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Barbell Medicine Podcast
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Is Creatine Causing Your Shin Pain? + Splitting Training, Endometriosis for Lifters | Direct Line · May 2026
2d ago00:33:59Tap to summarizeThis is the free preview of the May 2026 Direct Line, our monthly AMA for Barbell Medicine Plus subscribers. Three reader questions answered in full.We open with a mid-30s woman with bilateral shin pain and exertional foot numbness who started creatine a month ago and is asking whether the supplement is the cause. We walk through the compartment syndrome literature, the 2025 case report being passed around online and misinterpreted, what creatine actually does to total body water (and what it doesn’t), the four compartment pressure studies that exist, the Waterman 2013 demographic data on who actually gets chronic exertional compartment syndrome, and the workup we would actually run if this person walked into clinic.Next, whether splitting your resistance training across the day affects strength and hypertrophy. We cover BBM’s general heuristic on frequency as a distribution tool for training load, the Schoenfeld meta-analyses on frequency (2016 and 2019), the wrinkle on cardiorespiratory fitness and exercise snacks, and where we go off the reservation compared to a strict evidence-based read.We close with endometriosis for the lifter, including the seven-year average diagnostic delay, the 2022 ESHRE guideline shift away from required laparoscopy, what the menstrual cycle and performance literature actually says (McNulty 2020), why the anti-inflammatory diet narrative is mostly noise, the iron and protein levers that matter, post-operative return-to-lifting timelines, the meet-timing question, and Austin’s clinical case walk on supplement stacks and GLP-1 anti-inflammatory effects. A dedicated full episode on endometriosis is coming this summer.The full unabridged Direct Line covers ten more questions, including where the GLP-1 strength trials actually are, why DEXA misleads on muscle mass loss, how we arrived at the Vital 5 weightings, the salt sermon for strongman, running shoes for casual runners, hernias and crunches in older lifters, the Bristol Stool Chart, Austin on coaching his residents, and a fresh reading list. Full episode on BBM Plus.Timestamps:Question 1 · Creatine and shin pain01:2713:21Question 2 · Splitting your workout across the day13:2120:29Question 3 · Endometriosis for the lifter20:29What we cover:The clinical workup for chronic exertional compartment syndrome and why creatine is rarely the culprit. The Schoenfeld frequency literature and why training load matters more than the day it’s distributed across. Endometriosis basics including diagnostic delay, prevalence, and the 2022 ESHRE guideline change. Why most endometriosis “diets” don’t have evidence behind them, and which nutrition levers actually matter (iron, protein, energy availability). Post-operative return to training, meet-timing options, supplement stacks, and the role of GLP-1 receptor agonists in chronic anti-inflammatory effects.Resources:Subscribe to BBM Plus for the full unabridged Direct Line: https://barbellmedicine.supercast.com/Barbell Medicine coaching and templates: https://www.barbellmedicine.com/Signal book pre-order: https://www.barbellmedicine.com/shop/learning/signal/Waterman B.R. et al. 2013. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 41(11):2545-2552.https://pubmed.ncbi.nlm.nih.gov/24036570/Powers M.E. et al. 2003. Creatine supplementation increases total body water without altering fluid distribution. J Athl Train 38(1):44-50.https://pubmed.ncbi.nlm.nih.gov/12937471/Antonio J. et al. 2021. Common questions and misconceptions about creatine supplementation (ISSN position). J Int Soc Sports Nutr 18(1):13.https://pubmed.ncbi.nlm.nih.gov/33557850/Bruneau A. et al. 2025. Creatine supplementation associated with chronic exertional compartment syndrome: case report. [TO ADD: PMID once indexed]Schoenfeld B.J. et al. 2016. Effects of resistance training frequency on measures of muscle hypertrophy: a systematic review and meta-analysis. Sports Med 46(11):1689-1697.https://pubmed.ncbi.nlm.nih.gov/27102172/Schoenfeld B.J. et al. 2019. How many times per week should a muscle be trained to maximize hypertrophy? J Sports Sci 37(11):1286-1295.https://pubmed.ncbi.nlm.nih.gov/30558493/ESHRE Endometriosis Guideline Development Group. 2022. ESHRE guideline: endometriosis. Hum Reprod Open 2022(2):hoac009.https://pubmed.ncbi.nlm.nih.gov/35350465/McNulty K.L. et al. 2020. The effects of menstrual cycle phase on exercise performance in eumenorrheic women: systematic review and meta-analysis. Sports Med 50(10):1813-1827.https://pubmed.ncbi.nlm.nih.gov/32661839/Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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What’s Actually Driving Your Testosterone Down? | Signal Ep 3
1w ago00:59:29Tap to summarizeMost cases of low testosterone in modern men are not a problem with the testes. The number is downstream of body composition, sleep, and energy availability. The wellness-clinic algorithm walks past every one of them.Jordan and Austin walk through what actually drives men’s testosterone down, the mechanisms behind it, and the modifiable levers that bring it back up. MOSH, the leptin and Kisspeptin pathway, the aromatase loop, the sleep apnea picture most clinics never ask about, the GLP-1 and weight-loss data on testosterone recovery, the low energy availability case that hits high-volume lifters harder than they realize, and the closing question of when a standard-dose TRT prescription actually functions as a PED.This is Episode 3 of our four-part Signal book launch series. Mark, the patient we have been threading from Episode 1, finally gets his diagnosis revealed.Timestamps00:00 The 9x stat and Mark's diagnosis revealed 02:10 How body fat suppresses testosterone (MOSH) 07:26 Primary vs secondary causes, and Klinefelter 11:35 Leptin and the Kisspeptin pathway 14:38 Mark: the body-composition picture 16:10 The 40-inch-waist case 20:01 Weight loss, GLP-1s, and does Ozempic raise testosterone? 24:21 T4DM: adding testosterone to lifestyle 28:35 Sleep, OSA, and Mark's diagnosis 38:39 TRT in untreated sleep apnea 41:47 Can you train your testosterone down? (LEA / EHMC) 50:12 Replacement dose vs PED 55:47 Four takeaways 57:46 Episode 4 preview and book pre-orderWhat we cover:• How body fat suppresses testosterone at two different points in the HPG axis, and why the loop is self-reinforcing• The leptin and Kisspeptin pathway most clinics never address• Mark’s case: a 45-year-old with a 240 ng/dL afternoon draw, no workup, and an immediate prescription• Primary versus secondary causes, and why Klinefelter syndrome is the under-recognized one to not miss• Weight loss dose-response: how much testosterone climbs on lifestyle alone, with GLP-1 agonists, and after bariatric surgery• T4DM: why adding testosterone to a structured weight-loss program produced no extra quality-of-life benefit over placebo• One week of sleep restriction drops testosterone by about 15 percent in healthy young men; eight days of military field exercises drop it by 50 percent• Why CPAP for obstructive sleep apnea reliably improves symptoms but does not always move the lab number• The opposite extreme: low energy availability, relative energy deficiency in sport, and the exercise-hypogonadal male condition• The lifter calculus: when a textbook replacement dose is functionally a PED in a chronically underfueled traineeResources mentioned:Signal book pre-order: https://barbellmedicine.com/signal Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/ Barbell Medicine programs and coaching: https://www.barbellmedicine.com/ Episode 1 (Is the Testosterone Crisis Real?) Episode 2 (Is Your Testosterone Actually Low?Referenced studies:Wu F.C.W. et al. 2010. Identification of late-onset hypogonadism in middle-aged and elderly men (EMAS). N Engl J Med 363(2):123-135. https://pubmed.ncbi.nlm.nih.gov/20554979/ Travison T.G. et al. 2011. The natural history of symptomatic androgen deficiency in men. J Am Geriatr Soc. https://pubmed.ncbi.nlm.nih.gov/18454751/ Corona G. et al. 2013. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: systematic review and meta-analysis. Eur J Endocrinol 168(6):829-843. https://pubmed.ncbi.nlm.nih.gov/23482592/ Kounatidis D. et al. 2025. The impact of GLP-1 receptor agonists on erectile function. Biomolecules 15(9):1284. https://doi.org/10.3390/biom15091284 Grossmann M. et al. 2024. Testosterone treatment, weight loss, and health-related quality of life and psychosocial function in men: 2-year RCT (T4DM QoL arm). J Clin Endocrinol Metab 109(8):2019-2028. https://pubmed.ncbi.nlm.nih.gov/38311835/ Leproult R., Van Cauter E. 2011. Effect of 1 week of sleep restriction on testosterone levels in young healthy men. JAMA 305(21):2173-2174. https://pubmed.ncbi.nlm.nih.gov/21632481/ Penev P.D. 2007. Association between sleep and morning testosterone levels in older men. Sleep 30(4):427-432. https://pubmed.ncbi.nlm.nih.gov/17520785/ Wittert G. 2014. The relationship between sleep disorders and testosterone in men. Asian J Androl 16(2):262-265. https://pubmed.ncbi.nlm.nih.gov/24435056/ Alemany J.A. et al. 2008. Effects of dietary protein content on IGF-I, testosterone, and body composition during 8 days of severe energy deficit and arduous physical activity. J Appl Physiol 105(1):58-64. https://pubmed.ncbi.nlm.nih.gov/18450989/ Mountjoy M., Sundgot-Borgen J.K., Burke L.M. et al. 2018. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 52:687-697. https://pubmed.ncbi.nlm.nih.gov/29773536/ Areta J.L. et al. 2021. Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males. Eur J Appl Physiol 121(1):1-21. https://pubmed.ncbi.nlm.nih.gov/33095376/ Mäestu J. et al. 2010. Anabolic and catabolic hormones and energy balance of the male bodybuilders during the preparation for the competition. J Strength Cond Res 24(4):1074-1081. https://pubmed.ncbi.nlm.nih.gov/20300023/ Hooper D.R. et al. 2018. Treating exercise-associated low testosterone (EHMC). Phys Sportsmed 46(4):427-434. https://pubmed.ncbi.nlm.nih.gov/30074435/ Hackney A.C. 2020. Hypogonadism in exercising males: dysfunction or adaptive-regulatory adjustment? Front Endocrinol 11:11. https://pubmed.ncbi.nlm.nih.gov/32082252/Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Progressive Loading Part 3: Why the Novice / Intermediate / Advanced Framework Doesn't Work, and What to Do Instead
2w ago01:51:28Tap to summarizeThree weeks of stalled squats. The conventional answer is to switch programs because you've crossed into intermediate territory. The data says something else. In Part 3 of the Progressive Loading series, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through why the standard novice / intermediate / advanced framework runs into trouble in real training, what the four adaptive systems are actually doing across a training career, and why most of what gets called a stall is impatience with the noise floor at your current strength level.This is Part 3 of the Progressive Loading series. Part 1 covered why loading should react to demonstrated adaptation. Part 2 covered RPE-based autoregulation and the artificial-momentum approach. Today is the mechanism layer.Pre-order our book, Signal: barbellmedicine.com/signalTimestamps0:00 - Why your lifts aren't moving1:52 - The novice / intermediate / advanced framework, three claims to test13:23 - What 17 years of powerlifting data show about how long you keep getting stronger32:28 - How getting stronger actually works (four systems on four clocks)38:00 - What early growth is actually made of (the Damas 2016 deuterium study)50:33 - The connective tissue lag and why early-training injuries happen58:32 - Why heavy lifting works for bone density (and why "walk on a treadmill" advice misses)1:05:10 - Why new lifters get hurt 3 to 10 times more than experienced lifters1:12:56 - Fatigue is at least four different things (and most coaches treat it as one)1:26:19 - The CNS fatigue myth (and what the data actually says)1:33:52 - When the bar isn't moving: how to actually diagnose a stall1:45:51 - Takeaways and next week's tease: leptin and low testosteroneWhat we cover - The novice / intermediate / advanced framework: three claims and why each one fails the data test- The 17-year IPF strength curve and what the no-kink finding does and does not establish (Latella 2024)- The four adaptive systems and their separate timescales (neural, muscle, connective tissue, bone)- What early growth actually is, including the deuterium-oxide finding that most week-3 size is fluid (Damas 2016)- Why connective tissue lags muscle by six to eight weeks, and why that produces patellar tendinopathy four months in- The 9.5 vs 0.74 to 3.3 injury rate gap between novice and experienced CrossFit participants- The CNS fatigue myth and the Skarabot 2018 finding that locates the fatigue in the muscle, not the brain- Why the LIFTMOR trial result (heavy lifting for bone density in women in their 60s and 70s) is being missed by primary care- A practical decision tree for stalls: environment first, then load, then program- Tease for next week: leptin, the HPG axis, and the metabolic driver of low testosterone almost nobody connectsResources Training Plateau Action Plan (free): https://www.barbellmedicine.com/training-plateau-action-plan/Progressive Loading article series: https://www.barbellmedicine.com/blog/progressive-loading/Beyond Progressive Overload (Part 2 article): https://www.barbellmedicine.com/blog/beyond-progressive-overload/BBM Programs and Coaching: https://www.barbellmedicine.com/Support our work on barbellmedicine.supercast.comLatella C et al. Using powerlifting athletes to determine strength adaptations across ages in males and females. Sports Med. 2024. https://pubmed.ncbi.nlm.nih.gov/Del Vecchio A et al. The increase in muscle force after 4 weeks of strength training is mediated by adaptations in motor unit recruitment and rate coding. J Physiol. 2019. https://pubmed.ncbi.nlm.nih.gov/30644584/Lecce E et al. Resistance training-induced adaptations in the neuromuscular system. J Physiol. 2025.Balshaw TG et al. Neural adaptations after 4 years vs 12 weeks of resistance training. Scand J Med Sci Sports. 2019. https://pubmed.ncbi.nlm.nih.gov/30474171/Skarabot J et al. Voluntary activation and agonist EMG amplitude in resistance-trained men. J Appl Physiol. 2021.Roberts MD et al. Mechanisms of mechanical overload-induced skeletal muscle hypertrophy. Physiol Rev. 2023.Damas F et al. Resistance training-induced changes in integrated myofibrillar protein synthesis are related to hypertrophy only after attenuation of muscle damage. J Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/27219125/Damas F et al. Early resistance training-induced increases in muscle cross-sectional area are concomitant with edema-induced muscle swelling. Eur J Appl Physiol. 2016. https://pubmed.ncbi.nlm.nih.gov/26280652/Lazarczuk SL et al. Mechanical, material and morphological adaptations of healthy lower limb tendons. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/35657492/Kubo K et al. Time course of changes in the human Achilles tendon properties. Eur J Appl Physiol. 2012. https://pubmed.ncbi.nlm.nih.gov/22105708/Watson SL et al. High-intensity resistance and impact training improves bone mineral density in postmenopausal women: the LIFTMOR randomized controlled trial. J Bone Miner Res. 2018. https://pubmed.ncbi.nlm.nih.gov/28975661/Aasa U et al. Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med. 2017. https://pubmed.ncbi.nlm.nih.gov/27445362/Prieto-Gonzalez P et al. Injuries in novice participants during an eight-week start-up CrossFit program. Int J Environ Res Public Health. 2020. https://pubmed.ncbi.nlm.nih.gov/32155747/Kanayama G et al. Tendon rupture in body builders. Sports Med. 2015.Enoka RM, Duchateau J. Translating fatigue to human performance. Med Sci Sports Exerc. 2016. https://pubmed.ncbi.nlm.nih.gov/27015386/Behrens M et al. Fatigue and human performance: an updated framework. Sports Med. 2023. https://pubmed.ncbi.nlm.nih.gov/Halperin I et al. Accuracy in predicting repetitions to task failure: scoping review. Sports Med. 2022. https://pubmed.ncbi.nlm.nih.gov/Skarabot J et al. Neuromuscular fatigue and recovery after heavy resistance, jump, and sprint training. Eur J Appl Physiol. 2018.Garcia-Ramos A et al. Greater neuromuscular and perceptual fatigue after low-load to failure than heavy-load to failure. 2024.Minor, Brian MS, CSCS1; Helms, Eric PhD, CSCS2; Schepis, Jacob3. RE: Mesocycle Progression in Hypertrophy: Volume Versus Intensity. Strength and Conditioning Journal 42(5):p 121-124, October 2020. | DOI: 10.1519/SSC.0000000000000581Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Is Your Testosterone Actually Low? Why Higher Testosterone Doesn't Do What You Think | Signal Ep 2
3w ago01:01:45Tap to summarizeOut of 32 symptoms commonly attributed to low testosterone, only 3 actually correlate with it. All three are sexual. The other 29 — fatigue, brain fog, low mood, weight you can't lose, feeling not quite like yourself — are real, but they are produced by something else, and the wellness-clinic funnel runs on getting that wrong. Episode 2 of our Signal book launch series. Dr. Jordan Feigenbaum and Dr. Austin Baraki cover how testosterone actually works, what the number on your lab report is really measuring, and what a real evaluation of low T looks like.Pre-order our book, Signal: barbellmedicine.com/signalTimestamps:00:00 Mark, revisited (cold open)02:00 How testosterone actually works (HPG axis)06:14 Why "in range" can still be abnormal09:24 What your lab number actually measures12:25 Case: total 230, low SHBG — does this guy need TRT?17:04 The saturation model — why higher isn't better21:11 A patient at 480 wants 900: how the conversation goes28:57 What "in range" actually means (and why 264 is the cutoff)34:41 The 3 symptoms that matter (out of 32)37:16 Walking back a 10-symptom checklist42:31 How a real testosterone workup gets done46:42 Chasland trial — TRT vs. exercise at low-normal T49:31 A warning for hard-training men58:48 Takeaways, tease, and what's coming next What we cover:The HPG axis explained — and why one low total testosterone reading tells you almost nothing about where the problem actually sits.The difference between total, free, and bioavailable testosterone — and why SHBG, the binding protein the wellness-clinic workup almost always ignores, is what determines whether the number on your lab report is misleading you in either direction.The saturation model: above roughly 250 ng/dL, the prostate androgen receptor is saturated. Libido follows the same plateau. Pushing a normal man from 500 to 900 isn't doing what the marketing implies.The EMAS study finding: of 32 symptoms men commonly attribute to low testosterone, only 3 actually correlate. Every other symptom needs a different workup.How a real testosterone workup gets done — morning sample, fasted, repeat draw, LH/FSH/SHBG to localize and contextualize.The Chasland 2021 trial: when standard TRT is prescribed properly to middle-aged men with low-normal levels, does it beat exercise? The answer is what most of the wellness-clinic industry is built on getting wrong.A note for hard-training men: the exercise-hypogonadal-male pattern, what "low-normal" means in someone whose levels are an adaptation to training load rather than a baseline deficit, and why a textbook TRT dose in that man may functionally act as a performance enhancer.If you have a lab report on your kitchen counter right now, this is what we wrote for you. Signal, the book, drops in May. Pre-order available soon at barbellmedicine.com.Resources & linksSignal — Feigenbaum & Baraki (Barbell Medicine, 2026): coming soonEpisode 1 (Is the Testosterone Crisis Real?): https://stream.redcircle.com/episodes/b25a8006-57e5-4dc3-b74c-203f6fbcebc1/stream.mp3Training Plateau Action Plan (free): barbellmedicine.com/training-plateau-action-planBarbell Medicine programs and consultations: barbellmedicine.comTo support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.comReferenced studiesWu FCW et al. 2010 - Identification of late-onset hypogonadism in middle-aged and elderly men. NEJM 363(2):123-135. [The EMAS 3-of-32 finding]https://pubmed.ncbi.nlm.nih.gov/20554979/Bhasin S et al. 2018 - Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. JCEM 103(5):1715-1744. [264 ng/dL threshold; first-draw protocol]https://pubmed.ncbi.nlm.nih.gov/29562364/Travison TG et al. 2008 - The natural history of symptomatic androgen deficiency in men. JAGS 56(5):831-839. [MMAS: ~50% of initially low values normalize on repeat]https://pubmed.ncbi.nlm.nih.gov/18308002/Travison TG et al. 2006 - The relationship between libido and testosterone levels in aging men. JCEM 91(7):2509-2513. [Libido plateau data, Framingham + HIM]https://pubmed.ncbi.nlm.nih.gov/16670164/Brambilla DJ et al. 2009 - The effect of diurnal variation on clinical measurement of serum testosterone. JCEM 94(3):907-913. [Why morning, fasted matters]https://pubmed.ncbi.nlm.nih.gov/19112025/Morgentaler A & Traish AM. 2009 - Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. Eur Urol 55(2):310-320. [The saturation model]https://pubmed.ncbi.nlm.nih.gov/18838208/Trost LW & Mulhall JP. 2016 - Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med 13(7):1029-1046. [Free T unreliability at the low end; equilibrium dialysis as the reference method]https://pubmed.ncbi.nlm.nih.gov/27210182/Vermeulen A et al. 1999 - A critical evaluation of simple methods for the estimation of free testosterone in serum. JCEM 84(10):3666-3672. [Calculated free T methodology]https://pubmed.ncbi.nlm.nih.gov/10523012/Chasland LC et al. 2021 - Testosterone and exercise: effects on fitness, body composition, and strength in middle-to-older aged men with low-normal serum testosterone levels. Am J Physiol Heart Circ Physiol 320(5):H1985-H1998. [The 12-week trial]https://pubmed.ncbi.nlm.nih.gov/33739153/Arun AS et al. 2025 - Reevaluating the Threshold for Low Total Testosterone. Clin Chem 71(5):609-611. [2025 NHANES strength-dissociation reference]https://pubmed.ncbi.nlm.nih.gov/40066943/Baillargeon J et al. 2015 - Trends in Androgen Prescribing in the United States, 2001-2011. JAMA Intern Med 175(8):1413-1415. [25% no preceding lab; the 50% no follow-up monitoring gap - referenced from Episode 1]https://pubmed.ncbi.nlm.nih.gov/26075486/Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Direct Line April 2026: Stopping Ozempic and Lifting With Osteopenia
Apr 2100:38:39Tap to summarizeStop a GLP-1 and about two thirds of the weight loss comes back within a year. Three randomized withdrawal trials (SURMOUNT-4, STEP 1 extension, STEP 4) and a new BMJ 2026 systematic review of 37 RCTs and nearly 10,000 adults all land on the same signal. The cardiometabolic benefits, blood pressure, fasting glucose, lipids, drift back in parallel with the weight. The framing that actually fits the data: GLP-1s behave like a statin. There is a cumulative benefit during exposure, but this does not extend indefinitely,This month's Direct Line covers two subscriber questions. The first asks what the new BMJ paper on GLP-1 cardiovascular protection after cessation actually shows, and how GLP-1 durability compares to lifestyle-only interventions. The second asks how a postmenopausal woman newly diagnosed with osteopenia should structure her lifting.Studies referenced: SURMOUNT-4 (Jastreboff, JAMA 2024), STEP 1 extension (Wilding, Diabetes Obes Metab 2022), STEP 4 (Rubino, JAMA 2021), West et al. BMJ 2026 systematic review, Budini 2026 eClinicalMedicine regain meta-analysis, SELECT cardiovascular outcomes, FLOW renal outcomes, the Diabetes Prevention Program, Look AHEAD, POUNDS Lost, and LIFTMOR (Watson, JBMR 2018).Full episode on BBM+ covers 8 additional subscriber questions. Join at https://barbellmedicine.supercast.com/Timestamps0:00 Intro1:52 Q1: What happens when you stop a GLP-15:33 Lifestyle-only comparators: DPP, Look AHEAD, POUNDS Lost8:15 Austin on the cessation conversation 12:41 BMJ 2026: weight and cardiometabolic regression17:59 The statin framing23:41 Austin: first 6 months off GLP-128:07 Q2: Osteopenia and heavy lifting35:28 LIFTMOR protocol38:00 OutroNext StepsFor evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comResourcesAronne, Louis J., et al. "Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial." JAMA, vol. 331, no. 1, 2024, pp. 38–48. https://jamanetwork.com/journals/jama/fullarticle/2812936Wilding, John P. H., et al. "Weight Regain and Cardiometabolic Effects After Withdrawal of Semaglutide: The STEP 1 Trial Extension." Diabetes, Obesity and Metabolism, vol. 24, no. 8, Aug. 2022, pp. 1553–1564. https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725Rubino, Domenica, et al. "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial." JAMA, vol. 325, no. 14, 2021, pp. 1414–1425. https://jamanetwork.com/journals/jama/fullarticle/2777886West, Sam, et al. "Weight Regain After Cessation of Medication for Weight Management: Systematic Review and Meta-Analysis." BMJ, vol. 392, 7 Jan. 2026, article e085304. https://www.bmj.com/content/392/bmj-2025-085304Budini, Brajan, et al. "Trajectory of Weight Regain After Cessation of GLP-1 Receptor Agonists: A Systematic Review and Nonlinear Meta-Regression." eClinicalMedicine, vol. 93, 4 Mar. 2026, article 103796. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(26)00043-X/fulltextLincoff, A. Michael, et al. "Semaglutide and Cardiovascular Outcomes in Obesity Without Diabetes." New England Journal of Medicine, vol. 389, no. 24, 11 Nov. 2023, pp. 2221–2232. https://www.nejm.org/doi/full/10.1056/NEJMoa2307563Perkovic, Vlado, et al. "Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes." New England Journal of Medicine, vol. 391, no. 2, 24 May 2024, pp. 109–121. https://www.nejm.org/doi/full/10.1056/NEJMoa2403347Knowler, William C., et al. "Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin." New England Journal of Medicine, vol. 346, no. 6, 7 Feb. 2002, pp. 393–403. https://www.nejm.org/doi/full/10.1056/NEJMoa012512Look AHEAD Research Group. "Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes." New England Journal of Medicine, vol. 369, no. 2, 11 July 2013, pp. 145–154. https://www.nejm.org/doi/full/10.1056/NEJMoa1212914Sacks, Frank M., et al. "Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates." New England Journal of Medicine, vol. 360, no. 9, 26 Feb. 2009, pp. 859–873. https://www.nejm.org/doi/full/10.1056/NEJMoa0804748Watson, Shelley L., et al. "High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial." Journal of Bone and Mineral Research, vol. 33, no. 2, 2018, pp. 211–220. https://onlinelibrary.wiley.com/doi/10.1002/jbmr.3284Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Is the Testosterone Crisis Real? The Numbers Behind the Headlines | Signal Ep 1
Apr 1400:40:36Tap to summarizeEvery week there's a new headline saying men are losing testosterone. A quarter of men now start testosterone replacement therapy without ever getting their blood tested. The supplement aisle is full of boosters that either do nothing or contain undisclosed steroids. And the lab test that gets everybody to the pharmacy? Half of low results normalize on their own.In Episode 1 of the Signal launch series, Dr. Jordan Feigenbaum and Dr. Austin Baraki (both MDs and strength coaches) walk through the three-layer problem with how testosterone gets diagnosed and treated in 2026, then take apart the "testosterone is crashing" headline with the most current data available, including a 2025 meta-analysis of more than one million men.Pre-order our book, Signal: barbellmedicine.com/signalTimestamps0:00 Mark's story: treating the number, not the patient1:18 Welcome to the Barbell Medicine Podcast1:41 Problem 1: A quarter of men start TRT with no lab work3:36 Problem 2: Why testosterone boosters do not work (and what is in them)13:40 Problem 3: Why one low testosterone lab is not a diagnosis19:19 Setup: Is the testosterone crisis headline real?20:04 The MMAS data and the 1%-per-year number20:52 The 2025 meta-analysis of over 1 million men22:02 Why the headline is inflated: three causes22:27 Cause 1: The testing method changed (immunoassay to mass spec)25:58 Cause 2: BMI cannot see visceral fat29:37 The Nyante study: when you fix both problems, the decline vanishes33:58 What this actually means for you37:05 The broken testosterone system, summarized38:24 Five takeaways from this episode39:14 Next week: How testosterone actually works39:39 About Signal and creditsWhat you'll learn in this episode: Why 25% of new TRT prescriptions are written without any pre-treatment lab work (JAMA, 2015)What actually happens when researchers test 50+ "testosterone booster" supplements (spoiler: 12% are contaminated with undisclosed steroids)Why a single low testosterone reading is not a diagnosis, and the Massachusetts Male Aging Study data that proves itThe real size of the population-level testosterone decline (much smaller than 1% per year)Why BMI cannot see the visceral fat that is driving most of the genuine declineThe Nyante study that shows the decline essentially vanishes when you use an accurate test and measure waist circumferenceFive practical takeaways you can apply before your next lab drawThis is Episode 1 of a four-part series built around our upcoming book, Signal. Over the next four weeks we cover what testosterone actually is, how to tell when it is genuinely low, what is really driving population-level changes, and what the evidence says you can do about it.Next StepsCheck out our new book, Signal (coming soon)For evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comTo support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.comResourcesBaillargeon, J., et al. (2015). Trends in Androgen Prescribing in the United States, 2001–2011. JAMA Intern Med, 175(8), 1413–1415. — 25% no preceding lab; post-prescription monitoring gap.Rao, P.K., et al. (2017). Trends in Testosterone Replacement Therapy Use from 2003 to 2013 among Reproductive-Age Men in the United States. J Urol, 197(4), 1121–1126. — Prescription volume growth.Selinger, S., & Thallapureddy, A. (2024). Cross-sectional analysis of national testosterone prescribing through prescription drug monitoring programs, 2018–2022. PLoS One, 19(8), e0309160. — Recent prescribing data, 3-4 million estimate.Vesper, H.W., et al. (2015). Serum Total Testosterone Concentrations in the US Household Population from the NHANES 2011–2012 Study Population. Clin Chem, 61(12), 1495–1504. — Population testosterone levels, NHANES data.Clemesha, C.G., et al. (2020). "Testosterone Boosting" Supplements Composition and Claims Are Not Supported by the Academic Literature. World J Men's Health, 38(1), 115–122. — 62% no published data, 10% decreased T.Tucker, J., et al. (2018). Unapproved Pharmaceutical Ingredients Included in Dietary Supplements Associated With US FDA Warnings. JAMA Network Open, 1(6), e183337. — 12% adulterated with undisclosed steroids.Trost, L.W., & Mulhall, J.P. (2016). Challenges in Testosterone Measurement, Data Interpretation, and Methodological Appraisal of Interventional Trials. J Sex Med, 13(7), 1029–1046. — Half of low results normalize on repeat.Travison, T.G., et al. (2008). The Natural History of Symptomatic Androgen Deficiency in Men: Onset, Progression, and Spontaneous Remission. JCEM. MMAS data — 50%+ spontaneous normalization.Travison, T.G., et al. (2007). A Population-Level Decline in Serum Testosterone Levels in American Men. JCEM, 92(1), 196–202. — Original MMAS secular decline, 15–20% lower across cohorts.Santi, D., et al. (2025). Meta-analysis of secular trend in total testosterone levels, 1971–2024. 1,256 studies, N > 1,000,000. — 0.56%/year adjusted; LH parallel decline; mass spec subgroup no significant decline. Methods note on the ~0.56% per year figure cited in this episode: the Santi paper does not report a single percentage rate. The headline adjusted meta-regression coefficient (−0.6 nmol/L/year) is inflated by the random-effects weighting scheme and is not a biological rate. The 0.5–0.6% per year approximation comes from the pre-2000 stratified subgroup (Fig. 5, coefficient −0.1 nmol/L/year) divided by the dataset mean of 18.5 nmol/L. The post-2000 stratum runs larger (~1.1%), and the age-stratified coefficients in Table 5 cluster in the 0.4–0.9% range. The mass spectrometry subgroup (Table 3, Group 4) showed no significant trend (p = 0.845). The episode uses the conservative end of this range as the most defensible estimate of the real population-level rate after accounting for assay drift.Nyante, S.J., Graubard, B.I., Li, Y., McQuillan, G.M., Platz, E.A., Rohrmann, S., Bradwin, G., & McGlynn, K.A. (2012). Trends in sex hormone concentrations in US males: 1988–1991 to 1999–2004. Int J Androl, 35(3), 456–466. doi: 10.1111/j.1365-2605.2011.01230.x. — Archived NHANES samples, same platform, waist circumference added; no significant decline in total or free testosterone.Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Medical Mystery: The Man Who Got Weaker When He Started Training
Apr 701:15:46Tap to summarizeA 43-year-old man starts exercising and ends up in the ER with a CK over 100x the upper limit of normal. His doctor says it’s from training. We don’t think so. In this episode, Dr. Jordan Feigenbaum and Dr. Austin Baraki walk through the full case — history, labs, diagnosis, and what actually went wrong — then break down the mechanisms behind the answer, the nocebo research, and what the brand-new 2026 guidelines mean for the 40 million Americans on a drug class you’ve definitely heard of.We also cover the STOMP trial (do statins actually impair strength gains?), the SAMSON trial (how much of statin intolerance is nocebo?), the difference between myalgia, myositis, and rhabdomyolysis, Austin’s clinical approach to a patient whose strength is declining on a statin, and the treatment escalation pathway for statin-intolerant patients including bempedoic acid, PCSK9 inhibitors, and inclisiran. Plus, where GLP-1 receptor agonists like tirzepatide fit into the cardiovascular risk picture.Timestamps0:00 — A 43-year-old man is getting weaker, not stronger2:09 — Taking the history: Medications, lifestyle, and red flags12:53 — The labs come back: CK at 18,97916:05 — Metabolic syndrome and the modern treatment approach23:15 — Rhabdomyolysis: What it is and why it’s dangerous29:50 — Final diagnosis and what went wrong with the medications37:15 — 2026 ACC lipid guidelines: What changed40:32 — Three mechanisms: How statins affect muscle47:02 — The nocebo effect and the SAMSON trial54:17 — Do statins impair training? The STOMP trial1:00:30 — Who’s at highest risk for statin muscle problems1:07:36 — What happened to the patient and options if this is you1:14:12 — Five takeawaysFive Takeaway Statin myopathy is real but relatively uncommon. The excess symptom rate above placebo is roughly 1–5% in controlled trials. But in exercising patients, especially on combination therapy, the risk can be higher.There are three proposed mechanisms: reduced energy production from CoQ10 depletion, compromised muscle cell membranes from isoprenoid loss, and accelerated protein breakdown from calcium leak via the ryanodine receptor. Exercise amplifies all three, but the vast majority of people compensate.If you’re on a statin and your strength is going down, talk to your doctor before stopping the medication or changing your training. A CK test can help separate a drug problem from a programming problemThe 2026 ACC guidelines list vigorous exercise as a risk factor for statin-associated muscle symptoms for the first time. They also provide statin-intolerant patients a clear escalation pathway: bempedoic acid, ezetimibe, PCSK9 inhibitors, and more.Lower is better for LDL. There’s a 33% relative reduction in cardiovascular events at <55 vs. 70 mg/dL. Lower for longer. Healthy lifestyle changes plus effective lipid-lowering therapy are among the best things you can do for cardiovascular risk.Next StepsFor evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comTo support us and get ad free listening, plus special product discounts, and exclusive content, go to supercast.barbellmedicine.com ResourcesTraining Plateau Action Plan (free):https://www.barbellmedicine.com/training-plateau-action-plan/Fish oil episode:https://open.spotify.com/episode/4kRtXZBMZWKkZPDdIKpu1SLp(a): https://www.barbellmedicine.com/blog/lipoprotein-a-testing-and-treatment/GuidelinesBlumenthal RS, Morris PB, et al. 2026 ACC/AHA Guideline on the Management of Dyslipidemia. Circulation. 2026. DOI: 10.1161/CIR.0000000000001423CaseLászló A, et al. Exercise and Statin-Fibrate Combination Therapy-Caused Myopathy. BMC Research Notes. 2013;6:52. https://pubmed.ncbi.nlm.nih.gov/23388500/ LDL TargetsLee YJ, et al. (Ez-PAVE) Intensive LDL Cholesterol Targeting in Atherosclerotic Cardiovascular Disease. NEJM. 2026. PMID: 41910315Mechanisms of Statin MyopathyMeador BM, Huey KA. Statin-Associated Myopathy and Its Exacerbation with Exercise. Muscle Nerve. 2010;42(4):469–479. https://pubmed.ncbi.nlm.nih.gov/20878737/Safitri N, et al. Statin-Induced Rhabdomyolysis: Mechanisms, Risk Factors, Management. Drug Healthc Patient Saf. 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8593596/Molinarolo S, et al. Cryo-electron microscopy reveals sequential binding and activation of Ryanodine Receptors by statin triplets. Nat Commun. 2025;16(1):11508. doi:10.1038/s41467-025-66522-0Thompson PD, et al. Lovastatin Increases Exercise-Induced Skeletal Muscle Injury. Metabolism. 1997;46(10):1206–1210Nocebo Effect and Statin IntoleranceWood FA, et al. N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects (SAMSON). NEJM. 2020;383(22):2182–2184. https://pmc.ncbi.nlm.nih.gov/articles/PMC8453640/Khan S, et al. Does Googling Lead to Statin Intolerance? Int J Cardiol. 2018;262:25–27. https://pubmed.ncbi.nlm.nih.gov/29706390/Gupta A, et al. Adverse Events Associated with Unblinded, but Not with Blinded, Statin Therapy in the ASCOT-LLA. Lancet. 2017;389(10088):2473–2481. https://pubmed.ncbi.nlm.nih.gov/28476288/Moon JC, et al. Examining the Nocebo Effect of Statins through the FDA AERS. Circ Cardiovasc Qual Outcomes. 2021;14(1):e007480. https://pubmed.ncbi.nlm.nih.gov/33161769Statins and Exercise OutcomesParker BA, et al. Effect of Statins on Skeletal Muscle Function (STOMP). Circulation. 2013;127(1):96–103. https://pubmed.ncbi.nlm.nih.gov/23183941/Parker BA, Thompson PD. Effect of Statins on Skeletal Muscle: Exercise, Myopathy, and Muscle Outcomes. Exerc Sport Sci Rev. 2012;40(4):188–194. https://pmc.ncbi.nlm.nih.gov/articles/PMC3463373/Mikus CR, et al. Simvastatin Impairs Exercise Training Adaptations. JACC. 2013;62(8):709–714. https://pubmed.ncbi.nlm.nih.gov/23583255/Slade JM, et al. The Impact of Statin Therapy and Aerobic Exercise Training. Am Heart J Plus. 2021;10:100028. https://pmc.ncbi.nlm.nih.gov/articles/PMC8477381/Gui Y, et al. Efficacy and Safety of Statins and Exercise Combination Therapy. Eur J Prev Cardiol. 2017;24(9):907–916. DOI: 10.1177/2047487317691874 Genetic SusceptibilitySEARCH Collaborative Group. SLCO1B1 Variants and Statin-Induced Myopathy — A Genomewide Study. NEJM. 2008;359(8):789–799Autoimmune MyopathyBarkhordarian M, et al. Statin-Induced Autoimmune Myopathy. Am J Case Rep. 2024;25:e944261. https://pubmed.ncbi.nlm.nih.gov/39219126/Statin-Fibrate InteractionsJones PH, Davidson MH. Reporting Rate of Rhabdomyolysis with Fenofibrate + Statin vs Gemfibrozil + Any Statin. Am J Cardiol. 2005;95(1):120–122Bruckert E, et al. Mild to Moderate Muscular Symptoms with High-Dosage Statin Therapy (PRIMO Study). Cardiovasc Drugs Ther. 2005;19(6):403–414Sinzinger H, O’Grady J. Professional Athletes Suffering from Familial Hypercholesterolaemia Rarely Tolerate Statin Treatment. Br J Clin Pharmacol. 2004;57(4):525–528Tirzepatide and GLP-1 AgonistsAl-kuraishy HM, et al. The mechanistic role of tirzepatide in atherosclerosis. Int J Biol Macromol. 2025;329(1). https://doi.org/10.1016/j.ijbiomac.2025.147734Effects of Tirzepatide on Lipid Profile: A Systematic Review and Meta-Analysis. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11704219/Hamidi H, et al. Effect of tirzepatide on coronary atherosclerosis progression (T-Plaque trial design). Am Heart J. 2024;278:24–32. doi:10.1016/j.ahj.2024.08.015Fish Oil and Omega-3 Fatty AcidsBhatt DL, et al. Cardiovascular Risk Reduction with Icosapent Ethyl (REDUCE-IT). NEJM. 2019;380:11–22. https://pubmed.ncbi.nlm.nih.gov/30415628/Abdelhamid AS, et al. Omega-3 Fatty Acids for Prevention of Cardiovascular Disease. Cochrane Database Syst Rev. 2020. https://pubmed.ncbi.nlm.nih.gov/32114706/Manson JE, et al. Marine n-3 Fatty Acids and Prevention of CVD and Cancer (VITAL). NEJM. 2019;380:23–32. https://pubmed.ncbi.nlm.nih.gov/30415637/ Myopathy ClassificationSelva-O’Callaghan A, et al. Statin-Induced Myalgia and Myositis: Pathogenesis and Clinical Recommendations. Expert Rev Clin Immunol. 2018;14(3):215–224. https://pmc.ncbi.nlm.nih.gov/articles/PMC6019601/Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.c...
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Overtraining Syndrome: Causes, Diagnosis, and What's Actually Going On
Mar 3101:36:05Tap to summarizeIn 2022, researchers conducted the most rigorous systematic review ever performed on overtraining syndrome — looking specifically for controlled studies that documented a human transitioning from a healthy training state to an overtrained state. Zero studies met those criteria. The word "overtrained" appears in coaching certifications, wearable device dashboards, and clinical sports medicine guidelines — and in each context it means something different. That definitional chaos has consequences: it delays real diagnoses, produces nocebo effects with measurable physiological outcomes, and leads athletes to reduce training they didn't need to reduce.In this episode, Drs. Jordan Feigenbaum and Austin Baraki work through the full evidence base on overtraining syndrome — the taxonomy, the attempted studies, the six competing mechanistic theories, the biomarker failures, and what's actually happening when a lifter can't make progress. Timestamps:0:00 Cold open — the zero-studies finding1:21 Why "overtrained" does four different jobs simultaneously16:10 The FOR / NFOR / OTS taxonomy19:43 The supercompensation model — borrowed from endurance, never validated for resistance training32:28 Austin's clinical differential for fatigue and declining performance36:17 RT evidence — what happens when researchers try to induce OTS through lifting43:19 Austin — what actually drives the complaints he sees in practice47:30 Six theories for what causes overtraining syndrome1:01:09 The biomarker problem — why the T:C ratio and cortisol don't work1:05:09 What your wearable is actually measuring (and what it isn't)1:09:28 Austin — testosterone levels in trained athletes and when to act1:13:40 Heart rate variability — limitations for strength training1:15:36 Session RPE — the monitoring tool that actually works1:17:31 How common is overtraining syndrome, really?1:23:04 Three failure modes — what's actually happening when lifters say they feel overtrained1:32:14 Austin — what a proper medical workup looks like1:34:22 OutroWhat we cover:The definition problem — why a single word is doing four incompatible jobs simultaneously, and why that matters clinically and practically.The taxonomy — functional overreaching, nonfunctional overreaching, and overtraining syndrome as points on a continuous variable that can only be identified after the fact, not at presentation.The supercompensation model — where it came from, why it fails to describe how resistance training adaptation actually works, and how applying it too literally produces both overloading and underloading errors at the same time.Austin's clinical differential — what a physician actually works through when a patient presents with fatigue and declining performance, and where overtraining syndrome actually sits on that list.What resistance training research shows — including 140 maximal singles, 90 working sets per week, and daily 1-rep max attempts. No study has cleanly induced overtraining syndrome through resistance training. The hormonal data went in the opposite direction from what the endurance overtraining model predicts.Six mechanistic theories — glycogen depletion, serotonin/BCAA, autonomic imbalance, central governor, HPA axis dysregulation, and Armstrong's complex systems framework. Each one is partially supported and each falls short.The biomarker problem — resting cortisol is normal in 75%+ of OTS cases, the testosterone to cortisol ratio has never been validated against clinical outcomes as an individual diagnostic, and HRV recovery in strength training lags physical recovery by up to 30 hours.Austin on wearables — including a clinical pattern he's seeing with GLP-1 receptor agonists: wearable scores indicating deterioration when the clinical picture is actually fine.Session RPE as the real tool — why session RPE trending upward at stable training load is a more reliable signal of load-recovery mismatch than any biomarker currently used.Prevalence and confounders — the 60% figure, why it almost certainly captures all three FOR/NFOR/OTS categories plus REDS, depression, and illness, and why the residual true training-load-induced OTS in an otherwise healthy athlete may be vanishingly rare.Three failure modes — the three things Jordan actually sees in practice when lifters present saying they feel overtrained, and how to distinguish between them using session RPE.The medical workup — Austin's practical walkthrough of what to assess when programming and lifestyle changes don't move the needle, including iron deficiency (ferritin testing caveats, lab reference range problems), sleep apnea, post-viral syndromes, and hormone panels done correctly.Next Steps:For evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comFor ad free listening and exclusive discounts, become a Barbell Medicine Plus subscriber at https://barbellmedicine.supercast.com/ Resources Taxonomy / DefinitionsMeeusen et al. (2013)European College of Sport Science / ACSM consensus statement on FOR, NFOR, and OTS taxonomy. Defines OTS as a diagnosis of exclusion.https://pubmed.ncbi.nlm.nih.gov/23247672/Meeusen et al. (2006)"Often only after a period of complete rest" — the retrospective nature of distinguishing NFOR from OTS.https://pubmed.ncbi.nlm.nih.gov/23016079/Nocebo Effects in Sport2024 Systematic ReviewNocebo effects in sport were approximately twice the magnitude of placebo effects on performance across 20 studies.https://pubmed.ncbi.nlm.nih.gov/38999724/Stress-Recovery-Adaptation ModelOriginal general adaptation syndrome / stress physiology work in Nature. Foundational source the SRA model was derived from — not a sports science paper.https://www.nature.com/articles/138032a0Multi-system adaptation timescales; critique of single-wave supercompensation model.https://pubmed.ncbi.nlm.nih.gov/3057313/Multi-system adaptation timescales; further critique of the SRA "window of opportunity" model.https://pubmed.ncbi.nlm.nih.gov/15044685/Lack of empirical support for the supercompensation "window of opportunity" in real training scenarios.https://pubmed.ncbi.nlm.nih.gov/29189930/Resistance Training and OTSGrandou et al. (2020)Systematic review: 22 studies on resistance training overtraining. 10 showed zero performance decline under deliberate overload. No reliable biomarker established for RT overtraining; sustained performance drop is the only consistent signal.https://pubmed.ncbi.nlm.nih.gov/31313309/Coleman et al. (2024)9-week supervised high-volume RT protocol (~90 sets/week). No OTS criteria met. Ceiling for resistance training-induced OTS is considerably higher than commonly implied.https://pmc.ncbi.nlm.nih.gov/articles/PMC10809978/Zourdos et al. (2016)Case series: 3 competitive strength athletes performed daily 1RM squat for 30 consecutive days. All three improved.https://pubmed.ncbi.nlm.nih.gov/26816276/Daily 1RM Bench Press Study7 athletes attempted a true 1RM bench press every day for 38 days. All improved despite day-to-day fluctuation.https://www.thefreelibrary.com/Efficacy+of+Daily+One-Repetition+Maximum+Bench+Press+Training+in...-a08283175013 weeks of daily loading; volume arm hypertrophied. Daily frequency did not produce overtraining; volume drives hypertrophy, not frequency alone.https://pubmed.ncbi.nlm.nih.gov/27875635/Fry et al. (1994) — Overreaching ProtocolOriginal resistance overreaching induction: 10×1 at 100% 1RM daily for 14 days. 1RM dropped ~12 kg. Hormonal response was opposite to endurance OTS profile (cortisol decreased, testosterone slightly increased).<a href="h...
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Episode #391: VO2 Max vs. Cardiorespiratory Fitness, GLP-1 Costs, and the 10,000-Step Myth | Direct Line March 2026 (Free)
Mar 2400:30:34Tap to summarizeIn this free preview of the March 2026 Direct Line AMA. Drs. Feigenbaum and Baraki cover: VO2 max versus cardiorespiratory fitness for longevity (are Peter Attia’s targets evidence-based? — with Goodhart’s Law and the JAMA evidence), what GLP-1 medications actually cost now via manufacturer programs ($149–449/month), and whether 7,000–10,000 daily steps actually meet the bar for cardiovascular training. Full episode for Barbell Medicine Plus subscribers at https://barbellmedicine.supercast.com/Timestamps:0:00 — Introduction3:26 — VO2 Max vs. Cardiorespiratory Fitness for Longevity14:11 — GLP-1 Costs: What you should actually be paying now21:43 — Is Walking Enough for Cardiovascular Health?Next Steps:For evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comResources: JAMA Network Open — Cardiorespiratory Fitness & Long-term Mortality (Mandsager et al.) — Exercise capacity (METs) and longevity — the foundational CRF/mortality study cited in the episode https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2707428JAMA — Blair et al. — Physical fitness and all-cause mortality: a prospective study of healthy men and women https://jamanetwork.com/journals/jama/fullarticle/379243Barbell Medicine Vital Five — Multi-modal CRF benchmarks and longevity targets https://www.barbellmedicine.com/vital-5-action-plan/Lilly Direct — Zepbound (tirzepatide) — Manufacturer direct program ($299–449/month) https://www.lillydirect.com/zepboundNovoCare — Wegovy (semaglutide) — Manufacturer savings program ($149–349/month) https://www.novocare.com/patient/medicines/wegovy.htmlOrforglipron — Eli Lilly oral GLP-1 — What to know about orforglipron (small-molecule oral GLP-1 agonist, pending FDA approval) https://www.lilly.com/news/stories/what-to-know-about-orforglipronOur Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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Episode #390: Why Your Waist Matters More Than Your Weight — The Science of Visceral Fat
Mar 1700:44:34Tap to summarizeYou can have a completely normal BMI and be on your way to cardiovascular disease, type 2 diabetes, and metabolic syndrome without triggering a single alert on a standard health screening. The fat that predicts metabolic risk most accurately isn't the fat your scale or your doctor is tracking. Dr. Jordan Feigenbaum breaks down the science of visceral fat — what it is, how it causes disease, how to measure it correctly at home for free, and what the evidence actually shows about exercise, GLP-1 medications, and testosterone.Timestamps:00:00:00 Cold Open: The Visceral Fat Finding00:00:49 The Scale Problem — What Body Weight Actually Measures00:03:50 What Is Visceral Fat — and Why It's Not Just "Belly Fat"00:05:04 Three Competing Theories: How Visceral Fat Actually Causes Disease00:08:35 Adipokines: PAI-1, Angiotensinogen, and What Happens When Adiponectin Drops00:09:52 How to Measure: Three Sites That Don't Give the Same Number00:14:30 Clinical Thresholds, Ethnic Adjustments, and the Waist-to-Height Ratio00:15:45 The Weight-to-Waist Ratio: Tracking the Quality of Your Fat Loss00:19:20 Sleep, Cortisol, and Why the Hormonal Environment Has to Support the Work00:21:24 Why Exercise Reduces Visceral Fat 6× More Than Diet Alone00:22:02 Mechanism 1 — Beta-3 Adrenergic Receptors and Preferential Visceral Fat Mobilization00:24:10 Mechanism 2 — Myokines: The Fat-Burning Signal Only Contracting Muscle Can Send00:26:21 GLP-1 Agonists and Body Composition: What the Clinical Trials Actually Show00:28:05 DXA's Blind Spot: Myosteatosis, Glycogen, and Why Lean Mass Numbers Are Inflated00:30:10 SEMALEAN, the BELIEVE Trial, and the 1-in-10 Reality of Long-Term Lifestyle Programs00:33:15 Testosterone, Visceral Fat, and the Aromatase Feed-Forward Loop00:36:05 Three Testosterone Ranges: Deficient, Eugonadal, and Supraphysiological00:38:05 The Bhasin 4-Group Study — and Why AAS Are a Class, Not a Synonym for TRT00:39:33 Tesamorelin: The GHRH Analogue That Selectively Targets Visceral Fat00:40:53 Practical Framework: What to Measure, When, and What to Do00:43:20 Key TakeawaysNext StepsFor evidence-based resistance training programs: barbellmedicine.com/training-programsFor individualized training consultation: barbellmedicine.com/coachingExplore our full library of articles on health and performance: barbellmedicine.com/resourcesTo join Barbell Medicine Plus and get ad-free listening, product discounts, exclusive content, and more: https://barbellmedicine.supercast.com/To consult with Drs. Baraki or Feigenbaum email us at support@barbellmedicine.comBarbell Medicine Vital 5 Action Plan: https://www.barbellmedicine.com/vital-5-action-plan/Resources:https://pubmed.ncbi.nlm.nih.gov/11502820/https://pubmed.ncbi.nlm.nih.gov/33567185/https://pubmed.ncbi.nlm.nih.gov/35658024/https://pubmed.ncbi.nlm.nih.gov/40318682/https://pubmed.ncbi.nlm.nih.gov/41068996/https://pubmed.ncbi.nlm.nih.gov/41772149/https://pubmed.ncbi.nlm.nih.gov/23944298/https://pubmed.ncbi.nlm.nih.gov/20948519/https://pubmed.ncbi.nlm.nih.gov/27213481/https://pubmed.ncbi.nlm.nih.gov/23303913/Our Sponsors:* Check out FIGS and use my code wearfigs.com for a great deal: https://wearfigs.com* Check out Factor and use my code factormeals.com/bbm50off for a great deal: https://www.factor75.com* Check out Quince and use my code quince.com/bbm for a great deal: https://www.quince.comAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
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