PeterAttiaDrive #378 Women's health and performance: how training, nutrition, and hormones

Hey, everyone. Welcome to The Drive Podcast. I'm your host, Peter Attia. 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 a subscription. If you want to learn more about the benefits of this content, please visit www.thedrivepodcast.com. Our premium membership, head over to peterattiamd.com forward slash subscribe. My guest this week is Abby Smith-Ryan. Abby is the Associate Chair for Research in the Department of Exercise and Sports Science, the Director of the Applied Physiology Lab, and the Co-Director of the Human Performance Center at the University of North Carolina at Chapel Hill. She's authored more than 180 peer-reviewed papers, books, chapters, and has led NIH and industry-funded research. She's also been a co-director of the Human Performance Center trials on exercise and nutrition interventions. Her research focuses on body composition, metabolism, and cardiovascular health, but with a special attention to women's health through the perimenopausal and postmenopausal transition, as well as overweight and obese populations. She is also a dedicated mentor, educator, and advocate for empowering women with evidence-based approaches to health and performance. In this episode, we discuss how early exercise and play shape bone health, muscle development, and cardiorespiratory fitness in young girls, the impact of puberty and menstruation on athletic performance, motivation, and recovery, how to tailor training and nutrition throughout the menstrual cycle, including strategies for fueling hydration and managing inflammation, the science behind supplements such as creatine, omega-3s, and magnesium in supporting women's health and performance, the transition into perimenopause and menopause, and how hormonal changes influence metabolism, muscle preservation, and fat distribution. So, without further delay, please enjoy my very informative discussion with Abby Smith-Ryan. Hey, Abby, thank you so much for coming out to Austin. I really appreciate the invite. Tell me a little bit about your background in terms of what got you interested in this space. You look pretty fit. I assume you were an athlete growing up? Yeah, I'll take that as a compliment. I was a collegiate distance runner, but I have always had a love of strength training, which is a little bit impeding for endurance goals. I really fell in love with science, the ability to ask a question and answer it. And so I started early with research. And then fumbled my way in that space, really understanding the more you know, the more you don't know. And here I am. As my friend Bob Kaplan used to say, the further you get from shore, the deeper the water gets. Okay, so you're a distance runner. So in college, that's what, 5K, 10K? Yeah, 3K, 5K, 1500, 800 if my coach was mad. I'm not that fast. Yeah, my daughter runs track. I feel like the 800 is the worst, most painful event. In the lot. I would add the 1500, you have to do two more laps at a similar pace. So it leverages that too. Yeah. But there is something about that approximately two minute all out effort that is really brutal. So, all right, there's a lot I want to talk about. I'm trying to think of the best way to help orient it. But clearly, there are certain things that just seem obvious and true across the board. For example, we know that exercise is a remarkable tool to do. And so I'm going to talk about that a little bit. So I'm going to talk about that a little bit. To delay the onset of chronic disease. We also know that it's a remarkable tool to improve health span or quality of life. But particularly, I want to just focus with you and your expertise around what we can understand in terms of exercise across the life cycle of a woman. And I want to almost start basically at the beginning. So I'm pretty sure there are no teenage girls listening to this podcast. I would be comfortable saying there are exactly zero of them, but there are probably parents of those. those. And a previous guest made a point that I thought was amazing and has never left me, which is osteoporosis is a childhood disease. What she meant by that, of course, was that particularly for women, they are reaching their genetic ceiling at about the age of 19 in terms of bone density. And then from 19 until the end of life, they're sort of hanging on to what they've got. And then they've got all of these things that get in the way, such as menopause. Let's say you're a teenager, you're a 10-year-old girl. How do you think about the role of exercise across several dimensions, but not the least of which being bone health, but muscle health and reaching their cardiorespiratory potential? It's a big question. I would sum it up of exercise is the best medicine. Starting young, I would consider it more play and then transitioning into lots of different types of exercise. But really, there's lots of literature to suggest this. The earlier you start and the better base that you have, the easier it is over time to maintain that fitness. So when we think about young girls, the biggest conversation and even some of the research we do is the addition of menstruation often is a turning point when women and girls leave sport based on a number of things of how their body changes, how their performance differs. And so part of what my lab looks at is understanding how that menstrual cycle might impact performance recovery, bloating, mental health. And so part of why I'm here is the ability to have that conversation. When I was growing up, no one talked about it. Were you a runner growing up as well? Yeah, I played all sports. I loved every sport you could imagine. It was my ability to live life. And I'm very thankful for that. I grew up in a space where it was exercise more and eat less. And when you add running, it's this ability to really see how you're your fitness changes. Same thing with resistance training. You can see how strong you get. It's a very empowering tool. But I think we don't talk about it enough with young girls of what is menstruation? Why is it healthy? As when you go into sports, a lot of times it's like, oh, it's a badge of honor when you don't have your menstrual cycle. Or there's a lack of knowledge of it is very much related to nutrition. Let's talk first about pre menstrual cycle. Are there do's and don'ts that you think of for young girls who are playing sports in terms of what they can be doing to augment their training? So for example, if you're talking about a young girl who plays field hockey or volleyball or basketball, do you have any thoughts on what they should or should not be doing in the weight room, for example? I don't work a lot with young kids and I actually have two little boys. But I think I would tell you the same thing of there's a lot of really interesting data that we haven't done, but not specializing. Being in lots of different sports to accelerate lots of different types of muscles and movement. And I'll speak to my personal experience of my favorite lift when I was about 11 or 12 was the Romanian deadlift. Resistance training is the best prevention of injury. And oftentimes coaches don't include that. There's a lot of time on the soccer field or the softball field. And so total body exercises, whether we start with resistance bands or lightweights or plyometrics or body balls, those are all really great things. So let's talk now about this transition as a girl enters her reproductive years. It seems that intense exercise can delay that. The two athletes I tend to hear this most about are gymnasts and runners. Does that also happen with swimmers? I mean, they seem to have some of the highest volume as well. So I would guess that's the case? Yeah, it depends on I think the events, but yeah, absolutely. Cyclists. Is there a downside to that? I mean, there is. We've done a little bit of work, more capturing once the female is in college. So kind of the aftermath of that, and there is data that it very much negatively impacts bone. Because the delay of estrogen onset. Absolutely. I mean, there's a number of things oftentimes related to caloric restriction or indirectly over exercise. I am a big believer that it's not always intentional. The other thing we see often with things like track and field and gymnastics is every athlete we scan, they have not full on scoliosis, but a spinal curve, which really demonstrates the point you mentioned that osteoporosis is a childhood disease of setting bone. And what we do with those young girls has a lifelong impact, whether that's a straight spine or a curved spine. Say more about that. I wasn't really aware that the scoliosis component could be partially acquired. Yeah. Now I've been at UNC for about 15 years, but when we first started doing DEXA scans, we do a lot of whole body for body composition. Every high jumper and every gymnast has a very distinct curve. Some of them are aware, obviously it's a very thick scoliosis they know, but many of them were unaware. And it's really important then to say, okay, well, how do we stabilize this as you age? You've already got that. You can't necessarily change that at 18, 19, 20, but you can very much work on the musculoskeletal system. And I would guess pole vaulters as well, right? Anybody who's got an asymmetric. Exactly. Interesting. Do we see something different in male equivalent of those sports? We do not have a male gymnastics team. Don't see it as much. Love to get your thoughts. What do you think? To be honest, I've never thought about it until you brought it up. I don't know. You could make an argument that if it were less prevalent in males, that maybe males have more musculature around the spine and therefore they're more able to offset what's happening. That might be an idea, but I actually don't know. Yeah. Or even age of onset of puberty that could impact it as well. All right. So as girls get into high school and college and their training, let's talk a little bit about this idea of reaching your potential early. Let's start with something like VO2 max. So we talk a lot about it in adults and how important it is and how much you're trying to maintain it. But what do we know about the ceiling that a person has when they're that young? We don't deal with people so young, but I remember being that young and having basically an unlimited capacity to train. I remember being that young and having basically an unlimited capacity to train. And I'm pretty grateful I took advantage of it, but I know that that's not necessarily something everyone's going to do. Yeah. Maybe I'll reframe it. I don't know. And I don't do this work with young people, but there really isn't a ceiling per se. Meaning when you're young, I think the best part is, is to see those training adaptations. And I think the body is more responsive. So for example, I always joked of like, I went out for cross country to get in shape for basketball. Obviously very different than when I was in high school. But I think the body is more responsive. And I did not feel fit when I then transitioned to basketball because it's a different energy system. But that fitness then by the time the end of basketball, I was more fit. And so that adaptability is there when you're young and setting the stage. Is it a ceiling effect that you can never add? I always view it as exercise is one of those things you can do regardless how old you are. And you can always see improvements if that's the goal. So I wouldn't say a ceiling, but I think definitely on the ceiling. And definitely on our habits of understanding that you are in control. And you can see these really cool physiological adaptations by changing your training. So let's talk a little bit about nutrition as well. What do you think are the most important things for a young woman to be thinking about? And I guess we can talk about this under different circumstances. We can talk about this under eucaloric conditions where we're just trying to maybe. Do recomposition versus weight loss versus weight gain, take it however you would like to talk about it. That's a big question. I think if we talk about young women, my conversation would be all about nutrition as fuel. It's really getting adequate nutrition. And that is really where I landed with some of our nutrient timing work of often when you're young or let's say midlife and busy, you want to prioritize getting enough calories. But sometimes you can offset that or take a little bit of a break. And so I think that's really important. And I think that's really important. of your training by what you eat before, during, and after. Not that that it's necessarily any better. And so when I think about a young female athlete and this idea that there's increased GI distress, it's hard to exercise when your stomach is full, but really teaching them it's about providing nutrients so that they can perform better, recover better, that education about what it is versus necessarily what foods to eat and not to eat. I think about this again, just through the lens of my own self-advocacy. And I think that's around my daughter. So when she's running cross country, I'm always concerned she's not eating enough because practice is first thing in the morning. Understandably, nobody's really hungry in the morning. She's not really eating. She sort of has a bagel and takes a bite out of it. Then they run and then they're in class and then they're not really eating. And then I just worry that they're sort of not getting enough calories. So what are the strategies you think about for young athletes to hit their caloric requirements when training and school are impediments? One of the things is to think about what types of food. So in that scenario, especially into puberty is higher quality fat foods, essential fats, and often it's less food and still gets that caloric density. What are some things you recommend? Higher fat milk, higher fat yogurt, your nuts, your seeds, being really intentional about not necessarily changing the foods you're eating, but just small swaps instead of a skim milk, a whole milk and things that you can pack. With you, those would be the key first things. The other things would be there's a lot of people that talk about intuitive eating, eating when you're hungry, but when you're exercising, you're often blunting that response or most girls and women deal with GI distress. So I say that of planning more of that consumption. Why is that? Are you saying that the carbohydrate density or concentration, they tend to have more dumping issues or things like that? It's not just dumping. It's just the whole GI. I think some of it is stress induced. Honestly, it's a really good question. I'm not a gut researcher. Some data suggests that it aligns with the menstrual cycle. There's a lot of GI distress right before menstruation, and it's not just cramping. So there's a number of elements that go into that. It's not just carbohydrate driven, which is an important component because I do think now the conversation with young female athletes is to not eat as many carbohydrates, be very protein centric, when in reality, carbohydrates are very important. Carbohydrates are so important for any active individual, but especially our young females. What strategies do you recommend for any woman of any age who's training and trying to manage her cycle? So whether she's 18 or 38, how do you think about training around the cycle? We've done a lot of work in this space. And I'll tell you this based on our data and others is we can train at any given time in our cycle. But what we do see is it's very clear that women and girls feel worse during different phases of the cycle. And I think that's a really important point, particularly in the luteal phase, right before menstruation, often women feel more fatigued. They have more bloating, it can impact recovery and soreness. And I say that a woman can still compete, and they will. But often it's this ability to say, like, for me, like, maybe I didn't meet my max, my performance is not as good, then it's a little bit of, oh, you're fine. That's a physiological response. I've always wondered when you watch the Olympics or something where you've got this one shot in four years, and it's easy to sort of look at people like Michael Phelps, who have been so successful over so many Olympics or Simone Biles, but that's not the norm. The norm, which of course, there's nothing about the Olympics that's the norm, but the norm might be you get one shot at this in your life. And it's always struck me as the greatest injustice, for women, for female athletes, if their event falls at the time of the wrong time in their cycle, that has to be impeding performance, right? I mean, I would argue, no, it is a question that I've thought about, too, of like, how great would it be if we could ask our Olympians whether they're on their menstrual cycle or they're not, or having their period. But what all of the data shows is that a woman is going to compete regardless. I do think it's more about the recovery. So if we take an event where they. Often the Olympics is not just a single event, it's repeated. And so really bringing science into help with recovery and inflammation and protein breakdown, where we might do it differently in the luteal phase versus the follicular phase. So really using more tools to help with the recovery, not necessarily that peak performance, that seems to still be there. Let's go through the entire phase. So day zero or day one, when the period starts, in some sense, I would guess that from that point to the next, next week, from a hormone perspective, the hormones are very low. Tell me what's happening from a performance perspective. We'll do it in quarters. Let's do this. So this, we'll call that the first quarter of the cycle, which is when her period's actually happening, probably the first four or five days of that. FSH, LH, estradiol, they're all pretty low. So walk through the strategies. And we don't have to do this through the lens of the Olympics, but let's do it through the lens of you are training really, really hard. You want to maximize your performance, then recovery throughout the entirety of your cycle. So what are you doing this week? Let me just qualify. I think it's really important that we're going to talk about this traditional cycle, but it's very clear that every cycle is so, so very different. I say that we in the lab have used some really cool at-home monitoring tools. Technology has changed. I think that can be really powerful to say, okay, well, maybe you only bleed for three days or your hormones are not textbook. But if we talk about low hormone phase, that follicular zero to five days approximately, typically we have greater carbohydrate oxidation. We feel better. We perform better. Like I would say, and based on the literature, that's when I wouldn't say you want to do anything less, but it would be less thought provoking. You just do what you need to do and eat fuel. You will burn more carbohydrate. There's a lot of nuance, meaning it depends on if you have a long term event. But I would say in general, follicular phase, things are pretty steady. I would say with the loss of menstrual fluid. There's some things to consider, obviously, hydration. I mean, we always think about iron. Would there be a transient loss? Potentially. I think with iron, though, you're not going to necessarily just change that through menstrual fluid loss. What's the relationship between the volume of blood loss during the cycle and the intensity of exercise? Are those inversely correlated or is it more dependent on the woman's individual genetics or physiology? I have a colleague, Claire Bades, out of Australia that's looking at fluid loss and the ability to capture that, but it's so variable. I'm not so sure that we know because some women lose a lot of fluid and others don't. So I'm not so sure we know. Okay. You're dealing with the physiologic loss. You're losing oxygen carrying capacity. So for endurance sports, that's going to be noticeable. So you're saying in that first week approximately, you're going to see an increase in carbohydrate oxidation. Does that drive an increased appetite of carbohydrates? Typically not. And this is a general nutrition component of, I think I will go back to what we started with. Regardless of the phase of the cycle, we need to eat enough and really focus on that. When we think about that early phase of the cycle, maybe have a little bit more carbohydrate, but I wouldn't say it's necessarily directly related to appetite. Typically, we see the majority of the changes to nutrient timing and nutrition in the luteal phase, which we haven't got to. I would just say eat. Regularly, and then obviously match it based on your intensity and volume of your exercise. Okay. So now let's move into late follicular phase. So we're now kind of day seven to 14. So now we're really seeing FSH is going up, estradiol is really going up, and she's moving towards ovulation. So first of all, is a woman, I know that some women can sense that they're ovulating, but what is a woman feeling on average during this period? I always say this is the most important time, is it's when a woman feels their best, they're also the most fertile. And so often this is when we see, if we were to measure peak performance, maybe it feels a little bit easier. Women feel their best, which I think, although it may not change outcomes of performance, they might feel it has a direct translation to volume, quality of exercise, potentially sleep, kind of optimizing recovery. Okay. Anything beyond that in terms of behaviors or changes you would make in training if you were coaching someone during that period of time? I mean, in coaching, you often can't say, oh, it's ovulation, we're going to do things differently, especially if you have a whole team or an individual. But I would say that is a really good spot to understand peak performance. And so what we've done, and part of my interest in this field is understanding how certain aspects change so that we can do more research in females. So for example, I often wouldn't test in ovulation if I am trying to understand how a female's body changes or if I'm tracking changes, I would capture them in the follicular phase, or I would capture them in the luteal phase. Part of it is ovulation sometimes lasts a couple days, or a woman might have menses and bleed, but not actually ovulate. And so there's a lot more variability, but that's where that technology comes in, where we can begin to narrow it down. All right. So right after she ovulates, you're now into this early luteal phase. Estrogen is actually coming down before it makes its second rise, and progesterone is slowly rising. For most women, my recollection is this is not yet the period where they're experiencing the progesterone crash, and therefore, this is also not a particularly difficult week. Right. Some women have, like, do we know when you're done ovulating versus that early luteal? Unless you're really paying attention, you might not. Okay. So we could almost treat this week like the week before. Yeah. All right. So now it's this final week, this last week of the luteal phase, where perhaps the most dramatic things are happening. It's the progesterone crash and estrogen, but I think it's really the progesterone that's driving more of the emotional changes that are being perceived. What is the effect of that physiologically? Because the emotional effects alone could be sufficient. The last time I looked into this, it was not clear why some women were more susceptible to this than others. There are hypotheses out there. Some women have a greater density of progesterone receptors in the CNS. That may render them more susceptible to that depletion, but I don't think we understand this yet unless there's something that's come up in the past few years that I'm not aware of. I mean, I haven't looked as much at the brain aspects. You're right. It's very individual. That's where we see changes in anxiety, depression, but we also see things physiological, changes in thermoregulation, fluid water retention. Those things will change, greater inflammation. I'll go back to what you said that week prior to that rise in progesterone. Oftentimes, that's a strategy that you can prepare for that crash, whether that's prioritizing your sleep or targeting inflammation if it's severe. What strategies would you recommend there? Actually, we had a conversation before you got here. Let's say we have a female that does experience a lot of changes in anxiety, depression, and or fluid retention or painful periods. Really going into that luteal phase where progesterone peaks, there's some interesting approaches where increasing omega-3 could be helpful to start down-regulating inflammation. Slightly higher doses, two to three grams, potentially some zinc and magnesium to help with the vasodilation, sleep. Research says sometimes that luteal phase sleep goes down or the follicular, but for those individuals that are having more sleep disturbances, we can start to tackle that. Obviously, increasing fruits and vegetables, helping inflammation. The other thing is in that progesterone rise, there's some data that suggests that there's an increase in protein turnover, protein breakdown, and this edema. For instance, I really want to focus on supplements, but we looked at something like creatine, which really pulls water into the cell. We evaluated what happens in the follicular versus the luteal phase. Creatine was able to take that extracellular fluid and bring it into the cell. Help with fluid in the right places. Indirectly, that also supported performance. There's some strategies that we might change to really optimize that. There's also some interesting data that suggests caffeine might be more helpful in the luteal phase to help with those fatigue components. A lot of the things you've talked about seem like great ideas all around. Now, maybe omegas at that level is a bit higher and you would reserve those. You would pulse that in based on that. But obviously, magnesium is a good idea. I think it's a good idea to take it. Magnesium is critical all around. Our view is that creatine is quite valuable throughout. If a woman didn't want to have to manage it by cycle, would it just be safe to say, look, if you enjoy caffeine, by all means, take it. You might be getting more benefit in the luteal phase. Creatine might benefit you more by reducing actual bloating and pulling the water into the cell. I actually never knew that. I knew that creatine did it. I never made the connection that it would be of a benefit during the luteal phase. That's pretty interesting. By the way, how are you guys dosing creatine in women? I think I know your views on this, but in reality, in a lab-based setting. So we have a pretty cool study right now in the first with creatine and perimenopause. Because we have a lab restriction, we often will load first just to accelerate that creatine saturation and then follow it up with five grams a day. I'm a big believer that five grams, but even now that data in our midlife women or the brain health is up to 10 grams. Yeah, we've changed our thinking on this. And by the way, I completely hear you on loading because if you just go steady state, it takes weeks to get there. It takes way too long. Yeah, so totally get that. But yeah, it's actually funny. I had Rhonda Patrick on the podcast recently. We were talking about that. And I came out of that podcast thinking, you know what? I think we should move our maintenance dose from five to 10. And so we've kind of just done that. That's great. We typically will do five grams following that loading. And that's what we're doing now. And your load is how long? It's usually five days. Five days at 20? Mm-hmm. That five days split in four or five gram doses. Yeah. Okay. But for the average person who's not trying to enter a study, just go to 10 a day and we feel pretty good about it. So again, really interesting point. And I'd love to hear what women are experiencing if this is reducing some of the edema that they're getting during that luteal phase. Talk a little bit more about the protein issue. So are you saying that potentially during early luteal phase, muscle protein synthesis is not as efficient? This is a debatable topic right now. And I'll just say first, in the luteal phase, we also tend to see an increased metabolic rate. And what do you think that's driven by? Is that temperature? Is that. I mean, maybe temperature, maybe the luteal lining or the utero lining. I'm not exactly sure. There's a number of metabolic processes. Maybe it's the progesterone. How much is it, by the way? It's usually like a couple hundred calories. Couple hundred calories a day of. Energy expenditure. And I think that's relevant because in reality, what's two to 300 calories, but it's often when women and girls feel they're worst. And they might not appreciate it. They might not appreciate it on the scale because if anything, they're retaining more water. The scale might suggest you're gaining weight, but in reality, you're losing stored energy. Right. And if I'm gaining weight on the scale, I have extracellular fluid. I don't feel very good. I'm not going to eat more. Often I eat less. And this is also when we see those increased cravings. So it is this perfect storm for often under consumption of food. Some of it is just eat enough. And that's really. We've looked at different nutrients across the menstrual cycle. but it comes back to getting enough. So if we talk about the protein component, component. We have a paper in review right now looking at protein synthesis across the menstrual cycle in young women. If you're getting adequate amounts of protein, it's not something I'm super concerned about. And you're defining adequate above 1.6? Yeah, about 1.6. And I think you can also get away with nutrient timing around the workouts. If you're optimizing amino acids around training, you won't see those negative side effects. Got it. But 1.6, again, is not always easy to get. I just came back from a long travel stint. I was gone for about a week and I was all over the place. I don't think there was a single day I got near. I'm targeting two grams per kilo, not one day that I hit it. The reason I always target two to even slightly more is that if I fall short, I can be 1.6. But I promise you there were half those days I didn't hit 1.6. I think, one, it's really valuable that you say that. And I think people need to hear that. I recommend the same thing. I go about one gram per pound is my goal. And there's many days I don't get that, but it's still that consistency and optimizing timing. I'm not going for five hours without getting protein. So I have amino acids in the bloodstream, which can help maintain. Yeah. I was so frustrated with myself because I normally travel with protein snacks, got my David bars and my venison sticks or whatever. And I just, for whatever reason, I was in such a rush when I packed. I didn't take any of that stuff. And I was in Asia and you're eating these tiny, quantities of amazing fish all the time. But like, could you tell a difference? Could your body feel a difference? Yeah. I mean, I think part of the difference is my training volume was also so much lower. So you could perhaps argue that yes, even though I was probably getting only 1.2 grams per kilo of protein per day, I did actually lift every day that I was supposed to lift, but I don't think the lifts were nearly as intense as the hotel gyms. Not the same as my gym, my cardio workouts. I was able to lift every day. I was able to work out. I was able to work out a lot. So again, like I feel fortunate, it's just a week, but there's a person who's traveling constantly. This is a bigger deal and they've got to pay more attention to it. It's important to know that even when we know the right answers, it's hard to follow it. One of the benefits of exercising consistently is that a week here and there is not going to have these severe negative side effects. If a woman is getting 1.6 to 2 grams per kilo, we don't have to worry about it. But if a woman, for example, she's a vegetarian, she's going to have to eat a lot of protein. So she's going to have a real hard time hitting that. You're going to maybe make a note that says, look, right after your ovulation, this is actually a time to pay even more attention to protein intake because of this reduced MPS. Absolutely. Especially with an aging muscle. So a young female muscle and male muscle is resilient. But absolutely, if we're into our 40s, 50s, based on some of the science around anabolic resistance. And obviously the hormones change differently in that time. But if a woman is getting 1.6 to 2 grams per kilo, we don't have to worry about it. But yes, in that luteal phase, it could help with soreness, recovery, a number of components, injury prevention. Now, let's not talk about a team athlete. Let's just talk about an individual. We're long done with college. We're not on a team anymore. We as the individual are in charge of our own training. So a woman who's listening to this, who is herself active, whether it's my wife, she's training for marathons, or whether it's a woman who's just training to stay in shape, what guidance are you giving around? If anything, how you would change intensity and volume throughout the cycle? If we're talking about, let's just say someone in their 40s, I mean, I would say we're just trying to exercise and that intensity and volume would be periodized based on something else. Got it. So in other words, you're going to change intensity and volume based on longer mesocycles that are around peaking and tapering for whatever the events are. But we're not going to do a monthly up and down based on the cycle. Which means you are accepting the fact that you will sometimes train not feeling as good as you do during other times in the cycle. Right. I have two thoughts on that. Should we, or does your periodized four-week program, could we align it with our period and our menstrual cycle? That might be something that we need to look into. You're just shifting your four-week mesocycle. But yes, 100%, we are going to train whenever and do those long-term effects, but then also giving ourselves some grace of like, oh, if you didn't hit your goals or your minute per mile or whatever it may be, to take a step back and say, oh, where do my hormones play a role? Or I also maybe needed a little bit longer recovery. And there's some interesting data too with work-to-rest ratio. We might just need to, I think, empower women to say, first of all, when is your menstrual cycle? Or what does that look like? How long? Which helps us understand when it changes. How long are you bleeding? And are you more tired based on those hormonal things? Or is it something else? So this might be a relief to some women to hear that because it makes them maybe accept the fact that, hey, I don't need to like over-science this thing. It is what it is. And I can't imagine what it would be like as a guy where my hormones are pretty much always the same. And yet if these very powerful androgens are moving up and down throughout a cycle, the lack of predictability and how you're going to perform can be pretty frustrating. But it seems like. Like grace with yourself is a high virtue. Yeah, I'd say that's one of the reasons I came as a scientist. I have a lot of data and evidence, but how I do it in real life, I mean, some days I'm lucky. I'm training at five in the morning all day. Like we're lucky just to get it in. And so consistency matters. And I would say empowering women, we were not taught about our bleeding patterns, our changes in hormones, what's normal, even down to the changes in brain and mental health. And so I kick that back and say, if there's a way that we can measure that and a woman can track that, it's really empowering versus, wow, I just feel terrible or what am I doing? It allows us to tease out when there is something we need to change, whether it's our nutrition, our meds, or whatever it may be. But first and foremost, asking, okay, well, where do my hormones play a role? And how does that change as I do get older? Now, if a woman is on an oral contraceptive without the placebo week, so if a woman is just taking the hormone throughout the cycle, obviously completely suppressing ovulation and therefore completely suppressing a menstrual cycle, is there a performance advantage to that? In other words, if you were trying to make that Olympics, would that potentially be the strategy? It's more indirect, I would say, based on the literature and even working with female athletes is that that consistency, potentially over time, there's less variability. So there is more consistency with the training. And indirectly, a lot of times women are taking a hormonal contraception to help with symptoms of their cycle, whether that be mood or cramps. And so a lot of times females feel better. And then just in general, not having to bleed. Some women I know skip the placebo week so that they don't have to deal with that. And that in itself is a nice thing not have to worry about. All right. So let's talk about now as women enter the perimenopausal stage of life, which obviously for some women can be relatively short and brief and for others can drag on for a while. But if we identify it based on some sort of irregularity, a slowly upward drifting FSH, what are the ways you would advise a woman to start thinking about how she exercises and eats during that phase of her life, which again, could last for years? This is where a lot of the data has led me. Luckily, as I roll into it, it's not how I planned it, but I am happy to have more data. You're becoming an expert into the period of life you're going into at some point. Yeah, I mean, not really intentionally, but I would say that it's very much symptom driven. And so often we don't know when our FSH is rising or we're not getting our measures. So first and foremost, getting blood work done is really valuable into our even starting in our 30s so that we know individually when that changes. We have leveraged at home hormone urine analyses where you measure daily urine, which really starts to say, OK, well, maybe my hormones are changing. And what are you measuring in the urine? There's a couple of different devices that we've used. And this is just in the science perspective. Most of them are measuring some form of estrogen, some form of progesterone, FSH, LH, all in like a pee stick, a urine stick. And how accurate are they relative to blood? They're not. I always say they're not telling us the exact same thing, but we're trying to work on some of that validation. So you can correlate what you're seeing in the urine? Absolutely. Yeah. But more importantly, we're now able to see that daily variation. And so like if I have a spike or one of our participants does, or it's a drop and I feel terrible or I feel better, you can start to identify that. Or if there's no peak at all, it's impacting sleep or hot flashes. It really allows us to have those tools to say, OK, no, this is what's happening versus that single point in time we're getting our blood work done. And the estrogen that's being measured, is it just estradiol or is it estriol or estrone and everything? Yeah. I mean, usually it's one marker. It depends on the device. The thing I would advise women who are listening is to be really consistent. We think that day five FSH in the blood is probably your best test because again, you really consistently know what it should be. So when you're fertile day five, so if day one is the day your period starts, if you have an FSH level on day five, it really should be low. And that's the thing that we're watching to climb as she's entering perimenopause. So once that number is even hitting 10, we sort of know that she's now entering that zone. And obviously if you look at women in menopause, that number is going to very quickly rise to 25, 30, 50, et cetera. Can I ask you a follow-up? Yeah. What do you do if they have an IUD and do you ever use like AMH numbers? Yeah, we do look at AMH. It can be somewhat helpful, but yes, it's definitely harder if there's an IUD that's completely preventing that. I ask because it really is, there's so much variability happening. And as a researcher, we want to capture that real-time translation, but also the variability is there. And so to get some quality research, my motivation for being here too is that clinical connection. How do we take clinical practice and form research and vice versa? So that's good. I'll have to look at our day five numbers. And of course, some women with an IUD will still break through and have a period, but it might only be three times a year. And so you just try to capture those moments. That's great. Yeah. Okay. So going back to. I didn't actually answer your question. We have looked a lot. And I'll tell you, it wasn't, as a scientist, the data leads us. And so we did an initial study as a follow-up to some of the SWAN studies using very sophisticated measurements of metabolism, body composition, of what happens pre-menopause, perimenopause, and post-menopause. Repeatedly, we're seeing in perimenopause, there are some pretty, I want to say significant, but changes to metabolism, changes to muscle size, muscle quality, and bone, even menopause. And metabolic flexibility that tend to be a bit more stable into post-menopause. And so I will get to your question, but I say that of it really now, we are really diving into that perimenopause window because it seems that's where the time we really need to take advantage of lifestyle behavior changes to have this lifelong impact, improve health span. It's coming in our late 30s to our 40s to our 50s with our exercise and nutrition. So what is a specific change you might make for a woman? So maybe let's take the first example, which is a woman who's actually not exercising that much because she's got three kids under six and she has her hands full. Going to the gym every day is not on the list when you're trying to manage that. But as she's becoming perimenopausal, how do you make the case to her that exercise should be prioritized for her health? Usual things that you would hear, like, of course, exercise is good for you. But how do you make the case, if you can, that actually, despite how busy you are, this is a great time to start this or re-engage in this habit? I mean, I would follow it up of not just say re-engage or start this habit. You're never too old to start and it will literally impact your health forever. And I would say, based on the data, it doesn't have to be 150 minutes a week of exercise. It's really consistency. So there's data. I would love to get your opinion on this. But intensity is more important than volume. And consistency is more important than volume. And so really telling her that I know I struggle with mom guilt. And often these women are worried about taking care of everyone else with this desire to care for them. It's amazing how little dad guilt occurs. I mean, I was going to ask you, surely there's dad guilt? No, it's not the same. I think the truth of the matter is I'm way less selfish than I used to be. But the truth of the matter is my wife is infinitely more selfless. We're wired that way, aren't we? Yeah. And I feel bad sometimes. It depends. Like, look, if my wife is in the middle of training for a marathon and only one of us can do our workout, it will be her. But ordinarily, she'll always be the one to say, look, if we only have time for one of us to do something today, she'll take it. She'll take the hit and let me do it. I mean, you throw in the kids. I have two little boys and they say, don't go. Like, why are you going to run? It's bringing them into it, too. I think women, the other reason I'm passionate about it is that we have the ability to not only change our health span, but also generations behind us of, hey, this is really important so that I can. I always joke with my kids of like, do you see any other mom killing you on the flag football or the baseball of like, it allows me to be out there and to keep up with them as well. So I tie it back into health and longevity and quality. If you want to live healthier longer, you need to put the time in now and it will ultimately help you be a better mom, wife, et cetera. Grandmother. Exactly. Yeah. I want to touch on your point about volume and intensity. We've been looking at this a lot. And I'll tell you what our reading is of the literature is actually that with unlimited time, volume matters the most. As volume goes down, intensity becomes more important. And I think that's a really good point. I think that's a really good point. In other words, if a person only has 150 minutes a week to exercise, you have to prioritize intensity because you're not really getting enough volume to maximize conditioning. If a person is willing to train 12 hours per week, which is obviously a lot, then you have the luxury of relying on the volume for the benefits and the of high intensity to low intensity is going to be a lot shorter. And so this is a slightly more nuanced view that I think often gets communicated. And it's the difference between the professional runner or the professional cyclist who's out there 25 hours a week training. And yes, 80% of their volume is going to be really, really low intensity, but that's none of us. And so, yeah, we do have to prioritize high intensity training. And I was giving a talk recently and someone said, if I only have 20 minutes a week, I'm going to be able to do that. And I said, and they gave some incredibly low number of minutes to train a week, what would it look like? And the truth of the matter is, if you're trying to maximize the training effect, it's going to mostly have to be pretty high intensity. But of course you run the risk when it's just high intensity that A, you're missing some of the other benefits, but you're not building a strong base. Yeah. I mean, I think it would go back to what the outcome we're looking at. I definitely hear you and I'm an exercise physiologist. I love volume. I will tell you when I first started in this space ago, I was an endurance runner. I thought we had to train until you like couldn't walk and really started looking at high intensity training. And when we go back to that sedentary woman you mentioned with three kids, if we want improvements in VO2 max, that volume does come into play, but we can get those changes more quickly with that high intensity, which is sometimes what we need. Now I don't feel as terrible when I go work out when I'm just starting. And so the other thing is there's some fascinating data on exercise snacks, that higher intensity, short periods of time. And then are you familiar with Scott Trappi's work that shows he's measured and tracked some pretty elite endurance athletes over time? Just doing volume doesn't help maintain the integrity of the muscle size and quality. It does. It's very good at capillarization and blood flow. You're talking just endurance training? Yeah. We haven't talked about resistance training, but where volume is maybe not the only way. So I would just tweak that a little bit of intensity is going to matter no matter who you are. But yes, depending on our performance goals, sometimes you do need more volume. So let's talk a little bit about how you might structure that because I think this is the more realistic scenario. I think it's a luxury for the person who's got 18 hours a week to train where we can talk about how much zone two, how much zone one, zone three and zone five. But now let's talk about the mom who says, okay, I'm going to carve out three hours a week in total for training. That's going to be my resistance training. That's going to be my endurance training. First of all, how much of that three hours are you going to want to put in the weight room versus on the treadmill? Yeah. I mean, it would come back to goals, but if it was just a general, let's say midlife woman, I would absolutely prioritize a few days a week of whole body progressive resistance training. We're doing a study right now and have done where we try and get it into two days. We do a little bit higher intensity progressive and then two to three days where you're doing aerobic exercise. And hopefully two of those might be high intensity. It really does come back to the goals. Are they trying to lose fat, gain muscle, just move. But in reality, you need a blend of some resistance training consistently and some exercise that elevates your heart rate versus just low to moderate intensity. In that example, would you say, okay, we're going to do two 45 minute whole body resistance days? I don't even have time for that. Let's say 30 minutes. We've done a protocol and this is not the only way, but just to make sure that we're doing it. Just for time efficiency where it's 30 minutes, it's six to eight reps. So 60 to 80% one RM, 30 seconds in between each exercise, two minutes in between it's 30 minutes. We're done. Okay. That takes an hour a week. And then of the two hours that you're going to be left for say running on a treadmill or being on an exercise bike, how do you structure those? It sounds like you're saying two thirds of that time might be high intensity. A third of it might be low intensity. Yeah. I mean, I would say at a minimum one day a week of high intensity interval style training, if you can get two in, it's going to be a bigger bang for your buck as you're starting. And I do think there's a lot of value of just movement. So maybe on that day where you have a little bit more time, whether you're walking or doing more of that low intensity riding a bike, I mean the freedom to just get some blood flow and get that heart rate up. And how do you structure the high intensity days? I mean, there are so many different ways or the protocol that's been very effective for us in very fit individuals down to cancer individuals is 10 sets of one minute on one minute off with that one minute being anywhere from 90% to 110% of max. How do you explain 110% of max? What I would do is say pick an intensity that you couldn't go for a minute in 20. You pick an intensity that one minute is really hard and you need to take a break. We've done it where you measure VO2 max and very calculated, but we've also done it where we just said, hey, go do something for a minute that's really hard and you need to take a break and then that next minute you go again. In other words, most people are not going to have VO2 max measured, but you would say anywhere from 90% to 110% of VO2 max. Or of max heart rate we've used as well. My issue with heart rate training when it comes to anything that's that short is the heart never gets to max heart rate until the very end. I find that the lay person when they're training, let's say at the beginning of the interval, their heart rate has come down. Won't come down that much, but let's say it comes down to a hundred beats per minute. And let's say their max is 180. When they're 30 seconds in, it's only 140. They might look at that and back off a little bit. They might be a bit confused. So they might try to speed up more than they should. So I've always felt like you have to be able to teach people how to RPE their way through those efforts. Of course, the nice thing is on a bike or on a treadmill, if you're doing it on some sort of ergometer, the power or the speed are locked in and that forces you into the effort. A hundred percent. I also think the goal of the interval style training, if you're doing it in a lab, is that you'll still see benefits, even if you're not necessarily hitting that 90%. It might just take a little bit longer. And we've done this where we did some at home in a family med clinic and just said, here's some guidance so that they don't feel like they just have to do it on a bike or a treadmill. They begin to feel what a high intensity feels like. Also because RPE and heart rate does vary. And you suggested one-on-one off for 10 rounds? Up to 10. Sometimes we start with six, but yes, it just feels, you can do anything for a minute. Now there's a lot of good science of doing 30 seconds and we've looked at different protocols, two minutes, but that one minute on, one minute off is something you could do on your own. And it tends to be very feasible. And when you tell that woman, we go back to, it really takes 10 minutes of work, 20 minutes total. And I love doing that. And that sometimes when I say I won't have any time to exercise or I got to get my kids to baseball, maybe it's only six intervals today. You get it in, get it out. And you have a, not only an effect there, but that lasting effect for the day after. So if you're going back to the case of our hypothetical woman here, if she's got two hours that she's willing to put into cardio, cause you've taken one hour on resistance training, would you do two of those since with warmup and cool down your, let's just say each of those is half an hour. So now you're at two and a half hours. And if you're going to do two and a half hours, you're going to do two and a half hours. And if you're going to do two and a half hours, two of those is another hour for the remaining hour. Would you prescribe one or two low intensity days? Yeah, it all comes down to, do you have a whole hour by itself? Now, as I've aged, like I need exercise every day, otherwise I'm unwell. So that 30 minutes, it's a bit more manageable to do and depending on intensity. So yes, I would split it up so that more days than not, we're doing some sort of exercise. The other thing I'll add is prioritizing that high intensity training a couple of days versus an added low intensity days. It does increase lean mass as well, which can be helpful for that midlife. So let's talk a little bit about some of the goals that women might be coming into this with. So let's start with, do you ever differentiate between weight loss and body composition? I mean, they're basically the same thing, aren't they? It's one of the things I'm passionate about because most women say, I want to weigh less. Or we were taught like, oh, I don't want to know my body fat. When in reality, like we should know and you want to measure so that a lot of times the weight doesn't change or goes up. And so it is all about body composition, but a lot of women don't understand that. How would you counsel a woman that came to you and said, I want to lose weight, which would be the common statement for anyone. This is not, this is men, this is women. Everybody says, I want to lose weight. Yes. What they really mean is I want to lose fat. Yes. So we would do some sort of measurement and we do a pretty comprehensive, whether it be a DEXA scan or a multi-frequency bioelectrical impedance or an at-home scale. They're all different, but most of them do a pretty good job with tracking changes. And what I would do is based on that number, calculate ideal weight. And from that, it tells us, okay, here's our percent fat and our muscle, but here's my goal percent fat and muscle based on my health goals or my weight goals. A lot of times people think, oh, I want to weigh what I did in high school, but in reality, they'd have to lose muscle for that. And so giving them more of a target percent fat with that to inform our weight goal. And how do you make a determination of what the ideal body fat percent is? I mean, depending on the device, a lot of times you can use NHANES. Really around the 50th percentile, we see a lot of cardiometabolic changes. So using a lower percentage, there's normative data that I would use based on the individual. But to what percentile do you bank? Down to the 50th percentile? Oh, no, no. Usually we want it down to, like, the 25th percentile and lower. Yeah, 50th is what you want to stay away from. Yeah, got it. If a woman came in and she was five foot six, probably the average height, and 150 pounds, which tells us nothing yet, but now you do a DEXA scan and she is 30% body fat, my guess is that's probably about the 50th percentile of NHANES. How old is she? 40. Yeah, I would say that it's a little bit lower, probably 30th percentile. Okay. So if she's. She said, look, I want to lose 20 pounds. I want to go from 100, what did I say? 150? Yeah, I want to be 130 pounds. So how would you then advise her? So we would measure her body composition, see what her bone weighs, what her lean soft tissue or muscle and her fat, also where she stores her fat. And then we would understand how much food she's consuming. And a typical 40-year-old woman, let's say she's a mother of two, what would be the typical pattern of fat storage on her? So most. Most often, this is tricky because it's changed. I mean, most women store it in their hips, but as we age, we store more in our abdominal region. And so it's not always visceral fat, but that is a lot of the conversation and why we measure it. A lot of women then begin to store more in their visceral region, kind of on their organs versus their hips, which comes with an increase in cardiometabolic disease. So in the case of this woman, let's assume that her visceral fat is actually quite low. And let's assume that she's also metabolically quite healthy, even though you haven't necessarily measured that, but let's just say she's had some other blood tests and she's metabolically healthy and that this is just mostly subcutaneous fat, whether it be on her hips or on her abdomen, but it's not inside. That's great. But let's be honest, we all want to look better. She sort of says, look, I want to be 20 pounds lighter. And by the way, if she wants to exercise, it's great to carry 20 less pounds around on the knees. Right. Well, I would usually say that 20 pounds is probably too much. Based on historical measurement, we're probably looking at more of a 10 pound if she's 150, 5'6". 140 pounds based on that skeleton is probably more reasonable. And then it would include some follow-up measurement. So we're doing a project right now where many women are not necessarily losing weight, but they're replacing fat with muscle. Again, that comes back to some nutritional strategies. And so I guess the question is, how do we get her to lose weight? There's a blend of a hypo caloric intake. So we need a slight calorie deficit. So understand what she's eating. A conversation that we're not having in this midlife is it's not just taking out food. It's adding in foods like fiber that help with satiety, enough protein and complex carbohydrates. So it's balancing that with her workout and having some of a calorie deficit. Now, a lot of women or anyone for that matter, but we're talking about this hypothetical case. A lot of women in this situation of being a 150 could easily get to 130 with a GLP-1 agonist. And so let's just say a woman says, look, I'm going to take this GLP-1 agonist because I'm going to weigh 130 pounds. What are the strategies you're going to employ to figure out a way to say, look, I want of the 20 pounds that you're going to net lose, I'd like to make sure that no more than five of them are muscle and therefore 15 of them are fat, which by the way, would be an enormous improvement in body composition, right? She would go, I'm going to take this GLP-1 agonist because I'm going to weigh 30 pounds. She would go from being 35% body fat to 20% body fat or 22% body fat or something like that. So what kind of strategies would you employ there, both in terms of nutrition and in terms of her training? In those cases in general, in that life space, we know that our muscle quality is also changing. It just emphasizes the need for resistance training. And there's a lot of different ways to do that, but I would absolutely prioritize resistance training to help to maintain that lean mass and improve the muscle quality. And then protein has to be a conversation, particularly thinking about maintaining amino acids over the day. So consistently feeding, usually the goal is around 30 grams of protein evenly spaced throughout the day. We've also done some work with essential amino acids around exercise, which really helps optimize that maintenance of lean mass. And what would you target per day? So if she's at 150, would you target 150 grams of protein a day? Yeah. I mean, usually you use the goal weight. to identify. But yes, I would say 130 to 150 grams of protein, it has a higher thermic effect. That's a pretty aggressive fat loss, weight loss. So yes, if we could get to 150, that would be a good goal. Yeah. And the reason I bring this up is I think that we just have to accept that many people are going to use these drugs. They're becoming more and more tolerable. Manjaro or terzepatide is significantly easier to tolerate than semaglutide. And what I just want to make sure is that all the people that are out there wasting away have the insight into, hey, it doesn't have to be this way. I can still take this drug. I can still lose weight, but I also have to do something kind of deliberate to make sure I don't have a negative impact on my skeletal muscle. Which I think is such an important point that, I mean, most men and women, most women, really want to weigh less, but the loss of muscle can have a dramatic impact on our health long term. And we're just starting some of this work with these GLP-1s of what is the right amount, or can we alter the dose or help us feel better if we add things like resistance training and higher levels of protein? And there is good science on the protein side of things. Because they impact appetite, it's still focusing on the nutrients. And that really ties into some of our work with nutrient timing. Of if you are then on a GLP-1 and going to exercise, you absolutely want to think about having amino acids before and or after to really maximize the effect of the workout. Yeah. I was talking with someone yesterday actually about her experience on both semaglutide and terzepatide. And it was just very interesting because she said that nobody had talked to her about, and I think this is most people's experience. Nobody explained to her that when you're on one of these drugs, you don't just go about your day eating less. You actually have to create a new diet that of course is lower in calories, but has to be much higher in quality to compensate for the reduction in total energy. In other words, exactly what you're saying. But it was interesting that she didn't know that until she figured it out herself. And it of course makes me wonder how many people are not being counseled correctly to be able to use this drug. It's a great drug. It's an amazing tool. But it comes with a responsibility for lack of a better word, which is you're going to have to make these direct and very deliberate changes in the energy composition. And then obviously around the training. Most people are also not measuring body composition. And so you really don't know what type of weight you're losing. And we see this accelerated loss of muscle and bone. What's your theory on why the bone densities are going down? Well, that was my second point is depending on who's taking these drugs, if we're looking at a young person, who's taking these drugs, who's taking these drugs, who's taking these drugs, younger population, we're seeing with and without these drugs, but under consuming calories, there's this relative energy deficiency syndrome that is happening in parallel with perimenopause. So if we're under fueling, some of the same symptoms and side effects of perimenopause are really coming from just under fueling, which is I think going to only go up with these GLP ones. If you're eating less, it does impact hormones and you have the fatigue and the drop of progesterone and estrogen. But it's only going to go up with these GLP ones. So if you're eating less, it's not necessarily driven by your ovaries. It's driven by the lack of caloric consumption. So let's assume in this case of this hypothetical woman, she's showing up and she's not really got much of a huge exercise routine. So now you're kind of introducing her for the first time. And let's assume she's also in the, look, I've got three hours a week I'm willing to put into this. How are you going to divide her three hours per week where now her goal is recomposition? I don't think I would change much. I mean, I would definitely. Two 30-minute strength training sessions or would you flip it? If you're doing high intensity resistance training, like optimally you might do one additional. It does depend on the soreness and what we're doing. I think the other thing that we need to consider is the lack of energy. So if she's under eating, we might not have the ability to do as high of volume and intensity on those two resistance training days. The other thing we want to consider though is those cardiovascular changes. And that's why I like HIIT is that it can. Stimulate and increase in muscle at the same time and still improve those kind of vascular changes we would see. So maybe one day, maybe I would flop it. Meaning give a third day of resistance training? I mean, if we had it or encourage her to add. She's giving you the time. She's saying, look, I'm going to give you three hours. You tell me how to do it. Honestly, I would maybe do the three resistance training and take one of those 30 minutes low intensity cardiovascular days to add the resistance training. All right. So she's going to do. One low intensity cardio day, two high intensity cardio days, three strength days. All of those are 30 minutes a pop. Yeah. I would say if she's unfit, that might be a lot for her. Probably change one of those HIIT days for a low intensity day. Okay. So two low intensity, one HIIT, three days in the gym. And those three days in the gym are all whole body? Or at that point, do you start to go body type once a week? I still like body type or major muscle groups. Twice a week. So a push-pull. I really think it depends on the individual. Is she tolerating it well? Is she feeling good? Or is she run down? If she doesn't have energy, then I would split it up. Would you suggest a timeframe over which that degree of body recomposition is going to be more sustainable and therefore less dramatic in the getting there phase? Yeah. And I think it's a really important point, especially when we think about a lot of our lab-based work. We're looking for accelerated time. Our accelerated changes in a short period of time. So yeah, for more sustainable, I think the body part over a specific. So if we're looking at 24 weeks is often what we're looking at would be more of a concentrated push-pull, whether it be leg day, upper body, leg, upper body. And you would say 24 weeks. If she came to you and said, look, how long would you like this to take? Would you want this to take up to 24 weeks? Would you want to make this a one-year project? Again, part of this comes down to how you would even dose the. Terzepatide. Our view in this is we want the patient to be on the lowest dose possible and take as long as necessary to get there. So I would say I want this to take a year and you're on 2.5 milligrams, maybe five milligrams, but we want it to be long and slow so that the adaptation is gradual. We are in the process of looking at some of this now of actually including a lean mass indicator before titrating the dose up of saying, let's see how your body is responding before we change the dose. I feel like we're talking about a couple of different things here. So yes, we would want that to be long-term, but on the flip side, most people want to see some effects pretty quickly. So it's a balance of what are we, what type of weight are we losing? And are we tracking that and making sure muscle is an important component of that? Okay. Now you've done a lot of tracking in yourself, right? How many years have you been at this yourself, your sort of self-quantification? I gosh, at least more than 20 years. We measured it in college, all the way through grad school. And now I do mine every like six to nine months. Okay. So what have been your observations in yourself based on this and how generalizable do you think they might be? I mean, I think initially it's really important to understand low. So just for instance, when I was a distance runner, I had nine stress fractures and it was every time my body fat got below about 15%, which is really not ridiculously lean. So that injury indicator. You're how tall? I'm about five, six. And when you were at 15% body fat, that was what weight? 120, 115. So that looks pretty normal. Like you're a lean looking person, but you're not a beanpole. No, but it was my set point. And so it's really important to use these numbers of not like, Hey, how do I compare to someone else? But, Oh, about this is too much for my body. At that point you were amenorrheic, I'm assuming. Honestly, like no one talked about it, but yes, for most of my competitive career, probably. Is that a sign to a young girl that she's either not eating enough or she's exercising too much or to a woman of any age? Menses is a really good indicator of overall health and wellbeing. The hard part is we should catch it way before someone loses their menstrual cycle. And there is some competition level that it might fluctuate, but you don't want to go the entire year without having your period. Okay. At 15% body fat, you were clearly below the threshold at which, your body was now catabolic and you're having 15 stress fractures? Nine. Nine. Yeah. That's pretty incredible. When did you put that behind you? Graduate school? Yeah. I thought there was a lot of conversation about it being bone. Oh, bone density must be low. But when we actually measure bone, my bone is very high. So it very much was a fuel lean nutrient timing. But I went on to grad school to really dive into that. Not just that component, but understanding the nutrition components of it. And during grad school, I had some great mentors that brought in nutrition. And I did not believe in dietary supplements as a collegiate athlete. And really all my early work in grad school was around creatine and beta alanine and really understanding some of those impacts. And I think part of the fun part about being in this field is you are your own self-experiment and even how you measure composition. So is it DEXA? Is it BODPOD? Is it bioelectrical impedance? And knowing that those numbers are very high, I think that's a really good thing. are all very different. So I also very quickly learned that I didn't need to train for hours a day. That's where that bridge of intensity and volume come in, especially in grad school. And then even into my time as a professor, I always like to face my fears, which is why I'm here today with you, Peter. I did a physique show early in my career. How do you change the body in a way that maybe is not normal or in a way that pushes the envelope and really dials in science and then have since changed or measured before and after two kids? And my translation is science really matters. I just want to go back. When you were in college and you were running, were you guys spending time in the weight room? We were, and I loved it. So you were lifting and running. I was going to ask, because I'm struck by the point you made about how your BMD on the DEXA was normal, but you were still having these stress fractures. And I was kind of wondering if there was something that was missing in your body that you were able to lift and run. Because of the type of activity you were doing, but in the weight room, you're getting the appropriate deformation. Yeah. I mean, we've looked at this too with some of our other athletes. It really seems to be a muscle quality issue. I mean, this was more of a protein breakdown catabolic component. And these were all tibial or where were these from? It was all my left leg and left foot. So some of it was inside leg on a track. I was a D2 athlete. So we competed in cross country, indoor track, outdoor track. So some of it was just. Repetitive strain. Exactly. And there was twice it happened during a race. I finished and I couldn't walk. I say that in a way of, I love to push hard and work hard. And sometimes that's too much. It comes back to the training intensity, volume, specificity, and nutrition. You can't do one without the other. Do you remember how much protein you were consuming back then? I don't. But what I do remember is that, and this was an early sign of under consumption is that I had the worst GI distress. I remember having a colonoscopy. And in reality, like I couldn't have a big meal before I went and did thousand repeats on the track. I also went for extended periods of time without eating. So it wasn't necessarily total amount. It was just several hours in between that also played a role. Meaning you weren't getting enough protein around your training. I think it's protein and carbohydrates. We train twice a day, every day, morning, go to class, train in the afternoon, go to some sort of meeting. And so just gaps of long periods of time without fuel versus more frequent consumption. Got it. When you got to graduate school, did you continue to run? Yeah. And I thought you had to train all the time. I still train and love exercise, but I learned that you didn't have to train as much. And I really started to learn the keys of nutrient timing and optimizing nutrition and the impact of some dietary supplements. Besides creatine, what are your other staple supplements now? You mentioned some amino acids. Whey protein amino acids are going to get you the same, but sometimes I don't want a milky substance. And the amino acids are absorbed a little bit faster. Omega-3, like now is maybe a little bit different than then, but omega-3, vitamin D, magnesium, creatine, multivitamin, like a probiotic, which is debatable, but multi-strain based on my GI system. How did your body comp then change over pregnancies? So if you go back to prior to your first pregnancy, what was your body composition and how did that change at your second? And then obviously following that, I mean, this is probably something most women are very interested in, which is what should I expect is going to happen? Do I have a new set point after pregnancy? I don't know. I don't really need to talk about my personal numbers, but I think this is really important where science plays a role of where now and even through pregnancy, I think through with both my children, it was maybe about an 8% increase in body fat. And depending on measurement, sometimes you can't really tell the lean mass components, but I definitely didn't lose muscle and I gained some fat. And then as a follow-up, usually I would measure about three months postpartum and it took six months to get back to normal. I think it's important to say you don't have to exercise crazy. It's finding time when to train. I've been the same percent body fat and changed muscle depending on my training for the last 15, 20 years. After I learned a little bit in grad school how to optimize, a lot of my students always say, it's not fair you have science on your side, but we all can have that. Meaning consistency, some high intensity and appropriate nutrition. You don't necessarily have to have a new set point. And if you have that consistency, it can really help. So your youngest child is how old today? Eight. Okay. So you're eight years post your second pregnancy. And is your body composition today approximately the same as it was prior to the birth of your first child? Interesting. Not just your weight, but your actual body composition. Yeah. And I would say the biggest change, I like to periodize. Sometimes I'm leaner, sometimes I'm not. As part of my training, but it's not very different. And I also like to play around, especially now when the message is, oh, as a midlife woman, you can't gain mass or you're losing muscle mass. It doesn't have to be true. And I have gained lean muscle, or if I'm training for something that's more aerobic, I've maybe lost a little muscle. Or, I mean, you can appreciate this with your traveling of sometimes your diet is more locked in and sometimes it's not, but it's all about prioritizing that. And one thing I always say is, I don't know, I don't know how to do it. I don't know how to do it. I often tell women is the times that I want to be leaner is I'm actually eating more. I'm prioritizing whole foods, eating consistently throughout the day versus the times when I'm not paying as much attention is where I might gain some fat mass. Yeah. Explain that. That seems a little counterintuitive. When you say you're eating more during the periods in which you're leaner, you mean more volume of food, but lower caloric density, or what do you mean? And more frequency. And I'd love to talk through some of the fasting literature, but in reality, as a woman, this is not just me personally, this is based on science as well. Many women might wake up, not eat breakfast, might have something at 11 and then continue on or grab a snack. And those foods are typically not necessarily nutrient dense. Whereas if you shoot for about 30 grams of protein and some fiber, some vegetables kind of evenly throughout the day, it stimulates metabolism. You're getting more macro and micronutrients. Yeah. So in other words, the mistake that you think people are making is time restriction on their feeding. I think there's a time and place for time restriction. What we've seen right now, when we're looking at this as many women chronically time restricting, it can lower metabolism. And then there's the aftermath on our hunger hormones. When they start eating, they can't stop, or it does impact protein synthesis and metabolic rate and muscle loss. So especially in this midlife window, I think we need to pay a little bit more attention to food consumption. Yeah. By the way, going back to what you said about within six months of your pregnancy, you had returned to your pre-pregnancy body composition. Were you breastfeeding during that period of time? I was breastfeeding and I will tell you, I do not do pregnant research, but I did take this approach during pregnancy. I believe birth is one of the most athletic events you'll do and you should train for it. I exercised consistently and I slowly increased my calories in a way that was almost like a refeed period so that I had a bit of a caloric surplus. And then postpartum, obviously it's hard to nurse and feed yourself and all the things, but I was able to go back to normal calorie balance. And so yes, nursing does help, but I also was exercising consistently. And so there's a bit of calorie play you can do to help with those metabolic rates. What was your exercise in the third trimester? What were you prioritizing? With my first child, I could do some running, but it was resistance training. I squatted. I did lots of lats, like really thinking about what are the muscles that are going to help you deliver. Those are the ones that I worked up until the day I delivered. I wasn't doing as much necessarily high intensity work, but changes optimizing blood flow and muscle fatigue to help with birth. How long after you had your first child? I had two natural deliveries. So I definitely started walking within a couple days. And then I was doing resistance training within a couple of weeks, but lightweight. I mean, that's the benefit of being active. If I could go back, I would run within a few weeks. Nothing crazy. When you were pregnant, how much did you need to sort of fight cravings? Did you fight cravings? Did you give into cravings? Did you have the typical cravings that you had? Yeah. Oddly, I didn't want to eat animal proteins, which was really hard. And I didn't want a protein shake. None of that sounded good. And so I definitely had to prioritize plant-based proteins. That's just what tasted better. And then interestingly, I craved donuts. I'm not a person that eats a lot of refined carbohydrates, but I ate those. I included those. And I didn't track my macros necessarily, but I was intentional about eating. Consistently to fuel so that I was a bit on a caloric surplus. And then one day. Once you had your children, what changed in your nutrition? Did you very quickly get back to your baseline eating or was there a period in which you still had cravings? I mean, I think GI distress. So often there was probably some lactose intolerance immediately post. I do remember eating a lot of liquid foods because you're carrying a child. So I was prioritizing, then I kind of integrated protein shakes back and omega-3 and creatine to help maintain when you're not sitting down to eat full meals. So what do you think are the biggest mistakes women are making in the pregnancy and the post-pregnancy phase with respect to training and nutrition? For nutrition, I think it's, we either go one way or the other. We use it as an excuse to eat whatever we want or the opposite of not paying attention. It should be a key priority. And I always still think about the development of the baby, of the neural development. There's a lot of nutrition that can play a role there. And even down to the gut health. So like fruits and vegetables, variety. So really prioritizing nutrition. First resistance and aerobic exercise is, it is an athletic event to deliver a baby. We should exercise. If you've never exercised, you should include something. And if you've always exercised, then you can continue that. I think there's better guidance now than there was eight to 10 years ago. And then into postpartum, it goes back to not the mom guilt, but now how do I incorporate this? Especially with nursing and hydration. And sleep deprivation. Exactly. I do think there's something special that happens. Like somehow a mom can go with no sleep and still do all the things. But think about exercise and blood flow. It has a big impact on that. So let's now talk about this, again, going back to kind of this perimenopausal state and even into menopause now. So women disproportionately suffer from sarcopenia relative to men. Presumably there's two things that are feeding. Genetically, women have less muscle mass to begin with. And then secondly, it seems that women are less likely to engage in resistance training than men. Do we have data on what the differences are? I love that you're asking compared to men. And you started this conversation of, and what I think is important is let's just look at women too. It's not just the comparator. And there's some really good data, a paper by Bill Kramer. He just wrote and said about one in five women participate in resistance training. So about 19%. And it's only one day a week. That's women of all ages. All ages. That's all comers. Yep. I also think we're at this really unique time because we have, so Title IX was about 1972. So now we have this group of women that are aging that do have more experience with exercise and they're aging differently than we knew before. And so when we think about women in this timeframe, whether we compare them against men or not, there are key things that happen with our changes in hormones, even that impacts sarcopenia. Things like oxidative stress and inflammation and change in basodilation, all of that can impact nutrient delivery and blood flow and cardiometabolic health. So what are the most important things that a woman should do different in menopause compared to premenopause with respect to training? Or is the answer, whatever you were doing before, assuming you were doing the right thing is all you need to continue? In other words, do you need to make adjustments between that? I would say yes. Everyone throws out menopause and we actually have some good data on people post-menopause in our 60s and our 70s. What we're really missing is what's happening in our 40s and 50s and our data and some other labs show that muscle quality very much changes. And so we actually did a two-year longitudinal study and brought women back after kind of initial measurements. And in that initial measurement, we gave them pretty. Comprehensive information about their body composition, their strength, their nutrition. And what we saw was then two years later, individuals that followed some of those recommendations, there were less changes. It didn't align with a lot of our SWAN data, the study of women's health across the lifespan. They were able to maintain some muscle size, but we saw significant changes in muscle quality. And the way I describe that is very much like a ribeye versus a filet. Did you guys do muscle biopsies? We did muscle quality from ultrasound and PQCT. And that PQCT is very related to MRI. We have some of that data now that we've looked at with MRI. And it's the same theme. And there's also a group out of Australia, Severine Limon. They just did this long longitudinal study looking at perimenopause and post-menopause. And the data continues to show that muscle quality changes most in perimenopause. Is the muscle fat, is the marbling occurring between cells or within cells? I don't know if we know. Depends on measurement. I'm not sure I can answer that. Got it. So no one's doing a biopsy because that's obviously how we would figure it out? Or are people doing a biopsy? Yeah, there's a preprint that just came out from Limon's group that they did biopsies. I would say the downside, so they had pre, peri, and post. But I think there was only about five perimenopause. I'd have to go look and see exactly where the marbling was. There is a really good data on neuromuscular changes and the ability and muscle fiber type. My question back to you would be, what's your thought process on why it would matter? Intracellular fat accumulation would contribute to insulin resistance. Yes. That would be viewed as more pathologic. Athletes often have a lot of fat between cells. But the challenge of static evaluation is you don't know if that's a static pool of fat. Which would be a bad sign. Or if it's in flux. Is this fat being consumed? Because obviously fatty acids are very desirable to muscles. Especially a very metabolically flexible muscle, which can oxidize fat across a wider range of output, of energy output. So we're measuring that with different ways, not with biopsy, but both with indirect calorimetry through metabolic flexibility. And then we just finished a project looking at microdialysis. This was within the fat. It can also be. It can also be done within the muscle, but trying to understand fat oxidation, not only during exercise, but before and after exercise to get at that. What is the oxidative capacity? How is the muscle? Is it metabolically flexible? And you're measuring this in what subset of women? This is in perimenopause. Okay. And so what are you finding? Are you looking at maximum fat oxidation with indirect calorimetry? We're doing that as well as metabolic flexibility. So early, some of our early work demonstrated that. It's in perimenopause at moderate intensity that women were become, they were less flexible. How are you quantifying or measuring or defining the metabolic flexibility? What are you, and I assume you're measuring their IC across varying intensities? Yeah. So using a blend of our RER, our Q, so oxidative metabolism from carbohydrates and fat. And then because of that early data, we've then added our fat metabolism through microdialysis. To understand fatty acids interstitially before and after exercise. So what are you finding in terms of, are these longitudinal studies as well? Or are you only looking at women in perimenopause, but you don't have their data from prior to that? Both. So we have one that was longitudinal. And then we have one that's more of our acute, which has informed our current project looking now, trying to understand how resistance training might modulate that and or nutrition. So. So we definitely need more longitudinal work. We have some. So what do you see during, at least to the perimenopausal snapshot, in terms of metabolic flexibility? I think the most important takeaway is that exercise does make us more metabolically flexible. Even resistance training alone, or does it have to have some cardio? I mean, this is a biased view, but we've really dialed in and looked at more of our high intensity interval training, just because it accelerates. Lipid fat oxidation. And so obviously during exercise, we're using mostly carbohydrate. But post-exercise, high intensity work blunts any of our hormonal impact, meaning exercise will stimulate metabolic flexibility, regardless of hormones and age. What we're even trying to dial in now of how about fasting versus protein intake versus carbohydrate intake, which some of our early work. Right now that we've just analyzed is that it does seem that protein optimizes blood flow and does not blunt insulin response post-exercise. So it does seem to help with our metabolic flexibility post-high intensity work. We have not looked at resistance training. Tell me, are you defining metabolic flexibility on a continuum or are you using kind of a on-off switch where there has to be a threshold? Often we're measuring it through not a graded exercise. Test, but an increased exercise intensity using indirect calorimetry. So we're looking at that switch from fat to carbohydrate. And you're defining that as your RAR at 0.85. Are you asking the question at what intensity do they switch their RQ from below to above 0.85? Not just 0.85. There's some of Asker-Eukendrup's work we're using to use a mathematical model to understand the continuum, not just like an on-off. Okay. So help me understand. What is the unit of measure for that? Is it going to be transition from a certain number of grams per minute in total, or is it just a percentage of fat versus carbohydrate? Yeah. I mean, there's a couple of different outcomes. Sometimes the percentage is the easiest to look at. The ability that, yeah, the fat versus carbohydrate. So what you're measuring pre and post in these women is how much does their percent of fat consumption go up for a given workload? Well, yeah, then we can split it based on their intensity. So heart rate driven, measured heart rate of low, moderate, and high intensity and that fat to carbohydrate oxidation percentage. And then does that vary between pre, peri, and post? And then study two is looking at specifically metabolic flexibility based on hormonal concentrations, early, late perimenopause. So what do you think is driving the metabolic flexibility with aging in women? It's probably impacted by a few things. Some of it related to our oxidative stress and our inflammation. We do see changes in insulin sensitivity. I guess what I'm getting at is, do we have the same literature that cover men during the same period of time where whatever effects are just age-related would be the same, but effects that are hormone-related would obviously not be the same? Yeah. So I think that's a good question. Obviously not be present in men. And it would be interesting to kind of disentangle those two. A hundred percent. One of the ways we've tried to do that is measure phenological age, because obviously aging is a really important role, but how much is age versus lifestyle versus hormone-driven? And I think more importantly is how do we use lifestyle changes to optimize that or overcome some of those hormonal components? And currently we do not do. Prescribe or provide menopause hormone therapy, but that's the next layer of then how does artificially adding hormones impact all of that? It's really what we're trying to identify. So you haven't studied that, because that was going to be my next question, which is how does hormone replacement therapy impact this change, all things otherwise being equal? The bad thing about research is it has to be somewhat controlled. And so just now, especially based on the number of women taking hormone therapy, is now we're including. Including individuals that are on hormone therapy or are not. And some of my colleagues are prescribing that to understand, but that's really where we're at now. And I think it comes back to why we need more research and dollars in this space to dial that in, because it would be great if adding hormones would really help overcome that, but you still have to add lifestyle. So what is that combination? And then like you asked, what component is changing? Is it oxidative stress? Is it arterial stiffness? Is it blood flow? What are the things that are really going to optimize that so that we can really help these women as they age? Yeah. And again, what should the portfolio of training look like? To me, I think is maybe the most interesting question, because I just can't imagine there is anything that is going to change metabolic flexibility more than training. And because virtually everybody who is going to be exercising is going to be constrained on time, figuring out what is going to give the most bang for the buck matters. Agreed. And I think that's where a really important takeaway, I think, especially now, it's a little confusing. A lot of women are getting a lot of information about what they should and shouldn't do, but you're exactly right. First, we just need to exercise and that's a potent stimulus, but then it's about optimizing. And so when we go back to metabolic flexibility, a lot of the data, when we pull in nutrition is around carbohydrate feeding. But when you talk about insulin sensitivity and those changes, changes, which is where my group has focused and tried to look at what happens when you provide amino acids to also elevate protein synthesis and breakdown. And it seems that if we are eating our protein around training versus our carbohydrate are changing from high to lower glycemic index, that can also optimize metabolic flexibility. Yeah. And I guess the question is that would probably be true at any age, right? Yeah. I just think it matters more with such a big change. And I guess I don't, let's not quantify big, but when there is a significant change in muscle size, quality, cardiometabolic health, arterial stiffness, neuromuscular changes that are happening in our forties and our fifties, then those little tweaks do make a difference regardless. Like it's going to matter then, but it gives us a bigger bang for our buck when we have less time. What do you think are the most interesting questions around women's health that we don't yet have a clear answer to that could be answerable if we had the resources to study it and the will to do so? Well, I hope we do. I hope we can really build this out. I think one of them is women ultimately want to lose weight. So how do we combine our GLP-1s with the kind of what I would call minimal effective dose of exercise and nutrition in a way that women can still live their lives and feel good? So many women are not feeling great on those drugs or they're not feeling good off the drugs. And so there's also a very big component of mental health in here. I know exercise can have a really important role in. The other big question that I think is really important is the impact. We've seen a swing and I would be curious of your take that there's much more conversation now around menopause hormone therapy. I think there's a lot of indirect effects on muscle and training volume, for instance, adding hormones isn't going to increase muscle directly, but indirectly, maybe I have more energy or I can do higher volume. I can recover better. Exactly. But then does that also put me at greater risk for injury? Our tendons still change. Actually, one of the things I think we have in common, my biggest injury fear is an Achilles tendon tear. And so I think about that a lot of like, how do some of hormones and really helping women feel better with this new wave of very active women? They're women that are training, like how do they combine that has application to the military, et cetera. But we need to know a lot more as we're changing our pharmaceutical agents with our lifestyle components. Yeah. I mean, on that particular topic, my intuition is that the answer comes down to the type of training and you're less likely to tear your Achilles sitting on the couch. If you never get off the couch, you're not going to tear that Achilles. Now, of course, you're going to die a thousand deaths. So if we give a person hormones as a part of a broader strategy around improving their health, and as a part of that, that person becomes more active, that's wonderful. But that doesn't prevent them from having an Achilles injury if they don't do the type of training that would reduce the risk for that. And the good news is we have a pretty good sense of how to do that. I don't think we're going to take that risk to zero. I think you and I are still going to be at risk for it, but I think if we're doing the right things, if we really make sure the soleus and the gastroc are getting a strong range of motion, the bouncing exercise, like we're doing all the right stuff, maybe we take that risk down by 80%. And so I think that's where the education and the training specificity become really important. Now, those things are hard to put into clinical trials. It's really hard to do the clinical trial of, I'm going to take a thousand people and I'm going to put half of them on a business as usual training program. I'm going to put half of them on a business as usual training program, which is, you know, a pump and burn program. And the other half of you are going to go on a smart program where you're going to do all of that stuff, but you're also going to do all of this tissue and tendon pliability work and dah, dah, dah. And then we're going to follow you guys for Achilles tears over the next 15 years. That study will never get done. So on some level, I suspect we have to be able to think through these things in terms of common sense and best practices. I agree with you completely. I really think that this idea of figuring out what a world is for a higher and higher percentage of the population is using a class of drug that has for the first time ever really demonstrated long-term safe application of weight loss, but it does come at a cost if you're not careful. And again, I think the knowledge is there. What you're describing, this is not like hidden knowledge. We know what it takes to do this. I would hope that more physicians are equipped to help their patients understand that we should be able to take advantage of this great drug. We should be able to take advantage of this great drug. But it comes with a responsibility of how to incorporate it. And that's unusual because a lot of times with drugs, we don't do that. If you need a drug for your blood pressure, we don't have to give you like a long song and dance about how to take it. Same thing with a cholesterol drug. You take this drug, it lowers your cholesterol. We'll remeasure it. It's going to be fine. But yeah, the GLP-1, it's a different class and it comes with a whole set of, if you take it, great, but you got to do X, Y, and Z. And it's just as much work. That's interesting. What are the other, maybe, misconceptions about women's training? What do you find yourself at parties having to correct people on? Well, Peter, I don't go to many parties. It comes back to these absolutes that we're hearing. I have to lift heavy weights or I have to do high intensity training or I have to do plyometrics. And I really wish that we could just tell women of exercise and doing something is better than nothing. And then I do think we can leverage a lot of the traditional strength and conditioning research that we have that was founded in male science. the female muscle will respond. And so it's taking our program design that we know has worked, but then understanding that there might be some differences as far as recovery and rest or joint pain, like there's modifications that are needed. I guess I just wish we could empower women to do the things that they like to do and the traditional rules that we have of change it if we want strength, if we want hypertrophy, if we want fat loss, leverage what we have now. Meaning take all of the data we have on how do you optimize around hypertrophy versus strength, which again, to your point, a lot of those studies have been done disproportionately in male subjects. Are you saying that to the first order approximation, the results should be the same in women? When we look at things like strength and hypertrophy, yes, those same methods can apply. We do see differences, I think, in detraining or in the way that we're doing the work that we're doing. And so I think it's important to percentages of loss and strength and muscle of absolutes, but yes. Are women more susceptible or men? This is some early data, meaning I don't know if we absolutely know because it's so individual. And I think that's where we need to dive into. There are women that will gain more strength than men or have more muscle than men. But when we look at the baseline fiber types, because women tend to have, generally speaking, more type one fibers, they might change slightly different. And there's also some new data. I mean, that's not new, but neuromuscular aging and motor unit recruitment could vary between males and females. But it goes back to your question. Strength training works and a woman is going to gain strength and gain muscle, but not to the same absolute effect as a man. Are women more susceptible to the loss of type two A fibers when they age or are men? Yeah, that's a debatable topic. Men tend to have more type two fibers. So then there's a bigger area to lose or a percentage. But with age, there's denervation that happens where properties look more hybrid or type one for males and females. It does seem that it maybe happens a little bit faster for females, but there's a lot, I think that we're still, how much exercise prevents that? Yeah. Well, I was going to ask a couple of years ago, I had Andy Galpin on the podcast and he said something that always struck with me, which is that hypertrophy of type two A muscle fiber is. I don't think he said it this way, but it's basically the synchronicity of aging. And boy, that always stuck with me. And it really resonates. The first thing you're going to lose, you and I are long past our peak on this is explosiveness. We've lost power. We're way on the back nine of power. Strength, not so much. Hypertrophy, not so much. So strength, the next thing that starts to go and basically hypertrophy is the last thing we go. So the thinking, at least we're losing power in our twenties. If basically we peak powers in your twenties and it's all downhill, that's the thing I want to fight to preserve. Now, I'm never going to go and do the same sort of insane workouts I was doing in my teens and twenties, but I'm still going to fight for power. I'm going to do it in a more controlled way. I'm doing more stuff on a Kaiser as opposed to jumping around and doing insane box jumps and things like that. But I'm going to recruit that fiber whenever I can. And so would you make the case that that's even more true for women given that they are losing more of them? A hundred percent. And that woman probably, I would say who cares about power, but really it's about, here's why I care about power. I don't think you're saying a woman might say that. I mean, I think many people might say, why do I care about power? But absolutely, because there's so much relationship to health and quality of life in the world. And that's a tangible example. This to me is the best example of why every person needs to care about power. If you or I were to go and walk down the street right now, and we were so lost in discussion that we lost our footing as we stepped off a curb, it wouldn't phase either of us. We would step off that six foot curb and we would immediately be able to readjust our footing and prevent ourselves from falling on our faces. And we would go on carrying on talking about metabolic And that's the reason I want everybody to care about power is it's the difference between falling when you stumble versus regaining your footing. And it doesn't have to do with, if you want to dunk a basketball, that's cool. That's a nice ancillary benefit if you want to dunk or ski or all those other things, but it really comes down to life. Yeah. A hundred percent. And that matters more. And that's the reason I want everybody to care about power. And midlife. I mean, we want to do what we can right now. The more it matters. Exactly. Well, or what we can do now is have a bigger impact over time. If I do things right now in my forties to maintain power, it will help. Inevitably we are going to lose that. Like you said, I want to ward that off as soon as I can so that I have that ability to maintain power longer. Yeah. So maybe that is another one of the reasons that we see for, for potentially women suffering more falls. We haven't talked about some of the brain components, but even the side effects that happen in this midlife of a lot of women experience joint pain. And now you want me to go tell a woman to do plyos and bounce and things like there's some intangibles we need to consider of how do I tell a woman to maintain power based on some of these things that she's experiencing. There's also central fatigue and changes to brain health, whether it be indirectly from sleep. And that's where some of the things that we can do to help her. Yeah. So again, it always makes me sad when I hear about perimenopausal and menopausal women that are complaining of joint pain, when you realize that for many of those cases, hormones would probably fix those issues. And so, yeah, it's hard to ask somebody to train when they're constantly in pain, when we have a solution to that and we're not giving it to them. Now, what about the woman who's listening to this, who's 65, 70 years old and asking, Abby, is it too late for me? Has the ship sailed? No, I think that's the beautiful part about the human body and about exercise. You literally can do it at any time and you can start if you can start sooner. That's better. But no, you can gain strength and muscle at any age. Obviously, there's some challenges and you might change your volume and intensity, but no, 100% starts. And we all should be motivated to do so. It's the way we can control our health span. So what would be some specific advice? So now we're talking to a 70-year-old woman who's never exercised deliberately in her life. She's never had a workout routine. And she's healthy in the sense that she's not riddled with injury at the moment, but she's already experiencing a dramatic reduction in stamina and strength. Maybe she's struggling to open a jar. She got a lot of exercise. She's got a lot of exercise. She can walk up a flight of stairs, but it's sure she notices it in a way she didn't notice it 10 years earlier. So now she has one thing on her side, which is time. So how would you advise her to go about starting a routine for the rest of her life? And how would she titrate up? I would highly recommend hiring a personal trainer as an initial step to really teach her. How should she look for one? Because there's such a quality continuum in that spectrum. So what is she looking for in a personal trainer? There's a lot of recommendations. So I think referral is a really important starting point. I would hope that maybe a physical therapist has a good recommendation or someone locally. There are some credentials to look for, but it does depend on where she lives. But let's just say you were her trainer. She brought you in. She was lucky enough to find someone of your knowledge. How would you think about creating a program for her? I mean, it's all about adding a slightly higher stimulus than what she's doing now. So there's no stimulus at the moment. Yeah. So like, I mean, I think for someone like that, so one thing we haven't talked about is people are motivated by different things. Is she motivated by a group? Is she motivated to do it on her own? Is she motivated to be in a gym? In those scenarios, starting with resistance bands at home is a starting point. Or is she excited to go do silver sneakers somewhere? That would be a starting point. Or does she need to be in a gym with, I wouldn't start with a ton of free weights, more of our machine-based controlled stimulus. There's so many options. So yeah, let's say she's got a gym nearby. It's got a great range of everything. So, you know, she can do all the machines in the world. There's no machine she doesn't have access to. How would you think about putting a program together? I would do a total body program where we're really focused on, and this is not just specific to females, but glute activation to help with that lower body. Yeah. That will also help with slip strips and falls, a push pull for every muscle group. So a glute activation for her is going to be a leg press. A leg press, but also just some neuromuscular activity, standing up. A lot of times the leg press is not activating the glutes. So some banded work to activate the glutes to get started, maybe a leg press, leg extension. I wouldn't probably start with a lunge for this individual. And then from there, something like definitely hitting the hamstring. So every muscle group in the lower body, I'd do something to get the calves to help with the stability. We haven't talked about the shoulder joint, upper body, there's a lot of benefit in strengthening all aspects of the body. of the shoulder joint and the deltoids. So a full body, upper body exercise. Okay. And so how many days a week are you going to have her and how many minutes a week would you have her doing resistance training? That's a tricky question. I wouldn't start her. We'd want her to come back. So soreness is going to be a consideration. Basic initial, not knowing a lot about her, three days a week of resistance training, most days a week of some sort of movement, aerobic exercise is where I would start and obviously titrate depending. So kind of an every other day to allow for recovery. How long would you want before you would introduce things that are not tied to a machine? So carries walking with dumbbells in her hands or kettlebells in her hands. How long until you would want her testing multiple things where she's now testing core stability, grip strength, foot reactivity. What do you want to see before you would engage in that? I don't work with a lot of older adults and we often will start them in training. We'll start them with pretty progressive resistance training in a controlled scenario. So I don't know what would you say for that? What would you look for? I think I would look for the ability to do these things deloaded safely. And then if you can do something deloaded, then I would add low resistance and kind of progress from there. I like things like that a lot. I mean, I really love carries. I think grip strength is so underrated in a functional sense, like not squeezing a little grip squeezer. I would also maybe, if you were talking about machines, I'd also love to see a hip thrust or something like that. I know you love the carry. Would anything prevent you from having this woman start with holding some dumbbells to begin with? Definitely not. I was going to say that. I didn't know if there was. Before you walk. Yeah, yeah, yeah. Sure. Yeah. Can you just hold it? And I like doing a lot of sub maximal efforts. So I would want to, you know, a light enough weight that she can hold it for a minute, rest for a minute, hold it for a minute, rest for a minute, hold it on those. Seems to be a common theme. One minute on, one minute off. Yeah. Yeah. For that, for sure. I mean, that's one of my favorite sets actually is just a walking carry hold 20 sets of either 30 on 30 off or a minute on a minute off with a little less weight, of course. Yeah. I mean, Belinda Beck, this woman from Australia with that lift more study, I've always been impressed with that where they were able to basically teach these women how to do barbell deadlifts and things like that. And they were really throwing some weight around. We've done some work, with older adults. This is earlier in my career and they gained massive amounts of strength in 24 weeks doing things like squat and bench press. I don't know if I necessarily have them do squat. We usually do a leg press, but absolutely you can start at any age. Anything else you think where there's the most daylight between men and women in training that maybe we want women to be more aware of as they consider their own journey? I think this is not my area of research, but the impact on mental health is a huge, really important area that exercise has a positive impact on anxiety, depression, even brain fog. And I always use the analogy of there's days that I feel like I have about 20 squirrels in my brain and it's when I go exercise that the squirrels finally tame down. But in reality, a lot of times women think that they are abnormal or it's unique to them. And I think that's a really important area of research. But exercise, both resistance training and aerobic exercise has a huge impact on that mental cognition, focus, anxiety, depression. And I would love to continue to provide better prescription there too, or have women understand what they're looking for. Do you think there are any trends that are out there today that you think are at best incorrect, at worst potentially harmful as it pertains to sort of things women are being told about exercise or nutrition? As it pertains to conditioning? Yeah, I think it's harmful to say you need to only do this or not do that. Our very black and white pragmatic thinking is harmful because in reality, every woman is individual. And that's the best part about research is it's little tools in our toolbox. And that changes as we get an injury or maybe I have lifted heavy my whole life, but I still want to gain strength. Well, I need to modify and adapt. And so exercise, does not have to be overwhelming, neither does nutrition. And I think so much of it now is, oh, you have to do it this way, or this is the only way that'll work now that you're in midlife, or you have to change your training when in reality, most of us are just trying to get something in and do it consistently. So less rules, and really understanding that exercise is powerful, no matter really how you do it. And then thinking about the injury piece, I think injury and recovery from injury, we're not giving enough conversation, too. That can be really impactful, especially with injury rates taking longer as we age. One of the injuries we seem to see more in women than in men, and my wife has a theory about this, is high hamstring injuries. What's her theory? That after pregnancy, when the pelvis sort of moves a little bit, so my wife was a runner before and is a runner after, but she said, look, I've never run the same post-pregnancy. So she actually runs the same times. She ran the Boston Marathon this year, and she ran it 19 years ago. And her time this year was only 45 seconds slower than her time almost 20 years ago. Now she trains a lot smarter today. So I think that's why her running times are still really good. But she says, I don't feel the same. I used to float, and now I don't feel like I float. And she's had a couple of these really high hamstring tendinopathies. And we see this a lot in women. And again, more so than men, but I don't, it could be just a small N. But are there any other injuries that you're seeing that you think women need to be aware of? Yeah, I mean, this is probably because most of my colleagues at UNC are studying knee injury, but it does seem kind of ACL injury in midlife. You're seeing more in women? Yeah. And I think some of that, though, is just goes back to the caliber and the accumulation and competitive nature of women in this lifespan. They all played sports when they were young, right? Yeah. So I don't know if it's necessarily a male-female thing, but I do think an area of interest of mine is looking at muscle tendon stiffness and how that changes with not just age, but hormones. And then how do we change and prevent that? Because a lot of times this is not coming from a contact injury. It's coming from someone slipped because their dog pulled them. And so what's happening, I'm not sure, is it just because more women are more active and now we're hearing more about it? Interesting. Yeah, I'd be very curious to see. That would be really interesting to understand how much of that is occurring as a result of age, in which case you would expect it to be equal between men and women versus hormones specifically. I do think maybe some differences in inflammation and some of the neuromuscular aging that is seen with those hormonal changes, I would hypothesize that would have an impact, but not necessarily just to a knee joint, but some of those musculoskeletal injuries. You're saying that hormone loss is an impact? Yeah, hormone loss is increasing inflammation as the mechanism? No, not directly, but we tend to see more inflammation in perimenopause when estrogen changes. Measured how? It can be in the blood. But with CRP or what markers? Usually high sensitive CRP would be the kind of the key one. So you're seeing that higher in perimenopausal women and not on hormones? I can't answer that directly. So some of the work is showing that inflammation is changing. Whether it's coming from hormones or not, or if hormone therapy changes that, I'm not sure we know. Okay. I'm not aware of that, but I'd look into that. All right. Well, is there anything else you think we're missing in terms of trying to make sure we give women at all stages of their lives training input that they might otherwise be missing or dispelling any things that you think they're hearing? You've got to do this workout, or you shouldn't be doing this, as you said. Like, what are some of the things that you think are missing? What are some of those black and white things that you think are most misleading? Well, I have two thoughts. So right now, I know you've talked a lot about creatine on other podcasts. My lab is one of few doing it in women. And I think creatine is great, and there's a lot of benefit, but that doesn't mean it's magic. And I think it's important to realize that it can be helpful with training, but it's not the first thing I go to for midlife women. It's one of those things I think we'll continue to see more literature. So like being informed on that. And then the other thing I, one of my motivating factors is to having more conversation around these things of not just training, but physiologically and mentally around this midlife space. And so as a man who has a daughter and a clinician and a wife, I think there's a lot of conversation, or I'd be curious of how you would tell these women, or as I bring this back to the lab, of how do we have better conversation and be informed on what's hormone driven, and what can we overcome versus what do I need medical help for? And how do I advocate for myself? Especially as we pull in science, it's very difficult to do. And so many women are invalidated with their experiences. And how do we leverage men in the conversation? Yeah, well, I mean, I think my points of view on hormones are very well known. And I do maintain that it's, again, I've yet to find a better example of how the medical system has screwed up in the last 25 years. Then on this issue, both in the magnitude of what it is, and just the fact that it's 50% of the population have been hurt by this. So I've done this analysis literally in a model, and I can't come up with a greater negative impact. So luckily, I think the tide is turning. But unfortunately, A, there's a generation of women now that have sort of fallen outside of the window in which doctors who are even starting to come around on hormones feel comfortable prescribing hormones. Although Rachel Rubin was a guest on this podcast, and she made a very compelling argument for the fact that that's a little bit of a BS argument, and that really, if a woman is 60 and she's been in menopause for 10 years, that's not disqualifying. And there's no evidence that we can point to that we're driving rates of breast cancer by giving that woman hormones. And so if she's going to benefit from it, then she should be on it. As far as women that are going through this process now, I think, again, the good news is, I think there are enough doctors out there who, it's still a very small number in absolute terms, who are simultaneously. Willing to do this and competent to do it. The competence is a hard piece, because there are more tools than ever before. In the olden days, it was MPA and CEE, and that was it. And of course, today, we would never use either of those hormones. So you have to know more. But look, we also. That's why this podcast exists, right? I mean, anybody who wants to understand how to safely and intelligently provide hormones and think through the nuances. When do we want to start with this topical? When do we want to use this variation, that variation? I mean, we've got more content. We've got more content on that than I can point to. So it's out there. And I would just say, look, don't be satisfied with no. If a person says no, then it's time to find another person. And again, fortunately, it looks a lot better today than it did five years ago. Five years ago, it was pretty bleak. And I think in five years, it's going to be even less bleak than it is today. And what do you think about the exercise piece? So we were talking about GLP-1s with exercise. Often, when we're talking about hormones and hormone therapy, we're not talking about lifestyle behaviors. The combination of the two to help relieve symptoms. Do you ever see that coming in play or being an important component? Where I sit, it's not really a concern because we're always talking about all of these things all the time. So I'm probably not the right person to answer that question because I'm not seeing the other side of that. But I can appreciate the fact that any time you can take a drug, it's easier than making a change. And a lot of times, those changes end up being more powerful. The sort of quote-unquote lifestyle change ends up being a bigger issue. In both the cases that you've mentioned, a lot of times, the drug makes it easier to make the change. And in the case of hormone, I think there's just an independent benefit that also comes from it that's unmistakable. I mean, I think independent of whether you exercise or not, you're going to benefit from taking hormones. The point is, can you have an accretive benefit if you do both of these things? And I think the answer is almost assuredly yes. Again, we're not going to prove that. We're not going to study. But it's really hard to imagine a scenario where by combining both of those things doesn't lead to an even better outcome than doing one by itself. And do you see, is there any key research in this area that would inform your clinical practice? Or do you see a gap that would be beneficial? With respect to hormones and exercise? Yeah. Or midlife women, even thinking, obviously, hormones are often a part of the conversation, but not always. Well, there's the really interesting questions scientifically, that often don't matter that much in the real world. So for example, there are lots of questions I could imagine asking if we were talking about unconstraint or unlimited amounts of time. And that applies to some people. I do know some people who have eight to 10 hours a week to exercise. And I think in those situations, we could have a very different discussion about how to optimize training. I'm obviously pretty interested in how you would optimize it in a resource constraint. And that would be, are four by fours better than one by ones? I don't know the answer. I suspect that in the real world, the answer comes down to whichever you can do more diligently. And I think the application of this stuff is what matters the most. But I also think that, so this is the unfortunate reality of training, which is if you're not providing enough training stimulus, you're getting a suboptimal result. And so what I really want is for people to understand how post-training can help them. And I think that's a really important point. This tool is, if you can provide the right stimulus and the shorter your volume of training, the more important the intensity of that is. And therefore, if you're only going to lift twice a week for 30 minutes, you can't phone those in. Like you got to actually do the work. In fact, it's easier for me because I'm in the gym six hours a week. So it's like, I'm making up for it in volume. My volume is more than covering it. I'm going to one or two reps in reserve, but I have so much volume. But if you told me, Peter, you get two 30 minute shots, I mean, I'm probably going to go to failure on every set. And that's harder. That is neurologically way more taxing. If you told me I only have these two short cardio workouts per week, I can't, can't phone those in. You're showing up to push. Now, does that matter if you're starting out from a low base? No, because any training stimulus matters. But if it's you or I who have a training history that is, you know, this thick, then no, we actually have to show up and crush those workouts if we're going to get the benefit. But I also think it's maintenance as well. Like what you don't want to have to go in and crush it every four days as we age. So I think it's also understanding what's the outcome. We're still going to get, well, that's kind of why I like having the volume on my side is I don't really have to crush many workouts. I really only do one workout a week these days. That's really hard. I'm totally with you, but how would you tell me so I'm early forties, most days there are literally not enough hours in the day to get in training. So what would you say if my goal was maintenance? Well, I mean, again, I think you mentioned your kids. One is eight, one is 10 and you're a professional and you're probably working your tail off. And so, yeah, I think maintenance and you're in a very rare position, right? Most people at your age aren't in anywhere near the shape that you're probably in. So yeah, for you, maintenance would be great. And I don't want to minimize that. And I also don't want to minimize the importance of avoiding injuries and things like that. So there has to be enough training stimulus for you to maintain muscle mass and enough training stimulus for you to maintain peak cardiorespiratory fitness, but that still does require some intensity. And you can probably get that with the intervals you described. I wouldn't say that you need to be doing any more than that for sure. Yeah. No, I mean, I think it came off like, oh, we need to crush every workout. No, no, no, no, no. I didn't say that at all. And I don't think you can, I don't think a 40 year old can crush every workout, but it depends how we define crush. My point is if you've only got a couple of hours a week to exercise, I don't think most people who have never exercised understand how hard they do need to push. And the difference is you and I did workouts in our teens and twenties where we were left vomiting at the end of those workouts. Like that was actually the norm. So compared to that, we're not crushing anything today, but we're still working a lot harder than most people appreciate. And when someone is starting from nothing today, we're still working a lot harder than most people appreciate. I just want to make sure they understand if you're coming into this with very low volume, once you get over that early adaptation, it is going to have to be quite painful. Yeah. And it's teaching people what that good pain is. We do that a lot and understanding that it's not always about, sometimes it is maintenance of there's different phases of life where we change our goals and even more motivation to tell that you said that 39 year old, 40 year old to train now that can go a long way so that you don't have to do that again. My hope is that everybody finds their way to it. And if the most you can do is be at six out of 10, great. I'll take six out of 10 on this front all day long. But I guess I'm maybe speaking to a narrow subset of people who do exercise, who understand its importance, but maybe aren't making progress because they've kind of have hit a plateau on training stimulus. And I see this all the time, by the way, I talk to a lot of people and they think they're doing zone two, but they're not. They're doing zone two, but they're not. They're doing zone two, but they're doing zone one. And they're getting actually no training effect whatsoever. It's, they're basically doing recovery workouts every single day. People just have to understand the nuance around that. There's a line between those things and everyone needs to understand where it is. For sure. And what's the outcome? Is it health? Is it performance? What are our targets? Yeah. All right. Well, thank you again. This was enjoyable. And I really love this topic in general, but I especially think it's important for women to understand the complexity around this because I think there is a lot of conflicting information, probably some incorrect information. And then luckily I do think today, and maybe you see this more than I do, but I do think today women are realizing the importance of resistance training, perhaps in a way that they didn't 20 years ago. Now, when I talk to women and I ask them what they're doing for exercise, even the ones who don't resistance train will usually follow it up with something like, but I know I probably should be. And I don't know if I would have heard that 20 years ago. No, I think we're in a really cool space and And thanks for giving some science, some light in this. And I think we can really empower women and not just do cardio and do resistance training and find a time that they can make space for it. Thank you. Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional health care services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. 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