most to them. It's probably quite insightful. Yeah, it is. Let us know if we should do it and we will make it happen. But for today's AMA, we are not talking about that. We're actually going to talk about one topic and that is all things related to muscle mass and muscle strength. So it's something that we've talked about on a lot of different podcasts. You openly talk about the importance of it and we've gathered a lot of questions that have come in and these questions are going to deal with why is muscle mass and strength important? The difference between muscle mass and strength, which one matters more? How can you start to increase your muscle mass and strength, whether you're old, young, male, female, the role of nutrition and protein, one of your favorite topics in this? And then we'll end with some different programming options for different types of people if they want to start applying this to their life or if they want to start going further than their current exercise programming. So with all that said, some people may say you have a lot of information on this already in episodes with Lane Norton, Andy Galpin, Mike is retail and many more. So what would you say to someone who asks why are we now dedicating an AMA to this? It's a fair question and one that we internally kicked around and I think two things put us in the situation we're in. So one is we continue to get asked more questions about this than almost anything. I would say it's among the three most asked about topics. But I think the second thing is because we have so much content out there, if you want to get the TLDR on this, you're going to be spending hours and hours and hours, 20 hours worth of digging. And so what we thought we could do is organize the content in a way that would make it much easier for a person in what will undoubtedly be a much smaller adequate of time to get everything that they need to get out of this at the zeroth order and maybe first order level. And then really through the show notes and supplemental material go as deep as they want if they need more content. I think we're going to deliver on this one. We've put a lot of work into it. You should because it sounds like if you don't next time you go to school, pick up or drop off, you're going to hear in your full for some kids. So I'm half expecting the next time I go in for someone to be like, dude, why are you so weak looking? Why do you have such chicken arms? Do you not work out? I'm not saying it's a good idea. I'm just not saying it's a bad idea if you roll up to the next one shirtless, maybe after a little dehydration, a little pump prior to just to let those kids know who's in charge. On that, let's start with some definitions. Muscle mass, muscle strength. Two things that are kind of used intertwined but also a little different. We'll get into them here where I think it'd be helpful to start. What is the definition of each of those and how we're going to talk about it? I think most people understand that they are different. I think the confusion comes from the fact that we will interchangeably talk about metrics of both of them. We're going to clarify this. But of course, muscle mass is simply the total amount of skeletal muscle in the body. There are three types of muscle in the body. We have cardiac muscle, which looks and behaves a lot like skeletal muscle but has properties that allow it to basically run non-stop for the duration of your life. We have smooth muscle but is actually quite distinct from skeletal muscle. But the bulk of muscle in the human body is indeed skeletal. It has contractile muscle. properties that allow it to generate force. It has certain metabolic requirements, but nevertheless, this is what we're referring to. I think of this as having a structural function and a metabolic function. We're going to talk about both of these. Of course, the related metric is strength, and that's the ability to exert force to overcome resistance. So again, I think that's very intuitively obvious to everybody, but nevertheless, we could talk about those things. Two additional concepts, just to introduce is the idea of hypertrophy. So in addition to how strong a muscle is, how much force it can overcome, we can talk about the size of the muscle, and then we can talk about power, which is something that probably doesn't get talked about enough, although we certainly talk about it quite a bit on the podcast, and power should not be confused with strength, although there's a strong relationship between them. Power incorporates velocity. There's an inverted U shape that describes the relationship where as resistance goes up, one is able to move with a high enough speed that they can continue to increase power, but as the resistance gets beyond a certain point, speed will come down and actually power is coming down even while strength is going up. So that kind of rounds out some of the semantics. Just hitting this right off the bat, why is muscle mass and muscle strength important for someone to consider in the concept of lifespan? A.K.A. why should everyone who's listening to this care about this topic? I think what I want people to fixate on now is while we will go back and forth between them, that is simply an outcome of the data. We have to lean on what data are out there, and sometimes the data are looking at muscle mass, sometimes they are looking at strength, sometimes they are looking at both. What we really care about is strength, and therefore when we look at measurements of lean muscle, which is very easy to measure, that's a big part of why we measure it. It's objective, it's easy to measure, and it can be compared across studies much more easily than strength can, for example, although when you standardize metrics of strength, obviously it can be pretty easy as well, but it's the strength that we care about. And it's strength that is probably much more highly associated with, not just correlated with, but causally associated with mortality, cardiovascular disease, neurologic disease than muscle mass itself. What I would say is we talk about muscle mass a lot, we care about muscle mass a lot, it plays an important role in the metabolic function of muscle, but maybe above all else just think of it as a great proxy for strength. Not a one-to-one proxy, I know everybody listening to this has met a really wiry person who is insanely strong, and there are actually some people who have quite a bit of muscle mass, and yet they're not actually that strong. But if you exclude the extremes in the bookends, there seems to be a reasonable mapping between muscle mass and strength. Is there anything we know about how much of a difference muscle mass strength can make as it relates to lifespan? Yes, I think this is a great way to think about all of the things that are associated with mortality. So I sometimes will ask this question of people as just a way to demonstrate, and not to be cheeky, but just to demonstrate the obvious, has a way to reframe the discussion. So if I say to a group of people, what factor is most associated with mortality? Let me know what you think, and people will say of smoking, high blood pressure, all sorts of things. The answer is age. So nothing associates more with mortality than age, which by the way, as a total aside is why I still find ageing clocks to be unhelpful, because biologic age, chronologic age, trying to suggest that those are different, requires demonstrating that biologic age, as demonstrated through an ageing clock, is a superior predictor of mortality than chronologic age. And nothing has come close to even being within the zip code of the zip code of the zip code of the thing that I'm talking about. So when you look at Gompert's law for mortality, you see an exponential increase in mortality with age. I'm going to pull up a figure here in a second, in which I tried to depict Gompert's law by decade. In other words, what was the relative risk of mortality with each passing decade? And it dwarfed all the other stuff on here, so it didn't make sense to put on. I'm only throwing all that out there, Nick, as an aside to say, I am excluding the elephant in the room with this figure that we put together by excluding age. But if you take that off the table, what I'm showing you here is a collection of hazard ratios for all cause mortality. Again, not from head-to-head studies. These are from at least four, if not five different studies, all of which will be referenced in the show notes. But what we're showing you is what is the increase in all cause mortality for individuals across these various data points? So if you consider the figure here, some of these will be completely familiar to people who have heard me talk about this in the past. So if you look at the things on the left of this graph, we're looking at markers of cardiovascular fitness, the easiest way to measure that by far, of course, is VO2 max, which is why we talk about it so much. So if you're comparing what's called above average to elite, that's basically someone who's in the third quartile, so 50th to 75th percentile to someone who is in the top 2%, we're talking about a two-fold difference. By the way, the little bars on this thing, those are error bars. So 95% confidence intervals. If you're looking at someone with low VO2 max, this would be somebody in the bottom 25% tile to someone in the top 2% tile. You're talking about a five-fold difference in mortality, meaning there's a five times greater difference of dying in the subsequent year from any and all causes. I'm going to skip some of the other VO2 max ones, but let's say you look at grip strength. So you look at every reduction of grip strength by 10 kilos is about a 30% increase in all cause mortality. When you look at different metrics of muscle mass, if you compare bottom to, say, middle quartile of muscle mass, you're talking about 2.3 hazard ratio, which means 130% increase in all cause mortality. And again, at the right side of this figure, I'm just showing you things that people would commonly and appreciate are driving mortality, such as type 2 diabetes, which is about a 40% increase in all cause mortality, uncontrolled hypertension, high blood pressure, about a 60% increase in all cause mortality. And of course, smoking, which from a modifiable lifestyle behavior would be right near the top of the list at about a 2.8 hazard ratio, at least in one study. I've seen other studies that has it as low as 1.4. Obviously the duration of tobacco use comes into that, but there's no mistaking the role on that. So what do we take away from all of this? We take away from this that muscle mass, strength, cardiovascular, respiratory fitness, play an enormous role in predicting how long you're going to live. And while age is the king of kings, when it comes to predicting how much longer you're going to live, these things play a huge role as well. We talked about grip strength before, but I think it'd be worth just quickly double clicking on grip strength. And can you talk about how that is related to mortality? Grip strength is a very easy thing to test. A moment ago I said, hey, look, muscle mass is often used as a proxy for strength. Why? Well, it's because DexA is a ubiquitous test. It's very easy for researchers to use DexA. It can be standardized from one place to another. So it's easy to use. So then when you start to think about strength metrics, one of the easiest things that we can do is test grip strength. It's also not just easy to reproduce, but I would argue it's a great representation of upper body strength. So people who have a very strong grip tend to have a very strong upper body. You can't do many things that require a lot of upper body strength if your grip is very weak. So, nevertheless, if we look at grip strength, what do we know about it? So there was a study called the Pure Study that measured grip strength in somewhere in the ballpark of 140,000 people across 17 countries. And they found that lower grip strength compared to higher grip strength was a significant predictor of all cause mortality. So every 5 kg reduction in grip strength was associated with a 16% increase in mortality, meaning every 5 kgs or 10 pounds of reduced grip strength compared to someone who had more grip strength to that amount. There was a 16% chance of dying in the subsequent year from any and all cause. Another very interesting study looked at people in their eighth decade of life. So these were people aged 70 to 79 at baseline, and they followed them for seven years. And so these people were divided into quartiles based on muscle mass and strength. So separate analysis. So Dexa was used to quantify muscle mass. And I believe they use leg extension for quad strength. They might have used grip strength as well for upper body strength. Okay, so basically you have quartiles of strength quartiles of muscle mass in people who are in their eighth decade of life. And they are prospectively followed. And what we're looking for basically is what's called the Kaplanmeyer survival curve. So if you pull up these curves here, Nick, you can see that obviously because it's a Kaplanmeyer curve, it's cumulative, you can see a monotonic increase in mortality for all groups, but what you notice is the strongest groups and the groups with the most muscle mass always have the highest survival. Again, the mortality rates are pretty high in this figure. This is a seven year follow-up in people that are starting late in life. You wouldn't expect to see this steep immortality drop in, you know, if they were doing this in people aged 50 to 59, two decades younger, but the reason I suspect that they chose to do this is because they wanted to actually see some separation. So another very clear indication of at least a very strong association between muscle mass and muscle strength in terms of all cause mortality. Well, what do we know about muscle strength and muscle mass being causally related to mortality? Because I think sometimes you're going to hear people say, well, is it just that people who are stronger tend to be healthier in other ways too, and then live longer as a result? So how do you think about that? Yeah, I think this is a very important question because I absolutely believe that there is bidirectionality in this association. The healthier you are, the more easily you can do the things that make you stronger and make you have more muscle, and that should be playing a role in how long you live. In addition to the fact that doing those things allows you to live longer. So that's my thesis. How would you get at that? Well, it's very difficult to do a randomized experiment, but if we look at Mendelian randomization, which again, we've talked about many times in the past, but this is basically looking at genetic scattering of traits that we care about and asking the question, how does that impact the parameter of interest? So if we look at Mendelian randomization studies that look at the relationship between muscle mass and mortality, they do find at least partial causality rather than strength just being a proxy for general health. So one study that looked at 300, 350,000 Finnish bio bank participants used a polygenic score as a proxy for grip strength. So in other words, a whole series of genes were associated with grip strength. Again, this is not hard to imagine. Everybody knows that person who's just stronger than everybody else. And when they look at that polygenic marker for grip strength and assess the relationship to chronic disease and mortality, you found that each standard deviation increase in grip strength from the polygenic score was linked to a reduction of risk for vascular dementia by 7%, obesity by 6%, 5% for type 2 diabetes at 4%, per mace, and 3% for all cause mortality. That's one way to look at this, but again, it suggests to me by directionality here in that, yes, I think that the magnitude of the benefit that we see in the pure observational cohorts clearly reflects the health of the user as well that enables them to train. Peter in the past, when we talked about VO2 max, you've often spoke about how it is such a good metric because it's an integrator of the work done, meaning you can't just cram for a VO2 max test the week before and greatly increase your VO2 max. Is that also kind of similar to muscle strength, muscle mass? Yep, I think that's exactly why VO2 max, muscle mass, and strength show up as such strong predictors is that they integrate and aggregate years of work that go into producing high results. We say this all the time to our patients when they show up and test very poorly. So when someone shows up and they're in the bottom 5% for muscle mass and their strength is poor and their fitness is poor, we explained to them that this is not something that's going to turn around this year. This is not like fixing your APO B, even fixing your insulin resistance and things like that, which take a lot of work. This is the longest part of your health journey if you're starting with a very low base. And I think just understanding that and saying, look, it's going to be probably three years before we get your VO2 max from 30 to 50, but it can be done provided you're able to and willing to train. So far, we've talked about the benefits of lifespan as it relates to these metrics. What do we know about the benefits of health spans? So not only living longer, but also living better. Yeah, you've obviously heard me say this. I think that exercise should still be viewed as the most, if not one of the most important things that we can do to modify our behavior, even if it played no role in lifespan. So even if you told me that all the exercise that I do was going to shorten my life by a year related to being sedentary, what would I do? And the answer is I would still do it because of the effects on health span. Now, of course, that's a false choice. It's also increasing lifespan, but my point being is just the health span benefits alone are important. So I think there's lots of ways to talk about health span, but maybe we just put it all together and talk about all the benefits of muscle health. So there are lots of ways I think that muscle impacts health span and lifespan. Maybe we just take a minute and look at each. So let's start with metabolic health. So we've discussed this on many previous podcasts, and I alluded to it earlier in our discussion, but muscle is the predominant sink for insulin mediated and even non insulin mediated glucose uptake. So the more skeletal muscle you have, the more easily you can buffer blood sugar. And I would hope that I don't need to spend much more time explaining why maintaining low blood sugar is an imperative part of reducing not just the risk of type two diabetes, but more importantly, I would say heart disease, dementia and cancer. So anything that you have that aids in the shunting of glucose easily into muscle is going to improve that. And therefore, we want muscle that has sufficient size, say someone that can hold three to 500 grams of glucose in storage. And also we want insulin sensitive muscles that allow the muscle to take that up with the least amount of insulin possible. We talk about inflammation. So muscle is an endocrine organ. This is not necessarily intuitive to people. We don't really think of it this way, but it is indeed an endocrine organ, which means it secretes signaling molecules called myocines, such as interleukin six, which has an anti-inflammatory role. Most of the interleukins we think of are actually pro-inflammatory, but that's not the case with all of them. And so indeed, irisin, IL-6 can actually reduce inflammation and improve metabolism. By the way, it's worth noting, Nick, many people have looked at these interleukins and myocines as ways to biologically mirror the effects of exercise without actually exercising. So for what it's worth, I don't know, 14 years ago or so, I remember irisin was all the rage when it was discovered as a myocine. And of course, people immediately said, listen, we just need to figure out a way to inject people with irisin and we will produce the effects of exercise without doing it. And of course, these things have never panned out. Now, I'm not going to give up on this approach. I know one of our previous podcast guests, Mike Israel, really was convinced that within a decade, no one will need to exercise. We'll just inject people with myocines. I'm not nearly as bullish as he is on that nor do I think I would even find that interesting. I actually enjoy the active exercise, but at least his view was, look, we will be able to produce all of the metabolic benefits of exercise by doing this. The fact that we haven't, by the way, suggest to me the vastness of what exercise does. It's not going to come down to two or three myocines. It's going to be an entire cascade of things that probably affects why this is happening. And the show notes, we're just going to link to all of the places where these things have been discussed in great detail. The other thing to consider, which again, I think is something we fortunately don't have to think of under normal circumstances, but it really does matter when a person gets sick, is that muscle is indeed the reservoir for protein. So we don't store protein the way we store glucose and the way we store fat. So I think everybody's familiar with the idea that we store infinite amounts of fat. As much as our fat cells will get fat, we can store fat. And that can provide us with months and months of energy. We don't store that much carbohydrate. So we're kind of stuck there with our glycogen supplies. Of course, anything excess will store as fat. And we don't store protein in the traditional sense outside of the muscle itself. And so what that means is the more muscle you have, the less muscle you will end up losing in a period of illness or stress, like surgery, infection, hospitalization burns, things of that nature. So I think this is a big part of why people with more muscle mass consistently have lower mortality. They're more likely to survive hospitalizations, infections, car accidents, you name it, put stress on the body, more muscle is better. Then we kind of just get into the obvious stuff, which I don't think I need to spend much time on, which is movement and activity in life. The more you move, the more you're alive, the less you move, the less you're alive. I don't think too many people are going to disagree with that. And I don't think we need to spend much more time talking about the centenary into Cathlon as the mental model. I think about for how to prepare for the marginal decade. But there's really no scenario under which you're going to have an optimal marginal decade if you are not physically able to move and do as much of what your heart desires. We talk a lot about falls. I actually just sent the team in email earlier today about a study that I was looking at that very nicely summarized just the significance of the fall literature. Again, 300,000 hospitalizations a year in the United States alone. Apologies for those not in the US listening. I don't have the stats, but you can extend them by proxy 10 to 30% one year mortality for those above 60 and very few of these individuals. If they suffer a femur fracture are going to return to their state of previous health and mobility. So I think all of these things taken together should really remind people of why this matters. If you just want to look at how mortality is driven in falls, I'm going to rattle off by decade what the death rate per 100,000 is from a fall. So if you're 25 to 35, it's 1.1 deaths per 100,000. 35 to 45, it's 1.7 deaths per 100,000 45 to 55, 3.2 deaths 55 to 65, 5.7 deaths 65 to 75, 13.2 deaths 75 to 85, 50 deaths. And by the time you reach 85 and up, it's nearly 200 deaths. So anybody plotting that will realize it is the true definition of an exponential growth curve. Double click it on that before we move to how does someone start to increase their muscle mass and strength. Can we just talk a little bit more about what we know about how we gain and lose muscle as we age and why muscle is so important when we're older and why that means that you can't wait until you're at a certain age to start caring about it. So muscle strength peaks in the 30s typically, maybe even the early 40s. Again, notice I'm not talking about power, power peaks sooner than that. So that incorporation of speed, but strength is going to peak in the fourth or early part of the fifth decade, but it will decline with age at a rate of about 1 to 2% per year. This rate continues largely uninterrupted unless there is a significant change to health status. But once you hit about the age of 70, this acceleration continues. And one of our previous guests, Luke Van Loon, really made a point that I thought was so interesting, which is when you look at these curves that represent a decline in muscle mass, a decline in strength, and a decline in activity level, they look physiologic, which means they look beautiful and smooth. But he said that's just because you're looking at population-based averages. When you look at this at the individual level, for most people, it's relatively slow decline punctuated by rapid periods of decline with inactivity. So the key here is avoiding inactivity, avoiding time without training. One of the greatest things that leads to that inactivity is injury. So that's why, as far as I'm concerned, once you reach my age in your 50s, rule number one of training is don't get injured. Do not miss workouts because you are injured. And I think that just only increases as you age. And that's why I do worry when I see someone who's in their 60s and 70s having a significant injury, which is going to take them out of training for months at a time. We'll kind of link to much of the details around here. I don't really want to just rattle off all the numbers. It gets a little overwhelming, but we'll kind of go to some of the more granular data of what this looks like. I think we can summarize it by pulling up kind of a schematic. So there's a schematic here that talks about how, look, age on the x-axis, relative function, muscle mass, put wherever prox you want on the y-axis. It's going to peak at about the age of 30. And you'll see in this figure, basically, three levels of decline and the levels of decline are going to be dependent on the level of activity. So a very active individual, lower level of decline, still declining, a population average, quicker level of decline, and a sedentary individual, much quicker level of decline. And where does it become relevant? It probably becomes relevant in the 70s. So in the eighth decade of life is where you really start to see the difference. And the problem is you don't want to be on that red curve in this figure that I'm showing and figure it out when all of a sudden everything is taken away from you. If you're on the red curve today, get to that blue, get to that green curve by increasing activity. Yeah, and on that graph, I think it's interesting because there's almost two components too, which is, if you've already passed your peak, you really want to make sure you decline at the slowest right possible. But if you're of the age and listening or watching this and you haven't passed your peak yet, you really want to make sure your peak is as high as you can go because that's the other aspect that affects your decline, correct? Yeah, that's a great point. It's very true with something like VO2 max, very true with something like bone density. I'm very grateful for those formative years of my life age, probably 13 to 18, 19 when I was training absurdly hard. On the one hand, the drawback of that neck is I have awful scars to show for some of the stupid injuries, especially to my back. On the positive side, I like knowing that my VO2 max was in the 70s, or I think at one point, even the low 80s. And so even though I'm much lower now, I'm still relatively high because I started from such a high base. So yeah, you're right. I don't think our audience particularly skews on the younger side of 30, but for those listening or for those who have kids, you want to really encourage your kids or yourself to reach your maximum genetic potential because it's going to get that glider a lot higher and give you even more room to stay on that green curve as you age. If you can do it without injuring yourself like I did as an idiot, then you've really won the game because it wasn't necessary for me to do the stuff I did to injure myself. It was just due to sheer ignorance. That's another topic we could talk about with the seven year olds at the round table so we can park stupid ideas that you do when you're young. But moving on to now the crux of this and what most people care about is getting into the nitty gritty around how to increase muscle mass and strength. So I think starting with just a general question of, what do you think is the most effective approach when you look at resistance training for someone to put on muscle size strength mass? So I think one has to align around what it is that they're trying to optimize. So optimizing for strength and optimizing for hypertrophy will require different types of training. So to take two extremes of this, if you're talking to Lane Norton and he's preparing for a powerlifting competition, which even though the word power is associated with it is the purest demonstration of strength, his training looks nothing, nothing like Mike Isra-Tel's training as a bodybuilder where he is training maximally for hypertrophy. I say nothing like they're both in the gym. They are both lifting a lot of weight, but a closer examination will reveal pretty quickly that they're doing very different things. Now most of us are not doing either of these things. Most of us are going to be kind of in the middle. We're training for strength, but not maximum strength. I have not deliberately done a one rep max in 15 years, and I'm very confident saying, I will never deliberately do another one rep max in my life, meaning I'm never going to be training for maximum strength. At the other end of that spectrum, strength is still very important to me, and that means I do need to be in a slightly lower rep range than just the other end of the spectrum where I'd be training pure muscular endurance. I'm still doing things that are strength-based principles that I wouldn't necessarily be doing if I were purely optimized around hypertrophy. Okay, we're going to talk about this in much more detail, but I just throw that out there's a couple of extremes. The principle underlying resistance training, regardless of whether we're talking about hypertrophy or strength, is one of progressive overload. The idea here is that you constantly challenge the muscle with increasing demands to force adaptation. Now, how this works has been discussed, and I want to say, I think probably the podcast with Andy Gelpin might be the one where we went into most detail here. So obviously, we're going to link to all of that. But the reason all of this happens is basically a function of muscle fiber recruitment. So people might remember from those episodes that we have type one and type two fibers. The fiber type refers to many differences in these muscles. It refers to the force with which they can contract. It refers to their metabolism, whether they are more glycolytic or oxidative. But basically, we want to increase load and volume over time to recruit higher threshold motor units. So another important principle here is muscle protein synthesis. So we have to be able to provide the substrate for these muscle fibers to repair and grow. And then of course, you have to have neurologic adaptation. So this is something that has taken me a while to sort of explain to my daughter who really, really has taken a huge enjoyment for going into the gym and she's at that age where she's running track and wants to work out all the time. And I kind of have to explain to her that she needs to recover a little bit. Her neurologic system is actually fatiguing when she keeps trying to do all these things at all the times. But we have to basically be able to train the motor units to fire correctly, to sink how to control them, and again, all of these things factor in. So broadly speaking, I just want people to understand you have this overall idea of progressive overload, and you have to be able to tap into different motor units, you have to be able to provide amino acids for muscle protein synthesis, and you need time for neurologic adaptation. Let's talk a little bit more about how would someone implement progressive offer overload? I think it's kind of a term that people may have heard, but I think walking people through how they would actually go about that and the gym would be helpful. Yeah, there are many ways to do this. One of them is maybe the most obvious way that people would naturally think of, which is you can increase the load or the weight, but you can also do it by increasing the reps that you do in a given set or the number of sets or the time under tension, which is one of my personal favorites, or decrease the time between sets. Let's talk about each, and within each, I would encourage everyone to think about which ones might be safer, which ones might make more sense if you're lifting alone versus lifting with others, which one might make sense under certain types of exercises versus others. I'm going to use myself as an example here, but I would like people to sort of think about this for themselves. Okay, so increasing weights directly. It's obvious, I don't need to say it anymore about this, but I will call out places where this might not make sense. So for me, I just know that there are certain parts of my body that I don't want to add more and more weight to. So I'm not going to add weight. Where's an area where I feel very comfortable just adding weight because the risk of increased loading doesn't seem to matter doing a bicep curl. Great way for me to increase overload. What I do this on something that has some degree of axially loading, not anymore. I would in the past, I won't today. Increasing reps. This is great, but again, we want to go back to the principle here. If you are exceeding reps, it might imply that you weren't doing enough in the first place at a given weight. So remember, we're always trying to target one to two RIR. So I guess we could say here, if you're in the two-reppen reserve and you want to move to zero to one without increasing the weight, that would be a manner of progressive overload. But the truth of the matter is here, once you start exceeding 12 to 15 reps, you are shifting more stimulus towards muscular endurance. That's not a bad thing at all. You just have to be aware of what your goals are. Extra sets and volume, to me, is a great way to increase overload without necessarily increasing weight. Again, another part of that is decreasing time between sets or supersetting. I also enjoy that a lot. Again, as I said a second ago, one of my favorite ways to increase the overload or to progressively overload is time under tension. So my shoulders don't love bench press anymore. So one of the things I really enjoy doing is very slow sets because I can use much less weight. I have a little bit of arthritis in my AC joint on the right side. All the muscles are fine, but I just don't want to aggravate that AC joint. So A, I'm using dumbbells because I can put them in a position that's a little easier on the shoulder. Also, I don't have to use super heavy dumbbells. If I told people how much I bench press, they'd be like, "That guy's a chicken chest." But if I'm bringing it down slowly, if I'm doing pauses at the bottom, if I'm increasing time under tension, I'm still getting the stimulus for growth and strength without having to rely on enormous amounts of weight. So I think it's just helpful for people to think about these things in the context of themselves and within the exercises they do because you might adapt a different one of these for a different type of exercise. It would have been really great if you would have told that seven-year-old today when you were being lectured about your diet so how much you bench press because I want to love to hear what his reaction to how strong you were as well because maybe he had some tips for you. Yeah, there's no way I would have fessed up to that kid how bad my bench press is because he wouldn't have let me out of the cafeteria. He would have called the other kids over to just mock him. I love it. So for people thinking about this and how to apply it, how often do you recommend patients work on increasing those different levers in their day-to-day week-to-week, month-to-month training? I mean, the truth of the matter is you always need to be kind of trying to push this. Of course, as we age, it's going to get harder and harder and of course at some point we are going to be taking steps backwards. But the goal is you just don't want to get to the point where you're not pushing the envelope of what you're capable of. Now, again, someone who's just starting out, it's their first few months of ever-doing resistance training. They're going to be able to increase what I'm calling total load, which is a function of load, reps, rest, volume. The overall metric that encapsulates everything by 5 to 10% per week, whereas an advanced lifter might be at 1% increase load per week. It's just really a function of what your experience is, but think of it through the lens of always try to push forward. And then of course, just to be clear, we talk about having a deload week, we talk about periods of backing off, but I'm talking about not including those periods. Can we double-click on the phases of a movement? So concentric, eccentric movements, and how one just defined them again for people, and then also how people can utilize those both different movements as they think about getting stronger. So a concentric contraction occurs when a muscle is getting shorter while producing force. This is what most people think of when they think about lifting a weight. A bicep is the easiest way to think about this, but of course it's true for any muscle. So if my arm is straight and I'm curling a dumbbell up using my bicep, the concentric phase of that is while the bicep is getting shorter and I'm lifting it up. So training the concentric phase is where we build power and force output. So the faster you do the concentric phase, the more power you generate. Is there a time and a place for that? Absolutely. One of my favorite exercises is on the Kaiser leg press machine, which is a pneumatic machine, doing explosive single leg leg presses. Obviously something you do after a big warm up, you don't want to put an old guy like me into an explosive movement, but I'm usually doing this two thirds of the way through my exercise, which means I'm leaving a little bit on the table because I'm coming into a little bit of pre-fetigue. That's a trade off I'm willing to make at my age to reduce the risk of injury. And I'm going to not a maximum weight because remember maximum weight is not going to drive maximum power. I'm optimizing for power. So I'm taking kind of a weight that's maybe two thirds towards what I would really do for a high strength set. And I'm doing the most explosive movements I can do with each leg. And again, the reason I like this Kaiser machine, I have no affiliation with these guys is it's measuring speed and force and power. And so I'm just doing a power max optimize. By the way, once I fall below 92% of peak power, the set is over. So I'm really optimizing around peak power there. So again, that's all focus on concentric movement. Now, conversely, eccentric contraction is what happens when a muscle is lengthening under tension. Sometimes when we lift, we are ignoring that eccentric phase. When I'm doing that explosive movement, my leg is blasting out under maximum power of the concentric phase. When I'm bringing that leg back, I'm not making any effort to do so slowly. I'm not trying to put any stress in the eccentric phase. The slower you're bringing that weight back, the more eccentric tension you are under. So again, going back to the bicep curl, I curl this thing up. The slower I let that thing come down, the more eccentric tension I have. And by the way, that's what places the mechanical stress on the muscle fibers, which creates more micro tears and damage within the fiber. And that's what's actually driving hypertrophy. So whenever you're watching body builders train, because again, body builders, primarily concerned with hypertrophy, you'll be amazed at the eccentric control that they demonstrate. Now, this is very important for minimizing injury. One of the things that I think maybe sometimes people do wrong is they're not paying enough attention to their eccentric phase. And for example, like if you're doing a leg curl, so you're sitting on a machine and you're curling back under the concentric phase, you're shortening the hamstring. And you just let that thing go back very easy to injure these muscles. So I think we should almost always be in control under the eccentric phase. The question is, how much emphasis do you want to put on each? So to give you just one more final extreme example, when I was cycling a lot, so this is more than 10 years ago, anybody who knows anything about cycling knows two things are true. You want very strong legs and you want to be as light as possible. So what role would weights play in a cyclist's training? Well, one of my favorite exercises to do was very heavy. And by very heavy, I mean typically five reps, very heavy hex bar dead lifts with drop sets. By drop sets, I mean literally not dropping weights. I mean dropping the weight. itself at the top. So in other words, heavy pick up with good explosion on the concentric phase. And you have to do this with a trap bar, not a straight bar, because then you, from a standing position, drop the bar. So the whole hex bar just drops. And then you drop yourself down with no tension and you pick it up and you do it again. So why would I do that? Well, I wanted maximum strength and power with zero size, because size is weight. Cyclist doesn't want any weight. He just wants to have the strength. So that was a very powerful exercise. And by the way, I could do that three times a week, sometimes four times a week, because without the eccentric phase and without the tearing under tension of those muscle fibers, the recovery is very quick. There's a lot of other things I did around those workouts. I was doing a lot of plyometrics, what's called the post-activation potentiation type workouts. So there's lots of really cool things you can do. But maybe that's more than you wanted, Nick. I just think that understanding concentric eccentric is a very important tool for training. You mentioned this when you're talking about the Andy Galpin episode, where you talked about muscle fibers. Can you kind of give a brief summary of muscle fiber types and how they change with age again? So whether you're talking strength, power, hypertrophy, they all have an association with a type of muscle fiber. So strength and power are associated with the type two fibers, the fast twitch fibers. And the endurance type stuff is the type one fiber association. So slow twitch fibers. So again, type one fibers less contractile force, contract slower, less power, metabolically more fat dependent. They are more metabolically flexible. They're the red fibers, by the way. They're red because there are lots of mitochondria, lots of capillaries. Type two fibers, these ones have more contractile force, metabolically glycolytic. And I think one of the most interesting things that Andy talked about in the podcast that always stuck with me and has stuck with me since is that one of the most, and I don't remember if he even described as the synchronon of aging, but certainly one of the hallmarks of aging is the atrophy of the type two a muscle fiber. So the fibers that are most responsible for power, explosiveness are the ones that start to atrophy when we are already quite young in our 30s and 40s. So power is the first thing we're going to lose, then we lose strength, then we lose size. That's kind of the order in which things go. And therefore, we think it's very important for people of any age to always incorporate power training in what they do. There's a use it or lose it aspect to this. And we just think that it's imperative that we keep it. That makes sense. And so if someone's thinking, okay, how do I improve my power in the gym? What advice would you have for them? It's a lot like what I've talked about. You want to be able to move quickly through concentric phases. And that turns out to be superior to traditional resistance training. So there have been a number of studies that have looked at this. We found one review of 13 studies that found power training superior to traditional strength training for power. In other words, when you took people and you had them lift a certain amount of weight versus lift the same amount of weight, but doing it quickly, not surprisingly, the improvements in power came in the individuals that were lifting quickly. And just for the sake of time, I've taken a little longer than I intended to to this part. I'm not going to go through all of the studies. They're in the show notes, but they're actually quite remarkable. The differences in power based on the training. Again, you will become better at whatever it is you train for. You kind of hinted at this earlier, but I think it's worth explaining quickly in a question because it's when we get asked a lot, which is what quote unquote intensity should I be training at? So it's something that I think people hear a lot. And so how do you think about the word intensity when it comes to someone's training? Well, first of all, it is a very important variable in this entire equation. I think there are different ways that you can think about it. So you can think about muscular failure, which is the point at which you can no longer perform another rep. Do you need to do that very often? No, you don't. In fact, there are risks associated with doing that. I find myself there once or twice during an entire workout. And I'm not usually designing myself to go there, but it's going to happen. Obviously. Then you have technical failure. Now, this is a place where I do get to quite a bit in a workout. This is when I can't do another rep without compromising my form or cheating. And again, I think this is maybe easier for people who have been lifting weights a longer time. You have a little bit more of a sense of what cheating looks like. And that can be something as little as just rocking a little bit on a curl or not doing a full enough rep or bouncing on the bottom or something of that nature. And by the way, I'm not here to say that technically that you should always stick to perfect form. I've heard people far more intelligent and informed about bodybuilding than I will ever be talk about all sorts of reasons why sometimes progressing through technical failure and going into cheat reps is a great thing to do. And again, I would just defer to the experts on that. The way I think about this though, and I think the most helpful way is to go through the rep and reserve analogy or not analogy, but framework really, right, which is I think this is where most people ought to live is in the one to two RIR rep in reserve area. It's a very safe place to be. You're not going to get into trouble. And by the way, you're virtually getting the same benefits as going to failure on every set, which truthfully is almost impossible anyway. So that means I'm stopping at a point when I could only do one or two more reps. Now, you're never going to know what that feels like if you don't fail a couple of times. You got to accept the fact I'm going to have to fail. Maybe don't pick a bench press when nobody's around is the time to figure out what that feels like, but you can definitely figure that out when you've got a spotter and you can definitely figure that out on an exercise where the consequence of failure is very low. And again, everybody can figure this out. And once you know it, I would just encourage people to be in the one to two RIR range for virtually everything they're doing unless again, they have very specific goals around power or around extremes of strength. Peter, another question we get asked is when I'm in the gym, should I be focusing on specific muscle groups? Should I prioritize full body movements? How do you think about that for yourself and your patients? Compound exercises, which I think people are familiar with that, but their exercises that it would engage multiple muscle groups and joints. It's really the joints that they're talking about compound joint simultaneously. So a squat, a dead lift presses rows. These provide the foundation for overall strength and muscle mass. And so, again, when we talk about powerlifting, which again, is such an awful name, it should be called strength lifting. It only has three exercises, a squat, a dead lift, a bench press. So this is three of the most important exercises there are, clearly the foundation for what they do. Similarly, when you look at bodybuilders at the opposite end of the spectrum, trying to generate as much muscle mass as possible, pretty rare that they're not doing some variations of those. Now, a lot of times injuries will allow them to do other things. They might not do a perfect squat. They might end up doing variations of squats, but they're basically all working in the same thing. Isolation exercises are also totally helpful, valuable. We should be doing those as well. It's really kind of a question of time and goals. So if I don't have much time in the gym, I'm only doing compound exercises. I'm trying to make the time to do accessory movements as well. But I typically start with my compound movements and then move to my accessory movements later. Other things to think about is that compound movements, they're challenging. There's a skill to doing a compound movement. Anybody listening who's gone down the rabbit hole of powerlifting and learning how to do a dead lift correctly and learning how to do a squat correctly understands that you can have all the strength in the world. But if you don't have the control and if you don't have the coordination to do these exercises, you're not going to be able to translate your strength accordingly and you're probably going to get injured. So in many ways, that becomes part of the enjoyment of doing those exercises. Is it a technique? More than it is just kind of a mindless activity. Is resistance training the only way to build muscle? A lot of times we'll get questions on how effective our body weight exercises. Like I like calisthenics, I like yoga. Is that sufficient as we think about muscle strength, muscle mass? Resistance training with weights is hands down the most effective way to build muscle. It's not the only way one could clearly with the right types of body weight exercises build muscle. That's going to be especially true for beginners. But I think we need to sort of acknowledge that it's going to be very difficult with many of the body weight exercises to get to that one RIR phase. Now, of course, pull-ups and push-ups can get you there. The advantage of a pull-up is most of us are going to get there in a rep range that is more congruent with hypertrophy and strength. I'm sure there's data out there that say the average male and the average female can do X number of pull-ups. It's a low number. Conversely, push-ups for most people, I think certainly once they become fit, most people would be doing enough push-ups that going to failure, they're really going to be out there in muscle endurance land. Therefore, they're really not going to be able to put on much size. If size and strength our priorities, body weight exercises are not going to be your most effective way to go. Doesn't mean you're not going to get some benefit you will, but you're probably going to get more muscle endurance. How do women need to think about this compared to men? So one question we often get is, as a female, should I be thinking about resistance training any differently as you continue to talk about it? I think it's safe to say this is an area I'm looking forward to exploring a little bit more on the podcast. At the surface level, the advice is generally the same. So there's not like some wildly different magic principle that says, "Oh, women need to only go to three reps in reserve or need a totally different amount of volume." For the most part, it's generally the same in terms of these principles and protein requirements. But obviously, the strength to weight ratios are going to be a little bit different. Women tend to have more joint laxity, and they may be more susceptible to injury, so they might need to be even more mindful of tempo work, maybe more focus on the eccentric phase. But again, we're still thinking about the same rep ranges. The hormones create a totally different issue. So reduction of estrogen and testosterone during menopause, if they're not on HRT, will lead to elevated rates of sarcopenia. We're talking about women who are not professional athletes, but ordinary women. And so if anything, to me, that just says women need to be at least as mindful, if not more mindful of this. Again, I go back to the podcast with Belinda Beck, which is one of the most enjoyable discussions I've ever had just about the sheer bliss of watching these women in their 60s doing a clinical trial where they're basically instructed to just walk around and lift heavy weights and see how that improved their strength, how that improved their bone density, how it just improved their quality of life overall. So yeah, women need to be lifting weights as much as men is the big take home. And while there may be third and fourth order differences, I wouldn't let any of those discourage anybody from jumping on it now. What are some metrics that people can do in the gym to track their progress on strength, slash goals they should have? You've often talked about a few in the past and different spots, but you just want to talk maybe about a handful of if someone's in the gym wants to test where they're at. What are a few things they could do to see? Before doing that, I think we should acknowledge that tracking one RM's as a metric, one rep max as a metric of what one can do is a totally reasonable way to do it. And it's a way that I used to do it for many years, right? I used to be very tuned into my one rep max of a squat, a deadlift, a bench. And by the way, I didn't always do the one rep max. They're a very predictable formula is that say if this is your five rep failure, your four rep failure, your three rep failure, your two rep failure will link to the table that shows what the formula is. It's pretty straightforward. Truthfully, I would do a lot of twos and threes max two max three and impute my one rep. I don't do any of that stuff anymore. And today what I tend to focus on are other metrics that I care about. Summer power related, summer strength related. So I still keep track of my long jump. So just a standing broad jump. Why do I love that? I think Andy Galpin also talked about this amazing exercise. Once you're warmed up, don't do that one cold. That is testing in one movement, your maximum power and your eccentric strength. So I don't know if you've done many standing jumps anymore, Nick, but the take off is a maximum concentric power movement. But to stick that landing, you have to have the brakes. That's a maximum eccentric movement. One of the metrics that I just maintain in my life as I think about aging is I want to go as long as I can in life being able to do a broad jump that is taller than my height. On my floor, I have slightly longer than my height. I have six feet marked out on the floor. And every day I'm like, Hey, I don't do it every day. But every day I want to be able to make sure I can comfortably do that. And at some point, it's not going to be easy, right? And maybe at some point I won't be able to do it. Pull ups, I think are a great test for people, especially if done under control with complete range of motion, maybe doing an exaggerated eccentric. So we would say for males, five or more for females, three or more complete pull ups with a three second eccentric. People have heard me talk about a dead hang. We say a target for a male would be two minutes for a female a minute and a half. A wall sit with thighs parallel to the floor, two minutes for both men and women, a farmer's carry. We would say, can you carry 100% of your body weight? So 50% in each hand for a minute is a male, 75% of your body weight, half of that in each hand. If you're a female, a box step up with 25% of your body weight in each hand, five reps per side. That's a big, big ham glute test. And then a wall push up. We do a wall push up just so that your feet, you don't rock back and forth. It basically prevents cheating. So we'd say, you know, could a guy do 20 really well controlled push ups? Could a woman do 10? Those would be amazing markers of strength. And I think that what's more important to me is not whether you hit these targets. It's whether you're making progress. We've talked about this before. So I think we can go through it quick. But just if people are doing dexas to measure their muscle mass, do you just want to remind people what metrics they're looking at on a dexa and what percentile you like to see them out? Yeah. And some dexes just give you this information. Most don't. You usually have to calculate it on your own. So we look at appendicular lean mass index and fat free mass index. So assuming you have a dexas can that's not showing this to you, you want to go to the section where it says it shows you lean mass by extremity. So you would literally add up how much lean mass in left arm, right arm, left leg, right leg, put that in kilos. So if it's done in pounds, you got to convert it to kilos and then divide it by your height, which has to be in meters squared. And then that number you put on a nomogram, which will include in the show notes and then you'll see your percentile. You do the exact same exercise with fat free mass, although there it's easier because you're just looking at total mass, subtracting out fat mass and dividing that by the height and meter squared. And again, you'll see these things are often, I would say, concordant, but they can be discordant. We like to see people above or at the 75th percentile for each of those metrics. But again, not everybody's going to get there. Some people whose genetics, like my wife, will never, ever, ever get above the 75th percentile. She's just not built that way. She is a tiny build. And it's fine. We focus on her strength goals, not her size goals. She's not going to put that weight on it. We're not going to spend much more time on it because I don't think it's nearly as important as the strength side of things. That seven year old earlier today, what percent she think he was in LMI, FFMI, with the above 75, was he a strong kid? It's funny. I've never seen the kid know-mograms. They're going to be different because they're so short, but I'm pretty confident he's going to be 97th percentile by the time he's in high school. Okay. So he's strong. He's got potential. As long as he stays away from diet soda, yeah. Well, how do you think he got so strong to date? He's not sitting there sipping diet coax like a chump. Okay. Moving on from how to questions to now how often questions. How can someone balance rest and recovery with intensity of workouts? Common question we get asked is how frequently should someone work out? And obviously, that's going to matter on how much time they have, but also how do you think of that with balancing that rest recovery, with also needing to push to failure often, like we've talked about before? Your training age experience, age, genetics, other stressors, nutrition, sleep, play such a role in this. And because it's all so obvious which direction these things go into, again, I'm not going to go down the rabbit hole of each of these. It should be apparent that if you're young, if you're focusing on nothing but training, if you don't have any other responsibilities or stressors in your life, if you're sleeping eight or nine hours a night, eating nonstop. There's a scenario where you can just train all day every day. And then there's a scenario where you're like the rest of us and you got to pick and choose. I've experienced all sides of this and I'll probably just come at this through the lens of what I do and what I recommend my patients do because my patients like me have time is their bottleneck. And I think that's probably true for most people listening is we don't have infinite amounts of time. So how do we make the best use of the time we have? I think it is abundantly clear that if you train with the right exercise selection, with the correct intensity, the right volume, you might only need to train each body part once a week. In fact, some of the most serious bodybuilders of all time have got away with training each body part once a week. And if they can do it, certainly the rest of us, schleps can do it. Now, of course, you can do full body workouts two to three times per week and rotate the types of exercises that go into it. I find that approach to be better for people who are early to strength training. Whereas I find the more experienced you get, the more you want to kind of go deeper on a set of muscle groups for a given day. So I've played with all of these. I really like what I've been doing for the past year or so, which is three resistance workouts a week. A body part is done once a week, and that's it. It's done very hard. It takes me a couple of days for that body part to recover. So for example, when I do legs on Monday, which I do, my Tuesday zone two ride, that would be the most I could muster up. I would not have done it. not even attempt to do a VO2 max workout the next day. And sometimes I'm sore from the lift for a day or two, not uncommon. Of course, we also talk about de-loading. I referred to this earlier, Mike Ishtertel on a previous podcast recommended one week every eight to be either a significant de-load or even potentially a full off week. And then a two week, don't even go to the gym, maybe just do some other exercises once a year. I think that's part physical. I also think it's part mental. Now again, part of that is when you're training at the level that somebody Mike is at, it's probably an important thing to consider. At my level and for my patients, I typically am not recommending it because none of us are training quite hard enough where we really need that full de-load. Life tends to offer us de-loads through vacations and things of that nature anyway, where you might just use your trip away where you can only use the hotel gym as you're at time to de-load. Is there a way for someone to tell maybe if they are overtrained in, or another way I think about it is someone who's newer to training and they're starting to train? Is there a way or something that they can pay attention to to say, okay, maybe it is worth dialing it back for a few days to rest? I know this is gonna sound very unscientific, but I have not found anything to be a better predictor of this than willingness to train. Now I do look at other factors, so especially on the cardio front, I'm very attuned to my resting heart rate and my heart rate variability and my sleep quality. Those things tend to be far less predictive of my performance in the weight room. I think it's important that people learn to differentiate the reluctance to train because I'm really busy and I don't wanna get up from my desk or leave what I'm doing now to go in the gym versus, okay, now that I've gotten to the gym and I'm warmed up, I still don't wanna train. Those are two different things. I often experience the former. I'm too busy. I'm in a good groove. I don't really wanna go and do this thing versus, okay, no, no, I'm here in the gym. I've got through my warm-up sets. I actually feel like crushing it. When I'm in that second set and I still don't wanna be in there, that's usually a sign I shouldn't be in there. Or if I'm gonna be in there, I should totally mix it up and do something that is totally unrelated. Just work on a whole bunch of movement things and just sort of get out of it and come back for another day. That to me is, I think very important. I will add a caveat to that, which is, that technique tends to be more applicable the more experienced you are. So if I took a person who's never exercised and said, "Hey, just use your interest in exercising as a metric, they might never exercise." So unfortunately, you have to sort of develop enough experience to be able to use that. - One question we get commonly asked, which I think is just due to the rise of wearables that people have, is where does HRV fit into understanding where someone's at and if they should be training intensity, day off, et cetera? - Yeah, we've certainly talked a lot about heart rate variability and I do think that the absolute number comparing yours to your friends is not relevant but comparing yours to yourself, provided you have an accurate way to measure it. Again, I've talked a lot about how I like using a device called Morpheus, no affiliation with Morpheus, but I like it because you use either a chest strap or an arm band where the optical sensor is in the anacubital faucet. So you're actually getting a very accurate measurement. Things on the wrist and hand are not nearly as accurate. So for that setting, seeing your HRV consistently low, especially if accompanied by high resting heart rate, that usually tells you you're fatigued, low parasympathetic flow, high sympathetic flow, doesn't mean you're gonna have a bad workout, by the way. I've actually paradoxically had some insanely good workouts waking up on the heels of high sympathetic drive. Why? Because that at least transiently gives me a big boost. But chronically, that's problematic. And so chronically, one has to be mindful of how you meter that experience and finding. - Let's say outside of kind of what we talked about, HRV and willingness to train, are there any other, let's call them warning signs that if someone's in the gym, they're very willing to train excited about it, but if they're seeing certain things, feeling certain things, they should kind of think themselves, okay, maybe today is not a data push. - I would say persistent muscle soreness, you're not recovering. You're getting the good quote unquote burn that normally a company is maybe a workout a day or two after, but it's never going away. It might be that you really need to take a rest, at least from those body parts. Another one that I'm pretty mindful of is just decreased performance. Because I log a lot of my data, especially on the bike, I'm very cognizant to the meta cycles I go through in the year. And I sort of have a sense that like for example, because I live in Austin, this is not going to be surprising to anybody who's been here in the summer, my performance on the bike actually goes down in the summer, probably by five, seven percent. I've been here five years now, so it's a pretty reproducible finding. I believe it is solely just due to the heat. Even though I'm still going to go out early in the morning to do a ride, like it doesn't matter. The difference between riding at 85 degrees and riding in the winter, or if it's 55 degrees, is huge in terms of VO2 max performance. But knowing in addition to those changes, are there other decreases in performance? And again, here we're talking about being in the gym. I think that's important. I think you also have to be very mindful of pain that is indicative of potential injury. So joints that are hurting, things that hurt more with use, those would be things I'd care a lot about. There are probably other things. The problem is other changes like mood and irritability, which can certainly indicate overtraining. They are so non-specific that it's very difficult. I think you have to just try to gushed out through thinking about these things. A question that we can ask a lot about, especially when it relates to newer people to exercise. So if someone's listening and they're like, "Look, I haven't been resistance training. I want to start. I'm really worried about getting injured." Because you often talk a lot about the benefits of health spend not being injured and the ramifications I can have. You have a patient come to you and say, "Hey, I'm willing to do this. What are some ways that I can start this in hopes of knocking an injured and doing this for a long time? What advice are you giving them?" - It's in line with what we're saying here, which is I think everybody, but certainly a beginner or somebody coming back to it after a significant period of time off. So someone who might have been the high school football star who lived in the weight room, but now they're 40 and they're kind of coming back to it. Act as though you've never done this before. Focus on injury prevention, work on gradual progression, learn foundational movements, learn correct form, joint injuries often result from high load, fatigue, both of these. So you wanna have controlled movements, both on the eccentric and concentric side. So even if you're not exaggerating, concentric if you're just doing one to one tempo or one to two tempo, still controlling it. I think that assisted movements are really, really helpful. So even on pull-ups and things of that nature, there's enormous value in doing pull-ups with bands so that you can get into a complete rep range, use proper scapular control and not injure your shoulder or your elbow because you have to cheat because it's just such a heavy movement, doing lots of things with body weight until you figure out the right position to be in. Again, I've talked about some of these before but relying more on eccentric load to keep the weight down and I think another very important principle for everybody, certainly something I spend a lot of time adhering to is using unilateral things. So so much of what I do for my legs, I'm just trying to think one, I would say 50% of everything I'm doing on a leg day is single leg. My left and right leg are doing separate things which is allowing me to actually use a fraction of the weight but I'm still obviously getting the same amount of work. It also develops, I think, a better coordination for many things. So I think those are kind of some of the principles that are helpful here. - Moving on to now things outside of the gym, specifically nutrition. So obviously you've talked in the past, nutrition is an important factor as it relates to muscle growth. So how do you think about protein, which is something you've talked about before for a variety of reasons as it relates to growing muscle and how much protein should people get? - So again, the recommended dietary allowance, the RDA is 0.8 grams per kilogram per day. That's sort of the lower threshold to prevent malnutrition. It's generally very inadequate for trying to build muscle or even preserve muscle once you age. So if you're trying to do what we're talking about here, you're gonna wanna be in the 1.6 to 2.4 grams per kilogram per day, kinda call that 0.8 to 1 gram per pound of body weight. People who are less active and older might even need to be higher due to anabolic resistance. So easy rule of thumb, roughly a gram per pound of body weight. If you're older than 60, you might even need a little bit more than that. Again, if you're a little bit less than that, it's not the end of the world. But you don't wanna see as somebody at 0.4 grams per pound or 0.5 grams per pound of body weight. I think that's almost certainly insufficient to meet the demands of aging. - Another question we get off and ask, types of protein. Other types of protein that matter more than others. Proteins are made up of 20 amino acids. Nine of them are essential, so the body can't synthesize them. So those are the highest priority is getting essential amino acids. Lucene being one of them also turns out to be a very important amino acid at triggering muscle protein synthesis or MPS as we call it. And so we're really looking at the completeness of a protein source, so how many of the essential amino acids does it have? What's the digestibility? And when it comes to those metrics, animal proteins generally, if not completely outdo animal proteins for completeness and digestibility. So really the big three that we think of are dairy, eggs, and beef. So if you have a diet that's giving you sufficient servings of dairy and beef and eggs, you can be 100% sure you are getting sufficient amounts of protein just by hitting your volume numbers. Now, I realize that many people listening to us either don't fancy those foods or for other reasons might choose to abstain from them all together. The good news is it's okay. You don't have to consume animal products to meet your goals. You can indeed achieve these goals with plant-based proteins. It will just require two things. It will require probably eating more protein and probably cooking the protein whenever you can to increase the digestibility and absorption of it. We often recommend with patients who heavily favor plant-based proteins. And by the way, as you can appreciate, there's variability in here. So there's people who don't want beef protein, but they're still happy to consume eggs or dairy protein and vice versa. So there's lots of ways around this. But if we're talking about somebody who's really only going to be interested in plant proteins, we tend to get them to try to really focus on hitting the right amounts of some of the essentials. And I'm not going to lie. It's not easy. It's not the optimal way to do it. But if you're willing to make the choice, then I think you have to put a little bit of effort into that. What about protein timing? How do you think about the timing of protein throughout a day as someone is thinking about optimizing their protein intake? Think the data on this are still evolving. And I think the way I would have answered this question two years ago is probably different than the way I would answer it today. And I honestly think it depends a lot on the protein source. So a lot of times studies that are looking at this, they're using radio labeled isotopes of amino acids in liquid form and they're measuring muscle protein synthesis. And those studies tend to find that you want multiple small protein meals. You certainly want to get your first dose, bolus of protein right after working out. And you can only incorporate 30 or 40 of those grams and so you need to be continually reactivating over time. Again, that might be true for the situation in which that's on. But we've also seen that casean versus way, which is also a dairy protein, produces a much longer and slower delivery of the amino acids. And so I tend to think a lot less about this than I used to. I used to really worry about exactly when I was consuming protein. Now that I don't consume way protein shakes that much, if at all, and I tend to eat more of my protein, I'm just trying to get 40 to 50 grams of protein four times a day through a meal or snack and I'm not thinking that much more about it. What I try to do is avoid lower doses. So I'm not just going to be out there eating 10 grams of protein in a sitting and nothing else. Now again, we've covered this so much in one of our previous newsletters that I think just as everything that we're talking about here, the show notes will have a lot more detail on this. One question we can ask a lot about, I think as you kind of mentioned, this field is evolving, but I think one thing that sticks with people is the importance of post workout protein, how necessary is that? Again, I think it's less important than we used to think. I am going to consume protein pretty much right after a workout, but that's also because I'm not consuming protein typically before the workout because I'm working out in the morning. But that window, that anabolic window is pretty broad. I mean, four to six hours. So I don't think it's something one needs to lose sleep over. Your hunger will probably dictate it anyway because you're going to be hungry within an hour or two after a workout, although probably not right after. So I don't think you need to stop the press. I don't think you need to stop for breakfast right after the workout, be late for work or whatever. I think you can certainly wait an hour or two, especially with what we understand today based on that anabolic window. Another piece of this that we can ask a lot about is, let's say someone is time restricted eating or fasting, quote unquote, throughout a given day. So they're only consuming food for a few hours throughout the day. And then we also have people who are fasting for multiple days. So how does fasting, caloric restriction, whether within a day or multiple days impact muscle mass and how should people who are using those tools think about that so they don't potentially lose too much muscle? Some of these things are going to be less relevant if you're using high amounts of anabolic steroids where you can fight the inertia of this more. And if we limit this to people who are either not taking anabolic steroids or who if they are, you know, they're doing it under physiologic replacement levels. It's very difficult to maintain muscle mass as you are losing weight. So if you create enough of a caloric deficit, regardless of how you do it, fasting, intermittent fasting, time restricted feeding, whatever you want to call it, anything that creates a caloric deficit sufficient enough to induce weight loss is going to put muscle mass at risk. Now what can you do to minimize that? You can meet your protein needs of approximately one gram per pound of body weight and maintain high levels of resistance training. Now when I was doing a lot of fasting, obviously I was creating an enormous caloric deficit. I was not eating a thing. So I was not getting any protein. I did resistance train, but all the resistance training in the world wouldn't have mattered. By the way, had I still consumed 200 grams of protein for a whopping total of 800 calories per day, I'm not convinced I would have been able to have fought off much of the muscle mass loss because that is still such a low calorie amount that, you know, I'm in such a caloric deficit that I was going to lose weight. Most of that protein would have been converted into glucose, I suspect. I don't think I would have had enough anabolic stimulus to maintain muscle mass. So I would say that when you look at bodybuilders who again are the masters of this, they're not going through enormously rapid periods of weight loss. And that's generally what's allowing them to preserve lean mass in addition to, of course, the use is as often the case in untested bodybuilding, the use of antibiotics. But even if you look at people who are in tested categories of bodybuilding where they're drug free, I still think their fistidious attention to diet and how they're doing it is what allows them to do this. Now, there are data that suggests the protein intake by itself can be proactive. And we know this, right? So again, I think it was, I think it was Luke Van Loon who had this great analogy of the bricks are the brick layers. So protein by itself is able to induce muscle protein synthesis in the context of modest calories. There are some studies we'll link to that will show that even with significant caloric restriction, not as extreme as I just described, but say a 30 to 40% caloric restriction sufficient enough protein and resistance training is able to maintain some amount of muscle mass and maintain some levels of muscle protein synthesis. So again, it can be done. It's a needle that is not trivial to thread and for most people losing weight, especially if you're losing a lot and/or losing it quickly, you're going to probably give up some lean mass. Beyond protein, any other aspects of nutrition that someone should be aware of as they're using to think about supporting muscle gain. Obviously, hydration matters. It sounds silly, but given that muscles themselves are made up of 70% water, which explains why creatine plays a role here. So I'd say hydration, creatine use, and recovery. So failure to recover is going to make it very difficult to grow. That's one of the things that people who are overtraining are sort of missing on. So dehydration, of course, reduces the function of muscle. Creatine, again, we've talked about it a bunch, but it's just worth remembering what it is. Protein is a phosphate donor, so it's kind of the fastest way to generate ATP, multiple clinical trials, meta-analyses, non-stop, demonstrate that creatine is favorable in terms of strength, power, and muscle mass. So I always tell people it's really one of the few supplements that I almost universally recommend. There aren't many things that I just think universally makes sense to people who are exercising or anybody for that matter, and creatines probably the closest we have to that list for me. Beyond nutrition, any other "life style" factors that people should be aware of that can affect their ability to gain muscle, focus on muscle mass resistance training. Besides things you can't change like genes, we've talked about the training itself. We've talked about the nutrition itself. recovery, hormones sleep stress. huge, huge role here. So let's take the most obvious of these, which is hormones. The more testosterone you have, the easier it is to put on muscle mass full stop. This is true if you're a man, this is true if you're a woman, this is true if you're in menopause, this is true if you're not in menopause, more testosterone, all things equal, more muscle, especially when compounded with a training effect. But what's a lot more difficult to appreciate is more cortisol, less muscle. Chronically elevated levels of cortisol are actually catabolic to muscle. We see the most extreme example of this when we look at a patient with Cushing's disease or Cushing syndrome where they actually experience muscle wasting due to the hypercortisolemia. But for many of us listening who don't have Cushing's disease but who still probably walk around with too much cortisol, it's definitely hurting us and unfortunately, you don't have a pill you can take that makes your cortisol levels go down. You've got to do all of these challenging things that we all are working very hard to do to reduce our level of perceived stress. If you're not sleeping enough, you're not recovering enough. This is when the body is mostly going through its rebuilding and resilience phase. We joke about it. You see bodybuilders that like sleeping 9, 10 hours a day, they're putting their bodies under so much stress that they need that maximum time to recover. So the harder you're training, the more you need to sleep for sure. Consistency of course plays such a big role in this. So many things in health come down to compounding and you are not going to make great gains if you are inconsistent in what you're trying to do in the gym. So if you could have the best month of your life, but if the next month you're inconsistent and you repeat that cycle over and over again, it's not going to really matter. So Peter, I think what would be helpful as we kind of think about wrapping this AMA is picking a few different types of people. Let's say someone who's newer to exercise and newer to resistance training and is younger, what does some programming look like for them and how could they take that information to a gym and start to execute against it? We can look at someone who is newer to exercise but older and look at how that maybe differs than the younger person. And then I think we can look at someone who's seasoned at resistance training and has been doing it. Is there anything they should do to modify their workouts to really have maximal achievement here based on what we talked about? So I think let's start with someone who hasn't been resistance training is quote unquote younger. Patient comes to you and says, Hey, I'm willing to do this. What do you want my programming to be? What should it look like when I get to the gym? So first off, many ways to do this. There are going to be trainers listening to this. You say, I wouldn't do this. I would do that. Look, I think there's lots of ways to do it. This is one way to do it. And by the way, this is a really, really fun demographic of people to work with. Why? Because if they adhere to this type of routine, they are going to see pretty remarkable gains. So one way to skin this cat is to actually do the exact opposite of say what I'm doing where you do a three day full body program on each day, you will do each body part to some effect. I don't recommend this for someone who's more advanced than wants to use more intensity and things of that nature. But for this person, it can be great. So I would say, look, do a Monday, Wednesday, Friday, or a Tuesday, Thursday, Saturday, split. We're going to do time in gym one hour each workout. So again, this is, this is exactly what we're going to do with a patient in this situation who we're just introducing to the gym. So let's just say Nick, we've got a person who's been long on cardio. So more typically this, by the way, might be a female, not to stereotype, but that's more often the way it shows up. They're super long on cardio in great shape, very low muscle mass, though they've never lifted weights before. But then I'm going to say to them, hey, how much are you willing to exercise a week? They say they're willing to give me six hours a week of training. We're going to take them to very high levels on their cardio front in three hours a week, but I'm going to have them spend these three one hour sessions in the gym. So one hour in the gym, we would target a minimum of 10 and maybe as many as 20 sets per body part per week. So again, they're going to spread that out over the three workouts. They might do three to four sets per exercise anywhere from six to 15 reps per exercise anywhere from 90 to 120 seconds per exercise. I'm often going to have them super setting on this because we have the luxury of them doing whole body. They're getting rest from a given exercise, but while they're doing something for their back, I might have them rest, quote unquote, by doing something for their chest. So you're using opposing muscles. Start them out at a very low intensity of three to four RIR, working them up to one to two RIR. And this is a person who's not going to stop moving. We're either going to pair opposing muscles like chest and back or completely different. As recently as two years ago, I was doing a whole body workout every maybe three days a week where I was alternating lower body upper body lower body upper body super sets all the way through lots of ways to do this, but that would be one way to do it. You kind of hinted there, but just I think super set sometimes is a new term for people. So do you just want to give like a really quick clean definition in case people didn't pick it up from what you just said? Let's say you're doing a bicep and a tricep super set instead of just doing bicep curl rest, bicep curl rest, bicep curl rest, you would do a bicep curl and then a tricep extension or something like that. And then a bicep curl and the tricep extension. So you're resting one muscle while you're working an opposing muscle or a completely different part of the body. It's much more time efficient. To be clear, you wouldn't typically you could. There's a totally different reason for doing this, but for this person, I would not super set chest and tricep or back and bicep because those are not really opposing muscles and you're now getting into fatiguing supporting muscles. There's a time at a place for that if you're trying to make improvements. So for example, if you're trying to improve your pull ups, you will super set them with bicep curls because you're pre-fatiguing the bicep and so you're trying to double up on failure and break through plateaus and things of that nature, not what we're doing with this person. Perfect. So now let's take same person, new to training, haven't been resistance training, but they're older and age. How does the programming you gave the younger person differ here? The principles are the same because they're new to this, but we want to probably start with lower volume, lower intensity and maybe increase a little more gradually. Big form here, big focus is on form of course and probably slower tempos looks very similar to the other person, but the intensity is going to be considerably lower. That other person by the way is going to really feel smoked in the hour because they're not going to stop moving. This person, depending on their age, I might even not do the supersets by the way and therefore they have fewer exercises that they're going to get done if they're allocating the same amount of time. For these newer people, one of the questions we can get asked is if I'm going to the gym, I have two options. I have free weights, which could be dumbbells, kettlebells, etc. and I have machines. So based on the comment you just made about form, if someone's newer to the gym and has that optionality, do you traditionally like to encourage them to start with machines because there's less risk in the form variation than free weights? I think it depends on their setup. Sometimes they'll have a trainer and if the trainer's really good, I think it's fine to do anything. Look, I mean, again, go back to the Belinda back discussion of the lift more study. They were deadlifting. 65-year-old women who'd never touched a weight in their life were deadlifting. This is one of the most complicated movements you could ever try to teach somebody. What does it tell me? It tells me if you know how to teach somebody how to do an exercise, they can do it. So I don't think it has to be that, oh, if you're a novice, you have to do machines. I think machines are great. It's a great way to start and sometimes it's a less intimidating way to start, especially for a person who doesn't have a trainer and is kind of going to go and figure this out at their gym, which by the way might seem really intimidating if they have to go to the section of the gym where there's just benches and sweaty dudes and dumbbells. But maybe it's less intimidating to be where the machines are. So I don't want to make too much hay out of it. I just kind of want that person in the gym and move and stuff around and developing a little bit of confidence without hurting themselves. And machines are a great way to accomplish that. So let's now take a person who's been resistance training. Anything specifically you recommend to them for their programming, should they modify in any ways, what type of advice are you giving a patient who's resistance training some in the gym, but comes to you and says, hey, I want to maximize this for lifespan, health span benefits. What would you say? Honestly at this level, Nick, it's totally different. I mean, if you take the season person who's saying, I love doing this, but this is kind of like me talking to me. Now, what am I thinking about? And I have many patients who are in this boat as well. They love lifting weights. They've been doing it for a long time, but they need a direction to go in. And I think this is where the centenary into Catholic one becomes very, very helpful, which is, okay, you have to define your sport. What is it you want to be able to do in the last decade of your life? I want to be able to swim a mile. I want to be able to ride a bike. I want to be able to hike. I want to be able to play soccer with a kid. I need to be training in ways that allow my muscles to be able to do that. So a lot of it actually comes down to taking things away that were increasing risk. I haven't deadlifted in over a year. Truthfully, most of the times I do have a lot of things to do. deadlift that I felt pretty good. But once a month, I didn't. I was just too fatigued, was too distracted. I just did something where my back would get a little irritated. It was never a big problem. It's not like it ever resulted in sciatica or any of these cataclysmic outcomes. But it just occurred to me. I was like, well, I don't need to take this risk anymore. Now again, there's gonna be somebody listening to me that says this guy's horrible. How could he stop deadlifting? What an idiot? Okay, fill your boots. You want a deadlift all day? Knock yourself out. And I hope you do it safely for the rest of your life. I can just tell you that for me, the risk reward tradeoff wasn't there when there are so many other exercises that I can do. I can do head-filled lunges and squats. I can do belt squats. I can do so many things that are producing virtually no axial load on my spine. And I never, ever have even the slightest irritation. So that's an adjustment that I've made. Is that making me bigger or stronger? No, it's not. It's de-risking. So de-risking is becoming a component of taking myself towards my goals. It's also focusing on things where I see deficits. It's also focusing on areas where I say, hey man, like I'll give you an example. I am constantly worried as I think every middle-aged person is about tearing their Achilles. We all have a friend who's done it. I'm sure somebody listening to us has done it. I'm very paranoid about this. It's such a devastating injury. It sets you back so far and it always seems to happen when a person's muscles exceed the capacity of their connective tissue. It's often someone who's pretty athletic or who is formerly very athletic who tries to go back to do something and they engage in an explosive movement, but then they tear the connective tissue. So it sounds silly. Spend a lot of time bouncing. Spend a lot of time doing exercises like calf raises that are seemingly quite boring, but they just work on strengthening that connective tissue between the muscle and the bone. So I can't give a generic answer here other than to say, this is finishing school. This is why we created 10 squared. I haven't talked too much about 10 squared, but this is why we created an entire company around taking people regardless of their level of athleticism or experience and training them for the marginal decade because the level of precision that you need to train for this is as important and as nuanced as if you were training for a very specific sport at a young age like a decaflon or a triathlon or something like that. I think that covers everything we wanted to cover in this AMA. So that said, anything you wanna add, anything randomly in your head, any advice on life that you have for anyone out there still listening? Still listening, God, that sounds depressing. I don't think so. I think I've spilled all my advice for a month. There we go. Well, good thing we'll see you next month then and we'll get more of that life-spilling advice. I think that's all we got, Peter. Thank you very much for showing up again. Thank you. Thank you for listening to this week's episode of the drive. Head over to peteratiamd.com/shownotes. If you want to dig deeper into this episode, you can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us, review on Apple podcasts or whatever podcast player you use. 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