← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Can Peptides Heal Your Joints, Gut, and Brain? Doctors Explain the Evidence
02:01:05
In this episode, Rena Malik, MD and Dr. Jordan Feigenbaum unravel the hype behind peptides, discuss age-related muscle loss, and share evidence-based advice on supplements and exercise. Listeners will gain practical tips for navigating fitness trends and making informed choices for their health.
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- [00:00]
Dr. Jordan Feigenbaum
Peptides have had this glow up recently. It's kind of like anabolic steroids that studied abroad.
- [00:05]
Dr. Rena Malik
They're not a supplement, they're not regulated. People are still getting them and using them pretty easily. So how do we end up in this space?
- [00:12]
Dr. Jordan Feigenbaum
I think a good way to conceptualize this is that they're mostly zombie substances. Pharma adjacent company discovered them, sold it to pharma, and then they've been investigated and ultimately abandoned. And if you go down the list of most of the peptide agents that are being promoted by influencers or sold by research chemical companies, the majority of them are abandoned pharma projects.
- [00:35]
Dr. Rena Malik
Injecting a medication that seems to improve your life seems like an easy way to reduce pain. Sure, if it was, I wish it was. But I always thought if it sounds too good to be true, the other shoe's gotta drop.
- [00:49]
Dr. Jordan Feigenbaum
Yeah, I mean, you think about something supposed to heal your joints, heal your gut, be good for your brain. Like what? You know, all this panacea of like effects. And I'm like, I don't really know that that happens in medicine too often.
- [01:03]
Dr. Rena Malik
We all look for that magical solution, don't we? That easy fix for pain, for weight loss, or to improve our fitness. And right now it seems like peptides are being marketed as that very thing, with influencers all over talking about their peptide stacks and how it's changing their life. But what happens when you're sold a bill of goods without truly understanding the risks? I hi, I'm Dr. Rena Malik, urologist and pelvic surgeon. And you're listening to The Rena Malik, M.D. podcast, your trusted guide for leveling up your health, sex life and relationships with evidence based tools. Today I'm joined by Dr. Jordan Feigenbaum, a physician, elite powerlifter and founder of Barbell Medicine, a company that integrates evidence based strength training with medical practice and longevity. Together, we're talking about the science of peptides. From FDA approved drugs like Ozempic to the unregulated substances flooding the market, including the popular BPC 157. We also discussed sarcopenia breaking down, exactly why age related strength loss starts a lot earlier than you realize and how to prevent it. And if perfect form really matters, and the good and the bad about the new dietary guidelines. But before we get into the podcast, if you've been struggling with erections or simply just want yours to be a little harder, check out my brand new erectile mastery course. It is entirely science based with actionable steps you can start doing today. To help improve your erections before it gets too late. Check it out at the link in the description. Well, I want to talk today about peptides because I think there is a huge boom in peptides in the society at large. Everyone is talking about taking them, injecting themselves with these substances. So let's start with what are they and how do they work differently than like steroids or traditional, you know, anabolic things?
- [02:58]
Dr. Jordan Feigenbaum
Yeah, yeah, that's a great question. And I think peptides have had this sort of glow up recently. It's kind of like anabolic steroids that studied abroad. They're, you know, they're phrased in such a way or marketed in such a way where people think that they aren't medications, they aren't drugs, they're not controlled substances, when in fact they are. I mean, peptide. There have been peptide medications that have been FDA approved for a long, long time and even more recently become more popular with semaglutide, tirzepatide, you know, these anti obesity medications. So peptides are definitively not steroids. Those are just chemical structures. Peptides, as you know, are short chains of amino acids, building blocks of proteins. And then steroids are 4 ring cholesterol based chemical structures. And that's all the chemistry you're going to get in this podcast.
- [03:43]
Dr. Rena Malik
It's plenty.
- [03:44]
Dr. Jordan Feigenbaum
Plenty. Yeah. So chemically they're different. And then within peptides, you know, you think about non steroid sort of medications or drugs, there's a sort of arbitrary distinction as far as amino acid length and like what officially counts as a peptide. 2020, there was this bright line rule. It's mostly a regulatory sort of rule that if the drug is 40amino acids long or less, it's a peptide, and if it's 41 or longer, it's a protein or a biologic. So like technically insulin is I think 51amino acids, so technically it's a protein drug, whereas semaglutide is less than 40. So we call it a peptide. There are other sort of drugs that are even smaller than that. They're called small molecule drugs. So aspirin, statins, MK677 is classified or called a peptide or marketed as a peptide, although it's really just a small molecule drug. So it's mostly an arbitrary distinction of how long the amino acid chain is when you're talking about those type of medications. But definitively not a steroid chemically and then the effects. This is probably going to be the bulk of the podcast. They're marketed, advertised, billed as Being very specific. Whereas a steroid drug like testosterone, for example, it, you know, it affects androgen receptors everywhere on your muscles, on your prostate, you know, hair follicles, your brain. Yeah, everywhere. Right. Wherever there there's a receptor, it's going to bind and do something. And in fact, that was one of the driving forces behind developing another class of drugs called SARMs, so selective androgen receptor modulators. It was like, well, can we target specific androgen receptors in a particular area, most notably muscle, and skip everything else? Those drugs so far haven't really panned out. But peptide drugs are marketed in a similar way. It's like this is going to be very specific. And some drugs we have good evidence to show that they are in fact specific. And other peptide drugs, we have effectively no evidence. And so a lot of these, you know, that sort of marketing, this is going to do just this one thing. It's theoretical, it'd be nice, if true. But that's the big thing. If true.
- [05:51]
Dr. Rena Malik
So in terms of for a layperson, a small molecule drug versus a peptide versus a biologic, are they really that different?
- [05:59]
Dr. Jordan Feigenbaum
Yeah, in fact, their size and the complexity does make a difference as far as how you can take them and further, maybe the cost of actually the pharmaceutical company making them. So small molecule drugs, relatively simple, very stable, you can take them orally, aspirin, statins, stuff like that. Whereas very long chains of peptides we call protein or biologics, they're very complex, very challenging to make, usually require some proprietary type of technology and you usually have to administer them with an injection. Aircraft carriers, huge things. And then in the middle of those two things are peptides. Generally, you know, they're more complex than small molecule drugs, but not quite as complex as the biologics or the protein drugs, but still generally require injection for administration. So BPC157 have to inject it right now and you know, semaglutide usually have to inject it. Ozempic, Wegovy, although that did just come out with oral Wegovy, which highlights an important point. The oral Wegovy, previously known as Rybelsis, has a very proprietary, very expensive, very elegant solution to this oral availability issue. They have this, it's called an enhancer. And so I don't know how many millions of dollars they spent to figure out this enhancer to make semaglutide available orally. But it's not what's in your BPC157 that you're, you know, getting off Amazon. It says it's oral BPC157. Because not only what is the issue?
- [07:26]
Dr. Rena Malik
Why can't you take a peptide orally? Like what is the specific. I know we're getting nerdy, but like, yeah, fair, sorry. What is the specific mechanism?
- [07:33]
Dr. Jordan Feigenbaum
Yeah, so because they're made of amino acids, if it doesn't have this, we'll just call it an enhancer, pharmaceutical enhancer to protect it from the harsh environment of the stomach. The stomach's just going to cut it up into base amino acids that your body's going to recognize and say, yeah, it's not a drug anymore. These are just amino acids. Like you ate some protein for example. There are differences in various agents and kind of what happens if you take them orally. But you usually can't take something that you have to inject and then just squirt it in your mouth and get the stuff. Same effect. Usually doesn't work like that.
- [08:04]
Dr. Rena Malik
Right. And then in terms of peptides, discovery of peptides, specifically the small molecules, a little bit simpler. But how are people, and maybe you don't know the answer to this, but how are people identifying specific peptides? Because I feel like even though they're specific, they're not. I mean like if you think about semaglutide or tirzepatide, they do have effects on multiple different areas. Right. So they're not that specific.
- [08:27]
Dr. Jordan Feigenbaum
Right, yeah. It is interesting that there's this again, marketing push, this narrative. I call them like Instagram anecdotes or tales of TikTok where people say, oh, it just did this one thing. I'm like, well, how do you know? Yeah, if a drug affects a particular receptor, it's likely going to affect those receptors systemically, especially if you administer it systemically. So we don't really know. Yeah. Semaglutide and these anti PCD medications in the GLP1 class do seem to have these additional benefits by affecting those same receptors.
- [08:56]
Dr. Rena Malik
So you get in the brain and in the.
- [08:57]
Dr. Jordan Feigenbaum
Yeah, yeah. Reduction in heart disease, kidney disease, some liver disease stuff, maybe some Alzheimer's type stuff that's coming out, maybe anti cancer in some specific instances. And so to think that these other, this, these other medications that we're talking about, peptide medications, will have no additional effects. Interesting. You know, big if true. But to date, you know, that doesn't seem to be the case with any of the agents that we either have been FDA approved or are still waiting some further study. So yeah, for people listening to this, you know you're being sold this bill of goods that this peptide medication is very specific. It's a sniper rifle. We hope that's true, but unclear as of now.
- [09:42]
Dr. Rena Malik
So yeah, this is the issue right now. There's obviously a handful of peptide drugs. Two you've mentioned, also brimulanotide, which we talk about in sexual health a lot that are FDA approved. However, there's some, so many that are in this like gray zone. They're not a supplement, they're not regulated and they're still, people are still getting them and using them pretty easily. So how do we end up in this space?
- [10:03]
Dr. Jordan Feigenbaum
That's another interesting, interesting thing. You know, I think one way to conceptualize this is most of the peptide drugs. And again, I'm going to keep saying that not in a bad way, but that's just what they are. Because I think when people say peptides they say, oh, it's just a supplement, which is definitively not, not the case.
- [10:20]
Dr. Rena Malik
It's a medication, pharmacologic agent, if we
- [10:23]
Dr. Jordan Feigenbaum
want to call it a controlled substance like that has some DEA implications. I don't love that. But whatever, drug, medication, something like that. I think a good way to conceptualize this is that they're mostly zombie substances, meaning that pharma at some point identified them or a pharma adjacent company discovered them, sold it to pharma and then they've been investigated and ultimately abandoned. And if you go down the list of most of the peptide agents that are being promoted by influencers or sold by research chemical companies, the majority of them are abandoned pharma projects. AOD964 anti obesity drug 964 that was studied 30 years ago, didn't cause any weight loss compared to placebo, but is being billed as this anti obesity drug.
- [11:08]
Dr. Rena Malik
Fascinating.
- [11:10]
Dr. Jordan Feigenbaum
And you can just look at when they're selling something or saying, hey, this particular agent, well, where did it come from? BPC 157. There's like this, I don't know, a positive spin being put on the origin story. Well, it's not from big pharma, it's from this other. It was from a research lab. I'm like, well that research lab was owned by a pharmaceutical company which changed hands a few times, right. And then the, the final, the current owner actually tried to start a phase one clinical trial, two of them, and both of them were canceled a year in. And so the majority of these agents started in pharma or pharma adjacent and then have kind of petered out in the traditional research and development process.
- [11:48]
Dr. Rena Malik
One reason or the other. They were not effective.
- [11:50]
Dr. Jordan Feigenbaum
Not effective.
- [11:51]
Dr. Rena Malik
Safety issues, side effects.
- [11:53]
Dr. Jordan Feigenbaum
Yeah, yeah. Whereas on the Internet, again, if you stay in the comments section, it's mostly like, well, no, because they couldn't patent them because it's natural. I'm like, okay, well so GLP1's naturally occurring. Right. But you have to figure out a way to not only make it in a larger quantity, administer it in a particular dose. Right. And attach it to something like Rybelsus that prevents it from being eaten up by the stomach. So it's orally available. There are many ways to patent things that occur naturally. So I think if people came at it from this standpoint, all of these peptide agents come from pharma. Pharma has a vested interest. Right. And again, if you want to get super.
- [12:30]
Dr. Rena Malik
If it really worked that well, they would be making money off of it.
- [12:33]
Dr. Jordan Feigenbaum
Yeah, General. Generally speaking, I'm not, I'm not here to support big pharma or say that they're without, you know, fault any, anywhere at any time in human history. But I just think if that's the angle you come at this from, that these things come from pharma. They have a vested interest in seeing them through, so there's a payoff at the end. Then you do have to start to wonder like, why have these things been kind of stuck in limbo and you know, why are they currently being resurrected by influencers and other folks versus pharma themselves who have this vested interest? Maybe as conspiratorial as I'll get, but sure, it is kind of interesting to me.
- [13:09]
Dr. Rena Malik
Well, you know, I find it interesting. One is, is I didn't know that. So this is all new to me. I thought that these were peptides that were investigational still and people were just starting to use them even though they were still in investigation.
- [13:21]
Dr. Jordan Feigenbaum
Yeah. Which, you know, certainly some of the newer ones, 5Amino 1 MQ, like there's just a. They keep coming out. And certainly some of them do that do show promise, actually go through the correct, you know, channels and become FDA approved. But in any case, when they are discovered and then subsequently further investigated for what do they do in rodent models? What do they do in humans? What are they doing? Petri dishes. That's mostly pharma. So like again, it's not like, it's like a Robin Hood situation where there's, you know, some do gooder in a lab that's well outfitted, that, you know, is independently funded is like, oh, I found this thing, I'm going to tell everybody and Keep pharma out of this, like, generally is not what's happening. Again, not that I'm defending big Pharma here. I just think if people understand that these are medications, they generally come from pharma, then you do have to wonder, like, why have most of them been abandoned?
- [14:11]
Dr. Rena Malik
Well, because they put millions of dollars into these phase one trials. Right. So if they were able to continue, they would continue.
- [14:18]
Dr. Jordan Feigenbaum
Yeah. If there was a strong signal of either efficacy or better than something else that's coming down the pike or whatever. Yeah. And I think, obviously, again, big pharma is made multiple errors over the course of human history. So. So, sure, there could be other stuff going on, but I think if you think that pharma is doing something to block the development of. That they came up with, seems. Seems less likely to me.
- [14:41]
Dr. Rena Malik
Yeah, No, I guess my thought was, oh, pharma will eventually come out with it, and there's just people who are on the fringe who are starting to push it.
- [14:48]
Dr. Jordan Feigenbaum
If I had to. If I had to. So Konjichem is this pharma adjacent company. They are the people who discovered CJC 1295. Right. And their general business model, you know, I'm not on their board or anything, but from what they've done historically is they identify either a new agent or a new way to deliver an existing agent, and. And they effectively patent that and license it to a pharmaceutical company. They came up with CJC 1295 and they were trying to show, hey, does this thing increase growth hormone? Does it increase IGF1? Can it be used to treat lipodystrophy for HIV patients, for example? And a person in one of their first clinical trials actually died of a heart attack, and they stopped the trial. And subsequently that drug has been in zombie mode ever since. And so you got to wonder, it's like, well, that company has a vested interest in making this go further. It wasn't that they're on the fringe. This was back in 2005, 2006. So, yeah, it seems to me more likely that at various stages of development, there's been an issue. Right. And it certainly could just be a lack of funding. And maybe there did some promise there, but I suspect that pharma would pick that up.
- [15:57]
Dr. Rena Malik
Someone, another pharma company would be.
- [15:59]
Dr. Jordan Feigenbaum
Correct.
- [15:59]
Dr. Rena Malik
Yes, because they do. I've seen Brimontide move from company to company since it's been gone through the fda. And so certainly that does happen. Right. Like someone runs out of money or they, you know, and then someone else buys it do you think?
- [16:12]
Dr. Jordan Feigenbaum
Yeah, so. So PT141 bremelanotide. What is it? Violisi is. Yeah. So female hypoactive sexual desire disorder. Right.
- [16:20]
Dr. Rena Malik
For. For people listening. It is for female. It is FDA approved for female hypoactive sexual desire disorder. That does not mean it doesn't work for men. But it studied in women. It was also studied originally for tanning.
- [16:31]
Dr. Jordan Feigenbaum
Yeah. Yeah.
- [16:32]
Dr. Rena Malik
And that was abandoned and then it was found to increase sexual desire.
- [16:36]
Dr. Jordan Feigenbaum
Yeah, it's like a better version of Melanotan too, which was like, it'll get you real tan, but you might get rhabdomyolysis and you know, something like that. Yeah, but it's been studied in men who don't respond to PDE5 inhibitors. Cialis Viagra.
- [16:48]
Dr. Rena Malik
Well, those don't work for desire, but yeah, correct. It does help for. For rigidity a little bit.
- [16:52]
Dr. Jordan Feigenbaum
Yeah. So it's interesting and you're like, well, is this going to be rebranded as like a, you know, another drug for. For men and yeah, be curious. But again, pharma's picking up the cause on that. Right.
- [17:02]
Dr. Rena Malik
So I actually saw they're doing a study on. There are some compounding pharmacists already sort of doing this, but they're doing some studies on PT141 and the GLP1 inhibitors together.
- [17:14]
Dr. Jordan Feigenbaum
Oh yeah.
- [17:15]
Dr. Rena Malik
At a lower dose to see if that, you know, reduces side effects and also has other potential benefits.
- [17:21]
Dr. Jordan Feigenbaum
That'd be interesting.
- [17:22]
Dr. Rena Malik
I don't know. I don't know where they are in the study. I keep looking and I haven't seen any updates, so.
- [17:26]
Dr. Jordan Feigenbaum
But either way, pharma is behind that. Yeah, it's kind of what we keep getting at. And again, nobody's celebrating big pharma on this. It's just like the idea that these drugs have just failed to progress or whatever because pharma doesn't have any interest. So there's a reason that they generally don't have any interest. Either it's again, a potential side effect issue, complication issue, or it just wasn't really working as well. That's generally where I come at this from.
- [17:52]
Dr. Rena Malik
So how are people able to get them now in this unregulated space? What is going on? Right.
- [17:58]
Dr. Jordan Feigenbaum
Yeah, that's a good question. I think for people, if they're not medical professionals, they're like, look, there's a bunch of, you know, acronyms for different organizations and it's hard to make heads or tails what they all do. So the way I like to think about is that the FDA kind of controls what is approved, what, what, what medications are approved, what their approved indications are, although people can use them off label. So that's like the big umbrella organization below that is going to be the dea, which is like, well look, these are approved medications, but, but there's maybe some risk of abuse or there needs to be increased level of monitoring due to risks. And so we're going to restrict a certain subset of those medications in various schedules, schedules one through five. Schedule one being things that maybe need more control, although testosterone is on that list, which doesn't make sense to me. Whereas a Schedule 5 would need less sort of monitoring restriction. Okay, so the FDA has not approved the majority of the peptides that I think will, will discuss. Some of them have been approved and continue to get approved. The DEA doesn't care because they're like, we don't know enough about these things to restrict them. And also if they're not FDA approved, we can't really institute a schedule on them. So that's kind of what's happened. The FDA basically has said, yeah, if there's not good evidence of safety and efficacy and like, what does it do? We can't really approve you. So most of the peptide medications currently are not approved. People can buy these things through research chemical sites which effectively sell you this thing, say not for human use there. You know, Chad down at Gold's Gym could buy BPC157, TB500, whatever, and say, oh yeah, I'm running an experiment, you know, then I need this for my rats. Where both parties know Chad knows and the seller knows, yeah, this guy's gonna use it himself. It's not illegal. Chad may not know what's in that exact vial. And so that creates a whole new can of worms. As far as risks go. There are underground sort of forums and people trying to do better, maybe like risk reduction, they're like, look, we're sending batches of these different research chemical manufacturers out to labs to get tested to make sure that there's no impurities, that what they say is on the vial is actually in there in the correct dose. So I see that as like a risk reduction type strategy. But there was an interesting study that came out recently that was looking at SARMs. So again, selective androgen receptor modulators bought from research chemical websites. Nearly half of them didn't have what they said was in the bottle. In the bottle, 10% had nothing, no active ingredient in there. And a number of them had, were contaminated with lead or other heavy metals.
- [20:34]
Dr. Rena Malik
Wow.
- [20:35]
Dr. Jordan Feigenbaum
And and we see the same thing in the supplement industry. When supplements fall into either muscle building, sexual health or weight loss, those tend to be the most contaminated line of supplements or groups of supplements that exist compared to like anti aging or like, you know, immune system or whatever. So just various categories of supplements. So they're not only either contaminated or they can also just be mislabeled.
- [20:56]
Dr. Rena Malik
Why do you think that is?
- [20:58]
Dr. Jordan Feigenbaum
I think, well, in the supplement world, my skepticism, slash, you know, maybe a little conspiracy theory is that will look the your particular supplement wouldn't really work that well on its own, but if we put an anabolic steroid in there, this thing's going to work and we're going to sell it more. Something like that. As far as why we see this in research chemicals, like in the SARM study, I'm thinking about there's just not the same level of control when it comes from taking the raw material and the manufacturing process to the end product. And that's why these things are available at a cheaper price point. They don't have to go through all of the heavily regulated steps that a pharmaceutical manufacturer has to do to take the raw material that was, you know, inspected, tested or whatever in various batches and then it goes to the manufacturer and they do. Each step of the way there's quality control and then at the end it's tested again to make sure that what goes out is what people need. And even then there have been documented cases of like, we kind of still miss this. And that's with multiple steps, checkpoints around the world.
- [22:00]
Dr. Rena Malik
So these research chemistry companies, they're not ones that are used, I mean, are these used by like proper labs too?
- [22:07]
Dr. Jordan Feigenbaum
Oh, yeah. So that's a great question. I'm not, you know, I don't run clinical trials or animal trials. I have asked people involved in that space and they have trusted suppliers for these things, generally folks they've worked with for a long time. And now whether those initial contracts were set up based on quality or based on handshake deal, I can't speak to that.
- [22:26]
Dr. Rena Malik
Right.
- [22:26]
Dr. Jordan Feigenbaum
It just, I just know that those aren't the same companies selling research chemicals to the public.
- [22:31]
Dr. Rena Malik
Correct.
- [22:32]
Dr. Jordan Feigenbaum
So.
- [22:32]
Dr. Rena Malik
So the ones that sell to like an academic lab, you can't access them online.
- [22:37]
Dr. Jordan Feigenbaum
Say you got a BBC 157. Yeah.
- [22:40]
Dr. Rena Malik
I mean you probably have to prove that you're a research lab and you're.
- [22:43]
Dr. Jordan Feigenbaum
Yeah. Do you have a loading dock? You know that, that, you know. Do you? Yeah. What's your business address? All sorts of stuff. Yeah. It Is interesting. And you know, one question that keeps coming up in my world is so like Ozempic, Wegovy, Zeppelin, Manjaro. These are very, you know, relatively expensive medications. Right. You can get them a little cheaper though, through a compounding pharmacy, which maybe should or shouldn't keep making them, depending on how you side with the FDA's kind of thoughts on this. But you can get them way cheaper from research chemical. Right. And we know that they're, look, they're FDA approved. We know the dosing, we know the side effect profile, what to monitor for, and we know they're very effective for most folks. So would it be better for somebody who maybe can't afford the regular, you know, brand name drug, can't access compounding pharmacies for whatever reason, Would it be better for them compared to not doing anything to take a research chemical version? I don't think so.
- [23:36]
Dr. Rena Malik
The same risks apply.
- [23:37]
Dr. Jordan Feigenbaum
Yeah. Risk of contamination, mislabeling. Immunogenicity is another one, particularly with untested agents. By untested, I mean things that aren't really FDA approved. Immunogenicity being this idea that because these are synthetic versions of naturally occurring things in your body, there's a potential risk of your immune system recognizing that and saying, hey man, what are you doing here? And because the synthetic version looks so much like what your body makes itself, you could potentially develop some sort of autoimmune response to that. Also, it could just recognize the synthetic version and start blocking it, making it less effective. All because of things that are happening outside of normal drug manufacturing processes and the traditional R and D pathways, the
- [24:20]
Dr. Rena Malik
normal drug manufacturing processes reduce that risk of immunogenicity, basically.
- [24:25]
Dr. Jordan Feigenbaum
Seems like, it seems like, yeah, we're
- [24:27]
Dr. Rena Malik
not seeing that in the trials with GLP1s.
- [24:30]
Dr. Jordan Feigenbaum
No. Yeah, not at all. And so it's unclear to me, again, not being a drug manufacturing expert, like, is there something specific within the pharmaceutical manufacturing process that's not followed in the research chemical world? I suspect that's true, but I can't, you know, I don't know. Oh yeah, they use this one specific machine that is, you know, millions of dollars and a research chemical company doesn't have it. I don't know.
- [24:52]
Dr. Rena Malik
I think that's important though, because we do use compounds in medicine. Right. I send patients to compound pharmacies for things like testosterone or estrogen because they can't afford it or whatever, whatever reason. And that is generally safe because those compounds are manufactured differently. Right. Those don't have that risk. Whereas peptides being created In a compounding pharmacy, they don't have the same regulation and that's why we worry about them.
- [25:15]
Dr. Jordan Feigenbaum
Yeah, the compounding pharmacy thing was interesting mainly because there was this recent sort of kerfuffle with like Eli Lilly and Pfizer with the anti obesity medications. Mainly because these compounding pharmacies were making, I'm gonna call it TEMU versions of their own drugs and I don't know, B12. Yeah, yeah, weird stuff. And again, so there was some concern about immunogenicity there and also just people getting like a substandard version of the actual medication. So that's like, I'm gonna set that to the side. Otherwise, compounding pharmacies seem to be like pretty, pretty good, especially for agents that you otherwise couldn't find at a regular pharmacy. You have to send people there all the time for stuff that, you know, your regular pharmacy doesn't carry and would
- [25:57]
Dr. Rena Malik
otherwise have to make mixes or combination.
- [25:59]
Dr. Jordan Feigenbaum
100%. Yeah. Very common pediatric medicine as well. So what's happened though is the FDA has cracked down recently on compounding pharmacies that are certified through them to make medications, particularly custom mixes or dosing things or whatever, and said, look, you can't make BPC157 anymore, you can't make TB500 anymore, you can't make a handful of other things. There's actually some active court cases going on right now. Like A's this okay or not? Some people think it's Big Brother stepping in a little bit too heavy handed. And other people say, no, we needed this because of these risks. I'm not a legal expert. I don't know. I just think that if we don't have good safety data, if we don't have good efficacy data on a particular medication, in this case, I think it's reasonable for the FDA to have some, you know, policy about that and maybe restrict access until those things, those criteria are met. I think that's reasonable. On the other hand, I wish that people would be more transparent when discussing these, these agents and say, look, I think it does this, but there's kind of a gap in evidence.
- [27:01]
Dr. Rena Malik
Yeah.
- [27:02]
Dr. Jordan Feigenbaum
And that would be, that'd be more, more responsible way to talk about this. But we wouldn't have good podcast material if that were the case.
- [27:08]
Dr. Rena Malik
Well, then we wouldn't have, we wouldn't need to do anything on social media.
- [27:11]
Dr. Jordan Feigenbaum
That's true.
- [27:11]
Dr. Rena Malik
Yeah. I think the challenge is that everyone is looking for sort of like this thing, this magical thing that helps them. Right. And they see lots of people like I've seen very prominent influencers and celebrities talk about their peptide stack and they're this and they're that and they're getting it from doctors who are presumably buying it from the same research companies. And maybe they are having this nuanced discussion that, hey, we don't have evidence, but it appears to be good. And then the patient says, well, I'll take the risk. Right?
- [27:42]
Dr. Jordan Feigenbaum
Yeah, yeah.
- [27:43]
Dr. Rena Malik
And so are there, have you 1. Are there any reported risks that you've seen, either you've seen or heard of in the literature where people have taken peptides off label and had sort of downstream consequences like immunogenicity or is it more theoretical?
- [27:56]
Dr. Jordan Feigenbaum
Yeah, the answer is yes to all of those questions, mainly because there have not been a lot of case reports coming out on every particular agent showing, look, this person took all this BPC157 and you know, their precancerous polyp in their colon enumerated and now they're, they have colon cancer.
- [28:13]
Dr. Rena Malik
Right.
- [28:14]
Dr. Jordan Feigenbaum
On the other hand, a lot of the growth hormone promoting agents have known side effect profiles for, you know, increasing blood sugar, maybe some insulin resistance sort of risks, joint pains, arthralgia type risk. Some interesting stuff around maybe how people process trauma. Anyway, that's besides the point. Those case reports exist where you have people, look, I've lost fat mass, but my A1C hemoglobin, A1C a measure of how much your blood sugar is well controlled. Over a series of months it went up. Interesting, right? So to your first question though, like, is it okay or is it a reasonable clinical decision to maybe prescribe this medication for somebody with informed sort of consent, you know, the risks, theoretical or otherwise, you know, the benefits, theoretical or otherwise, and you're willing to accept that risk. I kind of laissez faire about that. I'm like, look, if you are informed and you demonstrate appropriate level of insight here, I'm kind of like, do whatever you want. I'm here more as a consultant. I have my own feelings about like my personal like risk aversion to the, to these things. And so as a person who's experienced, for example, a lot of musculoskeletal pain here, you know, from time to time like humans are want to do. I don't personally see the benefits of a BPC157 being outweighing the potential risks to me, but other people have different preferences, value systems and, and so I
- [29:41]
Dr. Rena Malik
guess I just, I just worry that like these are unregulated, unclear substances and you know, people are going to take supplements, they're going to take these things. But it's, it's really, I don't know that people are having a fair understanding of the risks.
- [29:55]
Dr. Jordan Feigenbaum
Totally.
- [29:56]
Dr. Rena Malik
That's what I really worry about. And like, you know, you can say you understand the risk, but do you really understand the risks and like potentially like in some cases lifelong difficulties afterwards?
- [30:08]
Dr. Jordan Feigenbaum
Yeah. I posted a thing on my, on my TikTok about, hey, look at, as of right now, there are no randomized clinical trials on BPC157, for example. None. Not, not on any particular indication whether it's from, you know, ligament tear to muscle muscle strain to, you know, gut health. Like nothing. It doesn't exist. Right. And I said if data comes out that, you know, in humans showing a robust, reliable signal of not only safety but also efficacy, I'll be the first one in line to me to use it, recommend it, talk about it, whatever. And then my comments, it's like 75%. It worked for me, 25%. I tried it. It didn't do anything. You know, and I have concerns about risks too. Right. And so to the 75%, I say I'm so happy you're feeling better. Thing one and two, I understand probably why you went down this pathway. You feel pain if you're sold this bill of goods, like hey, this is going to be potentially useful for you. I get all of that. Right. Very attractive sort of premise here. My concerns are on the unknowns at the margins. And to your point, I don't know if it's possible to truly understand what are the risks and what are the benefits when there's nothing to really draw from. You just have anecdote. Right. So yeah. And you know, our, our educational background going through medicine, you see not only like failed medicines and kind of what their trajectory, what's happened. Right. But you also see people who take legitimate FDA approved medications, they don't work as well or they have terrible side effects. 100%. Right. And you're like, so maybe we are more risk averse just based on our sort of probably, you know, the ping pong machine of life that we've been through. Right. Different scars and such. Whereas other people who may not have that experience will say what's the worst that could happen? And I'm like, I don't know.
- [31:52]
Dr. Rena Malik
Yeah, yeah. I mean there's a patient I'll never forget, he had Bactrim, which is antibiotic, which is used for, he got it for ut, I presume, prostatitis. He was A young guy, he got something called Steven Johnson syndrome.
- [32:05]
Dr. Jordan Feigenbaum
No. Oh, no.
- [32:06]
Dr. Rena Malik
Which is very rare. But it's basically sores in your mouth, in your face, and they're exquisitely painful. They require admission to the hospital. Hospital, you get dehydrated. Like, there's many multiple consequences of it from that particular disease. And it can be life threatening in some cases if it's very severe. And it was all because someone thought he might have had a uti. And so I think, you know, that's always in the back of my head. Even when I prescribe Bactrian for a real uti, I tell my patients, if you have sore, stop it right away. You know. But for any medication, right, Like I know Cipro, Ciprofloxacin was in the, in like TikTok for a while about Achilles tendon ruptures, which absolutely can happen. They are rare. But if people are going to vilify those medications, we also need to be sort of balanced about these medications that haven't gone through rigorous scientific study.
- [32:56]
Dr. Jordan Feigenbaum
Oh, yeah. I mean, I get in those comments too, to be like, oh, what about vaccines? There's no randomized controlled trials on vaccines. Or, you know, what about the COVID jab, right? And I'm like, well, what I'm hearing from you is that you would like excellent safety and efficacy data on the vaccine schedule. I think you should also want that on these peptide medications. You know, if we're being logical, you know, a classic example of this is like fen phen, right? So the two separate drugs that are combined to make fen phen were previously FDA approved, right? And people were using them independently with apparently no real ill side effects. They were then combined by one prominent physician and he saw a bunch of weight loss. And this kind of got picked up by a firestorm, right? Once people started using this, there were scientists and researchers saying, look, we don't really have safety data on this. I don't know. And then even in the phase the, the clinical trials ran on this, it was identified. Look, there's a safety signal here. But it was rushed to market. With that relatively little evidence and the scientific community saying, we're not so sure yet. And then the tragedy of fen phen happened. You know, all these people with these crazy side effects and, and people say, look, remember fen phen? I'm like, you remember Sven phen? You remember fen phen? When we're thinking about peptides, I don't know, maybe we cut that. Maybe it's not that interesting.
- [34:15]
Dr. Rena Malik
But it's like, I think it's interesting. I mean I think the people listening went through that.
- [34:19]
Dr. Jordan Feigenbaum
Yeah.
- [34:19]
Dr. Rena Malik
Like they lived through the Fen Phen era, or at least they heard about it. Right. And so I think that it was, it was like magic. People were in love with it, you know, similarly as they are now. So let's talk a little bit about the specific ones. And BPC150 is probably the most popular, at least the one that I've heard the most about. So 1. What is the mechanism? Let's start with what is the mechanism.
- [34:40]
Dr. Jordan Feigenbaum
Sure. BPC157 is an acronym supposed to stand for body protective compound. It was isolated from gastric juices. So stuff in your stomach, your stomach acid. And the thought was, well, look, the stomach is this harsh environment, hostile environment, and those cells have to turn over on a regular basis so you don't get an ulcer. So maybe there's something in your stomach acid that's prevent. That's either causing these cells to turn over or protecting these cells. Anyway, that's where they isolated BPC157 from. The thought is that it increases blood vessel growth, which we call angio neogenesis, in particular at the level of the tendons or ligaments. And if you just think mechanistically about pain related to your ligaments or tendons, they don't get enough blood flow. So you increase vascularity in those tissues, more blood flow, more healing signals through the vascular endothelial growth factor, vegf, sort of signaling pathway. And so that's the mechanism by which it's supposed to work. And lots of petri dish data, lots of animal rodent data. Unfortunately, the bulk of the data, I estimate this to be like 90% previously, like 99% of all the data comes from the research group that discovered this agent, which is not uncommon in pharmaceutical development. Like generally, the group that discovers it will do a bunch of preclinical work and then it goes to clinical trials. There's been this. Insurgents new. It's mostly review studies of like orthopedic groups or whatever, basically recapping all this sort of stuff. So that's why now it's 90% instead of 99%. So a bunch of like review studies. Unfortunately they're just reviewing the same stuff. Petri dish data, animal rodent data, rodent data. There's one human trial that's been published. It's like alternative therapeutics, journal of something. This clinic that had prescribed BPC157 to their patients, 16 patients, retrospective, retrospective calls them up, calls them up and says hey, your pain feeling better? And the majority of them said, yeah. And they're like, cool. They published that. Look, it's not the worst study, but I don't know that I feel particularly confident. Like, where's the placebo arm, for example? Right. It was retrospective instead of prospective. And so there can be some recall bias.
- [36:54]
Dr. Rena Malik
I mean, it's a pretty straightforward randomized controlled trial to do you inject saline versus you inject BPC157 and you see
- [37:01]
Dr. Jordan Feigenbaum
what happens if there are, again, it's the TikTok comments section, let me know. Millions of people using this. With success, it would be very easy for any one of these clinics to say, hey, look, I'm going to run a randomized controlled trial. Obviously I'm going to get consent from these individuals. I'll contact the local medical school, get this, you know, run up the IRB chain. Could be done, could be done, could be certainly funded with the current administration. So like, I don't, I don't know that I want to hear like all of these barriers. But look, if somebody wants to fund me, I'll, I'll do it.
- [37:29]
Dr. Rena Malik
Yeah, I'll help you. Increasing blood flow. There's lots of things that increase blood flow, right? I mean, if you think about it from like, there's also, you know, newer regenerative therapies like Shockwave and prp, which have some pretty good data, at least I don't know about exactly the data in the joint space, but I understand it's pretty good in terms of joint musculoskeletal issues. And so what are better options than BPC157?
- [37:53]
Dr. Jordan Feigenbaum
Yeah, well, so this kind of speaks to a larger point. Like when you talk about joint pain, generally speaking, people are like, well, it's because it's tissue damage. Ligament is, there's a tear there, or the tendon, there's a tear, or the muscle, there's some sort of anatomical or structural cause. A pain generator. That's a general oversimplification of the pain experience probably beyond the scope of this particular podcast.
- [38:16]
Dr. Rena Malik
Inflammation, there's all sorts of things.
- [38:18]
Dr. Jordan Feigenbaum
100%. Yeah. And just pain is complex experience related to biological things, psychological things, social things. Anyway, we have a lot of ways to increase blood flow to the area. Exercise, for example, increases blood flow massively to the tendons, to the ligaments, to the, to the joint. Topical nitrates. People been trying to use this to increase blood flow for healing related properties. We've done that. And to your point, a lot of other biologics as Far as those showing significant improvement in pain, the data is mixed, depending on the intervention, how long it lasts, the type of pain, et cetera. So I don't know, the idea that, look, just driving up blood flow, that's what's causing the response here, it seems plausible, but less likely, mainly because we know how to do this.
- [39:01]
Dr. Rena Malik
Right? That's what I'm saying. So is there another mechanism?
- [39:04]
Dr. Jordan Feigenbaum
Oh, yes. So the way I think about this, we don't have like a molecular mechanism, mechanistic bet that we're making otherwise. But to me, you think about the steps that somebody has to go through to get BPC157, whether previously. Well, yeah, but like they have to compare to compare it to taking ibuprofen. Ibuprofen, yeah, yeah. You could, you know, dash it to your home. You don't have to get off the couch. Right. It's not a controlled substance there. Take a pill. BPC157. Previously you'd have to call up your doctor or find a doctor. That was like going through a compounding pharmacy to get it. Now you can get a research, chemical, whatever. You got to get needles, you got to reconstitute it, you got to inject it. All of these things increase the likelihood of a significant placebo effect. We know that as clinical theatrics increase, the placebo effect potential goes up and up and up. And so I'm not saying that it's all in your head if somebody sees a benefit from this, but I do think it's likely a considerable portion of the effect has some placebo mediated effect, which is not. That's fine. I'm also fine with that. If you, if we know the risks, if the risks are relatively low and the potential benefits are relatively high, great. But we need to know that ahead of time. So to me, I can't quite extrapolate out what other potential mechanisms may be there. It seems likely to me that to the extent blood flow is helpful, that seems reasonable. But also a strong potential placebo effect, I think.
- [40:26]
Dr. Rena Malik
Yeah, yeah, that's interesting. And you didn't mention, but increasing. I know. You know this increasing muscle strength around the joint totally will significantly improve pain.
- [40:38]
Dr. Jordan Feigenbaum
Yeah, we think using muscles. So interesting couple mechanisms there. One, by physically staying active. So the, the idea to bed rest, relax, don't stress that area, don't be active. It's the same bad advice that's been given by doctors, our people. Unfortunately, for too long, you have osteoarthritis, you know, it's wear and tear. What should I do about it, doc? Just relax, rest, ice.
- [41:03]
Dr. Rena Malik
Ellie.
- [41:04]
Dr. Jordan Feigenbaum
Yeah. Meanwhile, exercise is very, very potent intervention for osteoarthritis and same thing for joint related pain. Most types of joint related pain, mainly because like graded exercise that a person can do without pain not only stops that sort of reverberating pathway of if I do this, it's going to make me hurt. Right. So you kind of unlearn that. Less kinesophobia, fear of movement. We also think that active muscle tissue releases these hormones called myokines, which tend to be anti inflammatory and can also be therapeutic. And yeah, as you mentioned, increasing the force generating potential of the muscles around the area lets the muscles do some of the work that the joints maybe had to pick up the slack for previously. So all good things. And it doesn't come with an unknown risk profile. We know the risks of exercise and we know the potential benefits. Oh, and by the way, you don't need to inject it, you just got to do it.
- [41:54]
Dr. Rena Malik
You just got to do it. Yeah. I had Lane Norton on the podcast. It was a while ago, but he basically said you can be in pain and weak or in pain and strong.
- [42:03]
Dr. Jordan Feigenbaum
That's my direct quote.
- [42:04]
Dr. Rena Malik
Yeah.
- [42:04]
Dr. Jordan Feigenbaum
Is that your similar doctor? Dr. Norton's a good friend of mine. Yeah. Previously he. It's interesting. His back pain trajectory was very intriguing to me.
- [42:15]
Dr. Rena Malik
Yeah.
- [42:15]
Dr. Jordan Feigenbaum
Originally the people that he worked with were very, I call them mechanically minded. Doesn't mean that they're bad people. It just means like, look, the reason you have back pain is because it's a disc issue, it's a ligament issue. It's something like that. We effectively have to wait for that to heal for you to have unrestricted activity. That didn't work very well for him. He ended up interfacing with our team and subsequently has done relatively well. And also fortunately, because he does have such a large platform, his messaging around pain is very, very good. So yeah, motion is lotion. You also, yeah, you can be strong and hurt or weak and hurt. Pick your, pick your poison here. Not to again, minimize anybody's pain experience at home.
- [42:53]
Dr. Rena Malik
Of course. Yes, yes, but, but I do think it's, it's important to think about it that way. Right. Like not. It's not, it's not easy. There's a lot of these like Instagram things like you can, it's hard to be like overweight and, and sick. It's also hard to eat healthy and you know what I mean, Pick your heart, pick your hard kind of thing.
- [43:10]
Dr. Jordan Feigenbaum
Sure.
- [43:11]
Dr. Rena Malik
So I think it's the same sort of thing here. It's like nothing is easy, right. Injecting a medication that seems to improve your life seems like an easy way to reduce pain. Sure, if it was, I wish it was, but I always thought if it sounds too good to be true, the other shoes get a drop.
- [43:28]
Dr. Jordan Feigenbaum
Yeah. I mean, you think about something that's supposed to heal your joints, heal your gut, be good for your brain. Like what? You know, all this panacea of, like, effects. And I'm like, I don't really know that that happens in medicine too often.
- [43:40]
Dr. Rena Malik
Yeah. I think the closest we're getting is with these GLP ones right now. They are actually. We're seeing benefits across a multitude.
- [43:47]
Dr. Jordan Feigenbaum
And notice the interest from pharma.
- [43:49]
Dr. Rena Malik
Yes, very strong.
- [43:50]
Dr. Jordan Feigenbaum
So, yeah, again, I keep going back to this. Not again, not because I'm trying to, like, get a contract from pharma here or whatever. It's just like, if this thing does what half of what people are saying it does, I would expect strong interest from pharma. The drug came from a pharmaceutical company who's presumably interested in making money and also helping people. So.
- [44:10]
Dr. Rena Malik
But it's so funny because you think about the messaging around GLP1. So I just saw a good friend of mine, Dr. Alexander, so also been on the podcast, she went on a talk show and they were like, well, doesn't it cause cancer? It was like in rats, it caused cancer. But obviously we see actually lower incidence of cancer in patients who take it. And so it's interesting that there's so much fear around this pharmaceutically made medication. Whereas these peptides were like, oh, where can I get it? Right? Like, it's very interesting how people perceive things differently.
- [44:43]
Dr. Jordan Feigenbaum
I do think that messaging that it's the narrative created around peptides. Oh, it's just like a supplement. If again, if every time an influencer with the. You know, we are. We're well lit here, we got a camera, the whole thing. But whatever, just imagine this, we're influencers. So, you know, they talk about, oh, so it's very small molecule, very. It's just amino acids, you know, like it's a supplement. But if they instead said, okay, it's a very small drug or it's a controlled medication or something like that. Start that out. I don't know that there'd be this same enthusiasm. Right. Because again, if you ask a general person, hey, what's a peptide? Or like, yeah, how would you classify it? Is it supplement? Is it a medication? Is it protein?
- [45:22]
Dr. Rena Malik
They Go somewhere in between.
- [45:23]
Dr. Jordan Feigenbaum
Yeah, I'm like, no, that's medication.
- [45:24]
Dr. Rena Malik
Now there's some other peptides that are really market for boosting growth hormone, increasing muscle mass. MK677CJC1295, you mentioned both those. How do these work and what do they do?
- [45:39]
Dr. Jordan Feigenbaum
Yeah, great question. These are all like growth hormone. I just call them growth hormone promoting agents. But secreta togs is the fancy word. You can impress people at the bar later with that effectively or make them
- [45:49]
Dr. Rena Malik
realize you're a big nerd.
- [45:50]
Dr. Jordan Feigenbaum
Yeah, yeah. Either way, depending on your, depending on the audience, they basically tell your body to produce more growth hormone through a variety of different mechanisms. So some act at the level of the brain tutorial gland, pump out some more growth hormones, more IGF1 and that would be like CJC 1295. Whereas like MK677 affects the ghrelin receptor, ghrelin being known as the hunger hormone. So when you're fasted, when you're working out, that's a low energy state. Right. And so the hunger hormone, ghrelin would go up and so does growth hormone. So growth hormone goes up when you exercise because energy levels are going down, growth hormone goes up between meals as you're fasting and energy levels are going down. And so, so through a variety of different mechanisms, all of these growth hormone promoting agents raise growth hormone and by extension IGF1. Great, great. As far as effects go of this class of drugs, we know that the visceral adipose tissue, belly fat is very sensitive to growth hormone. Once growth hormone levels go up, belly fat levels tend to go down. Which makes sense if growth hormone is like an energy sensing sort of hormone, as you're fasting, as you're exercising, you need more fuel. Right. Let's target this belly fat store, easily liberated energy store depot that you have. Outside of that growth hormone administration, whether it's human growth hormone itself, whether it's CJC 1295, whether it's MK677, doesn't really seem to do much else that we want, I think because the hormone is called human growth hormone. So guys that maybe look like me and want to look like a bigger version of me are like growth.
- [47:29]
Dr. Rena Malik
Yes, sounds great.
- [47:30]
Dr. Jordan Feigenbaum
Yeah. But it doesn't really pan out. We have data on human growth hormone itself administration. We have data on CJC 1295 administration. We have data on MK677 administration. Yep. In humans, growth hormone goes up, IGF1 levels go up. Nothing really happens to lean body mass as far as actual muscle tissue, as far as we can tell, yes, generally fat free mass can go up, but that includes everything that's not fat. So water, glycogen, bone, visceral organ tissue, any again, anything that's not fat. What you would want to see if you wanted to strongly link this increase in body weight or increase in fat free mass was actually an increase in muscle tissue. Is a functional test like, yep, lean body mass went up and strength went up, power went up, something like that?
- [48:19]
Dr. Rena Malik
Sure. We're not seeing that.
- [48:21]
Dr. Jordan Feigenbaum
We see the opposite. MK677 in a group of healthy older seniors showed a 1 kilo increase in fat free mass. And people were like, yes, it's a treatment for sarcopenia. No improvement in strength at all. We think it's mostly water and glycogen which actually speaks to the side effects that most people experience. This with is bloating, swelling like moon face for example, that they can get even in human growth hormone studies. In people who are not deficient in human growth hormone, their lean or fat free mass can go up, but doesn't seem to really increase their strength, doesn't increase their muscular power, doesn't improve their VO2 max. These are all functional tests that would be, you would expect to see an improvement in if actual muscle tissue increased. And so I'm kind of skeptical that growth hormone should be something that we're trying to micromanage in a way. Again, if it was branded differently, perhaps we'd have different feelings about this. And certainly if you're in the bodybuilding, powerlifting, that sort of space, human growth hormone and other agents around that area have been used by high level athletes for years. So there's some sort of like, well we've always done it this way, we gotta keep doing it. I don't know that it's effective like that. On the other hand, bodybuilders are using massive doses of human growth hormone with other agents. And so maybe in the specific way that they're using it, it is beneficial. We don't, we don't really know. But to date the studies on human growth hormone administration in humans, even at super physiological doses remain unimpressive. So that's at the top. Now we're at a lower level saying, well look, we're trying to get there with these peptides. CJC 1295 MK677, yep, they seem to increase human growth hormone in IGF1, but they don't also don't appear to be building any muscle, any actual muscle tissue. And to the extent that they have effects on belly fat, it's pretty modest compared to GLP1 drugs that we know the safety, we know the efficacy, they're cheaper, generally speaking, by the way, and they seem to have additional benefits. Whereas the side effect profile of these agents, the growth hormone promoting agents are generally your blood sugar gets a little bit worse, some risk of joint pain with it and then potentially depending on the specific agent. Is it like a shotgun blast, it affects everything at the level of the pituitary or is it like a sniper? Like right at one. You can also get some increased appetite, you can get increased sort of water retention, all sorts, all sorts of stuff that you probably don't want if you're using this for like lifestyle optimization. So I'm just kind of skeptical on growth hormone, generally speaking. And so these agents in the podcast we did on peptides was, I called it the anabolic mirage. It's like, look, it says growth on the label. I'm probably going to grow if I have this thing and does not seem to be the case.
- [50:59]
Dr. Rena Malik
Whereas anabolics, conversely do some of them do actually increase muscle mass.
- [51:04]
Dr. Jordan Feigenbaum
Yeah, anabolic androgenic steroids. So whether you're talking about testosterone, right. Whether you're talking about oxandrolone, classically known as Anavar decadurabal and so nandrolone, you can go down the list. Even some veterinary agents, to the extent that data exists on these things, they show a definitive dose dependent response between the agent and muscle growth. It's like testosterone for example. Testosterone is super interesting as you know, because like if you're in the normal range, right, depending on the lab, 300 to 800 nanograms per deciliter, it doesn't seem like if you're at the higher end versus the lower end, it really matters for like how much muscle growth are you going to have from exercise? Everyone does about the same because there are other downstream sort of factors that matter. What's your androgen receptor density? How sensitive are you to testosterone? What is the tissue level concentration of testosterone, but once you get above that sort of permissive zone, right? Yep, it's a dose dependent relationship. More test, more muscle growth. Yeah. And very clear. You don't have to torture the data to see it. You don't even have to exercise. Like people just gain more muscle mass.
- [52:06]
Dr. Rena Malik
And interestingly, actually there was a study I just reviewed that they talked about the FDA panel where they had guys take super physiologic testosterone. They looked at guys who did weight train, guys who didn't and actually the people who didn't weight train. Yeah, they got more. But actually if you exercise way more without. Without testosterone, you got more muscle.
- [52:27]
Dr. Jordan Feigenbaum
Yes, yeah. The. The old. That Basine study. Yes. Yeah. Challenger Basine, Dr. Shalander Basine, one of the titans in the space. I think Morgan Teller was on the. That panel anyway. So, yeah, he showed. He's like, look, you can rest and take testosterone and, yeah, you'll get bigger muscles. It'd be better if you exercise, though, if you had to pick one or the other.
- [52:47]
Dr. Rena Malik
Right?
- [52:47]
Dr. Jordan Feigenbaum
Yeah.
- [52:47]
Dr. Rena Malik
And it's safer.
- [52:48]
Dr. Jordan Feigenbaum
And it's safer. Yeah. But like I said, the interesting thing is that is a deafening signal in the data showing increased muscle mass and, oh, by the way, it's real muscle because their functional outcomes also improve.
- [52:59]
Dr. Rena Malik
Right.
- [53:00]
Dr. Jordan Feigenbaum
You don't have to torture the data. It's not a small, modest effect. It's readily apparent. Your eyeballs work, you can pick it up. Whereas in this other stuff, with respect to CJC 1295 MK677, it's one, a smaller effect and then two uncertainties about the outcomes.
- [53:17]
Dr. Rena Malik
Yeah, right. Right. I want to talk about retatrutride or reta, which is essentially the. The newest weight loss peptide that is being investigated right now that people are still getting sort of off label and using for weight loss. What are we seeing in the trials and what are we worried about with people getting it off label?
- [53:34]
Dr. Jordan Feigenbaum
Yeah, Retatrutide is. Is great. I'll be very curious what the generic name is, because I hate. Or what the brand name is, because I hate the generic.
- [53:40]
Dr. Rena Malik
Yeah, it's really hard to say.
- [53:42]
Dr. Jordan Feigenbaum
Very hard. So Retta, as it's called, pretty cool. Triple agonist. So if Ozempic and Wegovy were a single agonist for GLP1, then you have Tirzepatida Manjaro, a dual agonist. Right. Included a GIP receptor agonist. And then now you have a third agonist for glucagon. So this triple agonist, retatrutide.
- [54:01]
Dr. Rena Malik
Yay.
- [54:02]
Dr. Jordan Feigenbaum
Just finished its phase three clinical trial. The triumph four study. 28.7% average weight loss. Yeah. 76% reduction in knee pain because it was originally like a knee osteoarthritis study. And then also there was another study on individuals with non alcoholic fatty liver disease that showed like 85% of them effectively eliminated all of their liver fat, which is less than 5% remaining liver fat. So it seems to be very, very effective. So we know that the GLP1 and the GIP agonists reduce appetite main sort of mechanism of action, some other stuff, but that's the main mechanism of action. Glucagon seems to tell the liver to dump fat and also burn more calories. So we're really approaching weight loss from both a calories in standpoint with the appetite and then calories out with the glucagon. I suspect this agent will be approved sometime in 2026 and again really hoping for that, that it happens soon. So the brand name can replace retatrutide in my brain. The couple, couple of issues. One, there seems to be this maybe cardiac cost to it. Average heart rate goes up a few beats per minute which for most folks is tolerable. Not a big deal. But if someone had heart failure for example, that might be problematic. Other sort of cardiac conditions side effect profile also seems to increase once people get to max doses. There was like an 18% dropout rate, I believe so would want to have it monitored and administered in a stepwise fashion like most of these drugs are. And then the biggest problem right now is that because it's not FDA approved and because it is patented. Right. The only way that people can get it are through research. Chemical, same issue. Yeah. And so again I just, look, nobody's trying to hurt people on purpose. Yeah, I don't think that's, that's the case.
- [55:48]
Dr. Rena Malik
But don't have the funding to do all that safety testing.
- [55:52]
Dr. Jordan Feigenbaum
And if they did it would cost the same as pharma.
- [55:54]
Dr. Rena Malik
Right. So they just don't have the mechanism in place.
- [55:57]
Dr. Jordan Feigenbaum
Yeah. And so that's my biggest concern. And so what I think is actually happening that's maybe most interesting is that because of the compounding, pharmacies may be overstepping what they could do with Ozempic and Wegovy and Zepbound. Right. Continuing to make it even though they were told not to. And if people got used to this cheaper price point. Right. Well the manufacturers of these medications were like, well we'll just go direct to consumer and make it cheaper. So I'll be very interested to see the rollout for retatrutide. Is there going to be a straight direct to consumer route that is cheaper. So yeah, but that would eliminate the potential. My biggest risk right now is that people are just using it at doses that they don't know for sure that they're getting unmonitored. Unmonitored mainly and then potentially contaminated and
- [56:43]
Dr. Rena Malik
who knows what else is there for high level athletes. That couple beats of heart rate, would that make a difference?
- [56:48]
Dr. Jordan Feigenbaum
Don't know. Theoretically, yeah. I mean and that's the other thing is that this is just resting heart rate. But like does this carry over when people start exercising?
- [56:56]
Dr. Rena Malik
Right.
- [56:56]
Dr. Jordan Feigenbaum
Because what you see in exercise, especially prolonged exercise is cardiac drift. Right. So if you've ever noticed you, you get on the elliptical, you get with treadmill, whatever and your heart rate goes to one level. Right. As you warm up and get to your pace, it'll start drifting up later and later and later. Some of that's dehydration, some of that is just trying to maintain cardiac output otherwise, but yet drifts up and up and up and for a higher level athlete, five beats per minute maybe. We don't know. On the other hand, if they're a high level athlete, why are they on retta unclear, you know.
- [57:23]
Dr. Rena Malik
Well, because they may think it's, you know.
- [57:26]
Dr. Jordan Feigenbaum
Yeah. In a weight controlled sport, for example. Yeah, absolutely. Like at the end of our podcast on, on, on Peptides we were like look, if, if, if you have to take something, you're going to take something regardless. Maybe it's just testosterone, tirzepatide, you know, and so maybe it ends up being reta and test, I don't know. But yeah, to your point, I think it could, I'll be curious to know if there we need to have a study on these anti obesity medications and exercise first. Just like what, what happens then? I'd be curious. All we have right now is liraglutide, which is an old historic agent. Not very good. So yeah, that'd be step one and then two is. Yeah. What happens when high level performers take this stuff? What happens to that heart rate bump, if any.
- [58:07]
Dr. Rena Malik
Yeah. And yeah, I guess I just wonder because obviously they're, they're these high level athletes are getting paid to perform at a high level.
- [58:14]
Dr. Jordan Feigenbaum
Yeah.
- [58:14]
Dr. Rena Malik
Their livelihood is dependent on.
- [58:15]
Dr. Jordan Feigenbaum
Maybe we'll ask Serena. Yeah, maybe we'll ask Serena.
- [58:18]
Dr. Rena Malik
Well, we don't see that heart, do we see that heart rate change in, in Manjaro and no.
- [58:23]
Dr. Jordan Feigenbaum
Yeah. So we think it's. And again we, there are way better experts on glucagon signaling than you and I. But yeah, it seems to be because of the glucagon receptor agonism potentially increases the heart rate. Now other drug, we've had other weight loss drugs that have been like, you know, this catecholamine dump or sympathomimetics, you know, increased fight or flight noradrenaline that also increased heart rate doesn't seem to be the same mechanism. So I'm not really concerned about that. But Yeah, I think it's mostly related to the glucagon agonism.
- [58:54]
Dr. Rena Malik
Interesting. I want to switch gears a little bit and talk about sarcopenia. I think that people don't really see it coming, but let's. Like when they're, when they're about to be diagnosed with sarcopenia, what is sarcopenia and why is it dangerous?
- [59:11]
Dr. Jordan Feigenbaum
Yeah, great question. Especially with the aging population. Sarcopenia is classically understood to be age related loss of muscle, which is fundamentally wrong because people just think that their muscles are withering away, you know, going from a grape to a raisin. The reality is that the muscular force production, your muscular strength, is what's actually being compromised. In fact, over the age of 50, you lose strength three times faster than you lose muscle size. Right. But to your point, this starts early. We start losing our ability to produce force in around the middle of the third decade of life if there's no sort of outside intervening force. And so the issue with sarcopenia, which is probably better called dynapenia, reduction of force is a neurological event. The nerves that supply your muscle fibers, especially your fast twitch, type 2 muscle fibers that produce a lot of force, a lot of power, they start to die. And what happens when they die is that the muscle that they would otherwise connect to that muscle is either going to shrivel up and also die or it gets re innervated by a nearby motor neuron. And unfortunately, most of those motor neurons are type one slow twitch. And so what you see in older individuals who've been diagnosed with sarcopenia is that they've lost a lot of their type 2 high threshold, high force producing muscle fibers. And even if they're like runners, like master's level endurance athletes, you still see that same loss.
- [60:33]
Dr. Rena Malik
Really?
- [60:33]
Dr. Jordan Feigenbaum
Yeah. So like, running isn't enough and definitively walking isn't enough. So you're like, why do people surprised? Well, it started way earlier than they thought. Right. And then there were no mitigating factors.
- [60:45]
Dr. Rena Malik
And some of them may have been running and doing the doing.
- [60:48]
Dr. Jordan Feigenbaum
I'm active, I do Pilates, bar, whatever. Right. And it's like, all that's well and good. You know, all that's well and good. But they're the. What they should have been doing in order to prevent this loss is actually resistance training. Specifically resistance training that is relatively heavy based on their current strength level. Right. So it can't just be the pink dumbbells, unless the pink dumbbells are heavy for you. Right. No shade to the pink dumbbells. Some People need them. That's, that's all well and good, it just has to be relatively challenging. And so what that does is it gives the nervous system a signal to say, look, these muscles, I need them.
- [61:21]
Dr. Rena Malik
You need to keep, keep them, keep those fibers.
- [61:23]
Dr. Jordan Feigenbaum
And we see a big time slowing of that decline. Like we can't beat Father Time. Time is undefeated. Right. But as far as the actual strength loss, it seems to be going down far slower in individuals who lift weights compared to those who don't. So much so that like you might not notice a decline until somebody's in their 60s or 70s. And that decline is a relative decline. They're like, well, I can't lift this much anymore, but I'm still functionally independent. I can do everything I want to do. Sarcopenia is not coming for me. What you would want somebody to do earlier on in life is to build their sort of physiological or physical 401k, make all those deposits earlier on, and then you can withdraw as you need later on in life. Same thing we see in bone mass, right? For osteopenia, osteoporosis, you want people to have a high level of bone mineral density in their 30s such that by the time they're 60 or 70. Well, look, you started from a higher place, right. And so, yeah, it does seem to be a surprise. It's generally this sort of dual hit thing where, yeah, there was some age related loss that happened because we weren't really lifting weights. And then somebody gets sick and so then there's a period of excessive disuse where that's accelerated. Right. And so, and then they kind of, I can't get out of bed as quickly or as, you know, briskly as I once was, or I can't quite do all the things I need to do around the house as much. And so, yeah, it's that the diagnosis of sarcopenia continues to increase. And I think some of that's age related and other is environmentally related. People just not lifting.
- [62:52]
Dr. Rena Malik
If someone's sarcopenic right now, can they get back to it? Can they? Like once you've lost those motor neurons, is there anything you can do?
- [63:00]
Dr. Jordan Feigenbaum
Well, the motor neurons can't come back. Yeah. But we can strengthen what you still have and preserve further loss. So reducing the burden of disease and then further, you know, we have data up into people in their 90s showing they get, their muscles grow and they get stronger. So the actual functional capacity seems to increase markedly. Now to your question of can you like reverse it? It really depends. Why Somebody has sarcopenia, if it's purely age related, just age related disuse, for example, that has a, it's easier to come back from that than if somebody has that layered on top of like a chronic medical condition that prevents them from exercising, for example, or they have to take a medication that actually interferes with exercise related adaptation. So if they have an autoimmune disease that, you know, they have to take prednisone or something like that, it's not to say that one, you should stop your prednisone or two, if you're in that population, well, just give up, you know, it's just the degree of effect that exercise is going to have, you
- [63:54]
Dr. Rena Malik
know, because you just can't do as
- [63:56]
Dr. Jordan Feigenbaum
much, you generally speak, you don't respond as well. That doesn't mean you have no response though. Right. So 10 out of 10 would recommend resistance training.
- [64:04]
Dr. Rena Malik
So for people who, look, I hear this all the time, I don't like going to the gym.
- [64:08]
Dr. Jordan Feigenbaum
Sure.
- [64:09]
Dr. Rena Malik
I don't like, like resistance training is not fun for me.
- [64:12]
Dr. Jordan Feigenbaum
Sure.
- [64:12]
Dr. Rena Malik
What do they do?
- [64:13]
Dr. Jordan Feigenbaum
Ideally, you know, when exploring fitness with clients or patients, I generally ask them, like, what do you like to do? You know, what would you like to do physical activity wise, exercise wise. And you know, they usually give you some ideas. But I hear that all the time, I don't want to go to the gym. Right. One, I don't, I don't want to pay for it, I don't want to go there. I don't deal with all these chads, you know, no offense to people listening to this name, Chad. So what should I do? Can I do this at home? Yes, you can find ways to stress the musculoskeletal system at home. The issues are as follows. One, if you don't have equipment, you're going to be really restricted on what you can and can't do. And that's complicated by if you already have like relatively low strength levels, potentially low mobility levels, then trying to get you to do these restricted movements because you don't have machines, you don't have dumbbells, you don't have whatever is going to be even harder. Right. Like I could tell you to do squats at home or split squats, but can I tell that to my, you know, 74 year old mother?
- [65:11]
Dr. Rena Malik
Yeah.
- [65:11]
Dr. Jordan Feigenbaum
Like, doesn't mean that she can't do it, but probably would be better off with a leg press. Right. Or at least access to that. It makes it more accessible.
- [65:20]
Dr. Rena Malik
Yeah. So it's easier to do.
- [65:22]
Dr. Jordan Feigenbaum
Yeah. But I will say this. I don't let, don't let perfect be the, you know, get in the way of doing something. Because anything's better than nothing. Even we, we have this new emerging area of research and exercise where they're looking at what are called exercise snacks. It's like 30 seconds to one minute of just activity. Pretty big effect. The biggest effects on exercise happen from zero to something rather than like something to wow. I'm training like an elite athlete. You know, right now.
- [65:46]
Dr. Rena Malik
I spend a lot of time talking to my patients about like the atomic habits model. Right. Like just do something that's so easy you can't ignore. It doesn't have to be hard. It doesn't have to be even long. Like just start it.
- [65:57]
Dr. Jordan Feigenbaum
Yep.
- [65:57]
Dr. Rena Malik
And then after a week or two, you can add to it. Right. Once it becomes just so easy. But just trying to be like, I'm gonna go from sitting on my couch to the gym every three times a week. It's not feasible for most people to do that successfully and maintain it.
- [66:10]
Dr. Jordan Feigenbaum
Yeah, yeah. You know, ideally, in a perfect world, a person gets introduced to exercise in a way that they enjoy. They get bit by the fitness bug. Now they're like, well, not only do I know this is good for me, but I like it.
- [66:22]
Dr. Rena Malik
Yeah.
- [66:22]
Dr. Jordan Feigenbaum
And you get hooked. And that's my, one of my roles. It's like, let me identify, you know, particular fitness kink that you like and let's, let's get you into it.
- [66:31]
Dr. Rena Malik
I like that fitness kink.
- [66:32]
Dr. Jordan Feigenbaum
Yeah, yeah. Yes. Pg. PG show. So sometimes with people at home, you know, if they're again, very. I can't, I just won't, you know, whether it's, I don't want to go in there, I want people to see me like this, or they self conscious or they just don't want to do it all fine. If you think about an individual with sarcopenia, problem with the muscle quality, how much strength do you have? One of the diagnostic tests, functional test is a sit to stand. Can you sit to stand without using your hands? Getting out of a chair five times and you know, less than 30 seconds? I believe so that you could use that to train at home. Hey, get on, on the couch or out of your chair. You got to do sit to stands, you know, five sets of five, whatever. Don't use your hands. Take as much time as you need. But start there. You can do push ups against the wall. You could do wall sits. You can do isometric type stuff. You can get some, you know, elastic bands you can get some dump. I mean, whatever you want, right? The, the this is the world is your oyster here in the fitness world. I just think that if you put too many constraints on a person, meaning, like, look, I don't want to go to the gym, I don't want to get any equipment, and I won't do these things. It's like we're running out of options here relatively quickly. So what I did with my dad, my Dad's in his 70s, he just had a knee replacement. Is. I was like, you should go. You need to go to the gym. After you complete your pt, you have to go to the gym.
- [67:46]
Dr. Rena Malik
And he's like, was he a gym goer before?
- [67:47]
Dr. Jordan Feigenbaum
No, no, no. In fact, I would. My whole life after I got into fitness, I was trying to get my dad in fitness. 1. I want to hang out with my dad. But also I'm like, look, dude, you're getting older. Let's like, let's help you out here, you know? And he does think he does a normal dad thing. Well, I mowed the grass today. And I'm like, okay, well, I would do a walk. Great. Love that energy. Love that for you. Keep doing it. But we need to make your muscles work hard. Relatively hard for you. Not the same as for me, but relatively hard for you. And so when he got his first knee replacement, the way I got him into the gym was he sort of was self motivated. He's like, look, I don't. I feel like I lost a step. And I'm like, yeah, you need to get stronger. And he's like, would you take me to the gym with you? So that's how I kind of bridged that gap. There was no information gap for him anymore because I was totally with him. Yeah, exactly. And he felt more comfortable just being with his son. Same thing. This time he came in and, you know, if people are gym goers at home, this may be meaningful to them. He, after second knee replacement, he started his deadlift. 135 pounds, which, you know, it's one plate per side. Everyone was like, already stoked. Look, this guy's in the 70s, he's deadlifting. Hooray. That's great. I'm like, yeah, it's not heavy for him yet, though. It's just he's going through the motion at the end of his progression. Before, before he moved back, he was 295 for sets of five.
- [69:03]
Dr. Rena Malik
Amazing.
- [69:03]
Dr. Jordan Feigenbaum
Yeah, it's 70. 75. Yeah.
- [69:06]
Dr. Rena Malik
That's amazing, right?
- [69:07]
Dr. Jordan Feigenbaum
I'm like, well, now I know where I get it. I thought it was all my hard work. Turns out, maybe just genetically predisposed. But yeah, I think that he was open to it and I leveraged that sort of where he was at in his behavior change process to take in the gym. Not everyone's going to have that access. Not everyone's going to have a son or offspring that's willing to do that. But I just think people's aversion to going to the gym. I understand. I just would. I would like to maybe push back on that a little bit. There's just so many options if you can do that and ultimately give your muscles a signal and to give your nervous system a signal to stick around. Harder to do it at home. Not impossible, just harder.
- [69:44]
Dr. Rena Malik
Yeah. Yeah. I definitely. Every time my parents are in town, I take them to the gym.
- [69:47]
Dr. Jordan Feigenbaum
Yeah.
- [69:48]
Dr. Rena Malik
But they don't live with near me, which makes a little bit of a challenge. But I think there's a lot of fear there and I think they just need to, like, I think it's helpful to have some help.
- [69:56]
Dr. Jordan Feigenbaum
Yeah.
- [69:57]
Dr. Rena Malik
But knowing that the gym community is pretty helpful.
- [69:59]
Dr. Jordan Feigenbaum
Totally.
- [69:59]
Dr. Rena Malik
Like, I've had people come to the cave that you might hurt yourself, like, be careful or whatever. And if you ask me, even five years ago if I'd be a regular gym goer, I would have said no.
- [70:08]
Dr. Jordan Feigenbaum
Are you gym rat now?
- [70:09]
Dr. Rena Malik
I am. And I started going because my husband was going, and so I went with him. And I was like, look, I've always been a little nervous about going to the free weight section. They come with me. And so we did it together. And now we take our older son with us. Our younger son can't go to the weight section yet, but now he's into it. And it's become like a little bit of a game. Like, oh, how can we see ourselves progress? And so I just tell people, like, you would have asked me. I would have been zero chance. I'm going to be a gym goer. And now I'm gym goer.
- [70:34]
Dr. Jordan Feigenbaum
How did you. I know you're supposed to ask the question. How did you end up getting into the. Like, what was the final. What brings you in the office today? What puts you in the gym for the first time?
- [70:43]
Dr. Rena Malik
Well, I think I was doing, like, peloton. I was doing other stuff. I'd gone to, like, gym classes. I always wanted to lose weight. Right. But it became obvious to me after watching learning from people on social media and learning from colleagues that muscle mass was super important. And so I said, well, you know, gotta practice What I preach.
- [71:02]
Dr. Jordan Feigenbaum
Yeah, right. Love that.
- [71:03]
Dr. Rena Malik
Yeah.
- [71:04]
Dr. Jordan Feigenbaum
Fear of embarrassment is.
- [71:07]
Dr. Rena Malik
But I think for some people, having perfect form is concerning. So what does that mean? Is there a perfect form?
- [71:13]
Dr. Jordan Feigenbaum
No. That's a great question. Yeah. In fact, you look at survey data on people who are currently insufficiently active, which is a nice way of saying they don't go to the gym. If you ask them, hey, why don't you go to the gym? One of the biggest comments is going to be, I don't have time. And then this right behind that is fear of injury. And you ask them where they learned that fear of injury from. They say, usually healthcare professionals, which is unfortunate for us because most of the time doctors like you should exercise. And if you ask doctors about concerns,
- [71:39]
Dr. Rena Malik
the whole conversation, though, you should exercise by.
- [71:42]
Dr. Jordan Feigenbaum
Yeah, exactly. Right. Sorry, we're on a clock here, by the way. I know I was late to the appointment and also you got to go because I got another person. Yeah. So it's unfortunate. So, yeah, there's this fear of injury that does prevent a significant amount of people from exercising or at least doing certain exercises. Right. And there's this idea that, well, if you do the exercise perfectly with the correct technique, that it's less injurious. Right. So that is a very interesting argument. Fine hypothesis. So then you have to define, well, what is perfect form? And to date, it's only been described once in the literature. It's a 2009 paper, and it's a circular argument. It's like, well, look, if you do the exercise with the correct range of motion, the correct velocity in a way that achieves the most optimal fitness adaptations and does not produce injury, that's perfect form. And I'm like, that seems vague. It seems like a tautology. And also. Yeah, like, very vague. So doesn't make sense. So then when we look at, like, how do injuries actually occur in the gym? What is the injury risk? And like, how does perfect form or form in general tie into this? Well, all right, going to the gym, lifting weights, relatively safe. Two to four injuries per thousand participation hours. Compare that to, like, walking, where, like, one. Cycling is like one and a half. So, like, it's relatively low. You compare that to things like football, rugby, soccer, you're, you know, up towards 30, 50, 60, 80 injuries per thousand participation hours. Okay, so relatively safe to lift, lift weights. Most injuries are also not catastrophic. They resolve on their own within about 14 days without any medical care. So already people should be thinking, well, look, maybe this injury thing shouldn't be as big of A concern. And that should also tell you because most injuries resolve that quickly, don't require medical care and are not catastrophic. That should give you an indication of what is the nature of most of these injuries. Are they a muscle tearing or a ligament snapping, something like that? Well, no, they're overuse injuries, chronic overuse injuries. And so then we keep going down this rabbit hole and we're like, would a form particular type of technique cause an overuse injury independently of, of how much exercise you're doing? Unlikely. It's kind of like rotating your tires here. Right. So you rotate your tires so you don't get a flat spot or overwear on one spot. If you don't. Yeah, they can wear out prematurely. And so that's what we're seeing here with these overuse injuries. People are doing too much without enough variety and they get that sort of overuse or bald spot, early wear on their tires or on their body. That's the overuse injury. So ways that you can reduce the risk of overuse injury, more varied exercises and then also making sure that you're doing the correct amount of training or exercise for the person. And the amount of exercise is not just how many days you go to the gym, it's how much stuff you're doing in those days and what kind of stuff. Right. So all of that is to say the training load or the amount of exercise that a person's doing is the primary factor that determines their injury risk as it goes up, particularly out kicking their coverage, what they can tolerate right now, that is what increases injury risk. Primarily this form argument is kind of silly because it, you know, instead of thinking like, oh, you weren't doing too much, you were just doing it wrong. That would beget like an acute injury. Right. Something catastrophic or whatever. We just don't see that it is possible obviously to have an acute injury. Those are mostly accidents that happen in the gym.
- [75:02]
Dr. Rena Malik
Like something falls on your foot.
- [75:04]
Dr. Jordan Feigenbaum
Yeah. And in fact, you look at people under the age of 18, 75% of their injuries are dropping a weight on themselves. This goes down as people get older and older and older. But people can fall, people can, you know, other stuff can happen. But the majority are overuse injuries, which is a training load or exercise load related thing. So the way I think about technique is that it should be somewhat repeatable. We look at elite athletes and how they lift. For example, there are variations in all dimensions, all three dimensions, slightly forward, twist, whatever, they're slightly different rep to rep, but they're mostly repeatable. Each Rep looks somewhat similar, but not a carbon copy. But repeatable. That's criteria one. Criteria two, is the technique efficient? How much extra energy are you putting into the implement to lift it versus other stuff that doesn't actually cause the weight to move. This would be like loss of balance. This would be like the bar or the dumbbell or whatever. Starting in the wrong place, extra wasted energy. This is mostly for performance, not for injury risk reduction, but mostly for, hey, can you lift the most weight, for example?
- [75:59]
Dr. Rena Malik
Yeah.
- [76:00]
Dr. Jordan Feigenbaum
So might not be important for many folks, but for a person who competes in powerlifting, it's important for us.
- [76:05]
Dr. Rena Malik
Sure.
- [76:05]
Dr. Jordan Feigenbaum
And then the third part, last criteria is does it meet the points of performance that you've determined ahead of time? So for a squat, for example, how deep should you go? We're going to set an arbitrary standard of blow parallel or to parallel, or for another person above parallel. You're just setting up these arbitrary constraints, right, for how you do the exercise so that you can compare like to like, you can gauge your progress, you can make sure that you're doing it the same way each single time. That's the way I think about technique. It's the rep model. Is it repeatable, is it efficient, does it meet the points of performance? Then it's probably good enough. Technique perfect. I don't know what that is.
- [76:39]
Dr. Rena Malik
Well, isn't it variable based on anatomy a little bit too?
- [76:42]
Dr. Jordan Feigenbaum
Right.
- [76:42]
Dr. Rena Malik
Because your range of motion is limited by your anatomy to some degree, it's gonna look different.
- [76:47]
Dr. Jordan Feigenbaum
To your point, I can come up with a model for an exercise like this is the most efficient model of exercise. Right. Build muscle or lift the most weight.
- [76:56]
Dr. Rena Malik
Yeah.
- [76:57]
Dr. Jordan Feigenbaum
Right, Efficient. It's the most efficient. Right. So in a squat, the bar, whether you held in the front or back or whatever, it would be over your center of balance, which is somewhere in the middle of your foot. Right. And you wouldn't lose balance on the way down. And the amount of knee flexion and hip flexion would be carefully timed. So the bar stayed in a vertical line on the way, like all these things. Right. None of that has anything to do with injury risk. Right. Because the human body is very adaptable. We can, if we're given a stressor at an appropriate dose, adapt to just about anything. Just about anything. Right. Where our muscles adapt by getting stronger and bigger, our ligaments and tendons adapt by getting thicker and more resilient. Right. Our bones adapt by getting more dense. There's even data in like 15 year old weightlifters where they get vertebral end plate thickening on their vertebra.
- [77:45]
Dr. Rena Malik
Really?
- [77:46]
Dr. Jordan Feigenbaum
Yeah. And yeah, as an adaptive response, right. Their anterior cruciate ligament gets thicker, hypertrophied due to the force that they're forced to absorb. Tennis players and their dominant serving arm grow longer. Right. Than their other non dominant arm. And it's like these are all adaptive processes to better suit you for the task that you're doing.
- [78:04]
Dr. Rena Malik
Right.
- [78:05]
Dr. Jordan Feigenbaum
So the, the analogy I like to use for injury risk is you're overdrafting your account. You got 12, you got a thousand dollars in the account. You try to draft 1200 out, well, you can get an overdraft fee, which we call an injury. The technique thing has nothing to do with your balance and what you're trying to take out. It's, oh, you swipe the card with your left hand, not your right hand. You swipe the card wrong. And I'm like, well, that sounds silly. Yeah, it's just an overdraft fee. That's the best way. I can kind of describe this.
- [78:28]
Dr. Rena Malik
What about like deadlifts and RDLs? I think people worry a lot about injuring their backs.
- [78:32]
Dr. Jordan Feigenbaum
Totally average human is going to have a back injury at some point in their life, right. Or low back pain, whether or not it's from an activity or, you know, happened with unknown cause or whether from trauma. Right. We don't, we don't know. When you look at the actual evidence on competitive powerlifters, right? So powerlifting is a sport. We use that term sport charitably because I don't know how athletic we are, but it is an organized set of rules that people agree to participate in. Where you do the squat bar on your back, squat down, bench press, everyone knows what that is. And deadlift, picking a bar up from the, from the ground, you have three attempts in each discipline to lift the most amount of weight, heaviest total, best attempt between all three disciplines wins. There's weight classes, age classes, etc. When you look at data on power lifters who have to do the deadlift, right. The injury risk is again, two to four injuries per thousand participation hours. And you compare that to CrossFit to bodybuilding, to Olympic weightlifting, where you don't actually have to do the deadlift in order to participate in the sport. It's the same injury rate. So if deadlifts were uniquely injurious, you'd expect to see a spike in power lifters, especially in low back. But as it turns out, just humans have a couple hot spots for injury anyway. Shoulders, knees, backs. And that doesn't seem to matter if you exercise or not. Those are just the most commonly injured or commonly reported areas of pain in humans. And so what I think happens is that most people, especially as they age, have had some incidence of low back pain from something, whether it's from sport, whether it's just from some unknown cause. And so the area remains underdeveloped, under trained. And now you have somebody like me saying you should deadlift, you know.
- [80:14]
Dr. Rena Malik
Yeah.
- [80:15]
Dr. Jordan Feigenbaum
Or some sort of hinge, Romanian deadlift, something like that.
- [80:18]
Dr. Rena Malik
Sure.
- [80:18]
Dr. Jordan Feigenbaum
Dumbbells, kettlebells, barbell, I don't care. Do something. Right. And they're like, I haven't done that before. And I've been kind of restricting myself from anything that loads that area. And then they get a little overzealous the first time that they go in. They do too much, too many reps, too many sets, that too high of a weight. So effectively, they try to withdraw $1200. They only had a thousand dollars in the account. That's the general experience that when people report back pain from those specific types of exercise, it's not that the exercise itself is uniquely injurious outside of, like, loading the area. Right. Which. It's just that the dose was too high.
- [80:56]
Dr. Rena Malik
Yeah.
- [80:57]
Dr. Jordan Feigenbaum
And further, I'd say I think the risk of not doing those exercises is actually higher of the risk of doing them. Meaning, like, if you're unprepared to interact with your physical environment in a way where you have to bend over, pick something up, whether it's kids, groceries, something. I'd prefer to be prepared for that.
- [81:14]
Dr. Rena Malik
Yeah. Well. And interesting. I don't know if, you know Jordan, the other Jordan, Jordan Syet, he does his deadlifts with a rounded back, which is like antithetical to what people think about deadlifts, because he's like, I want flexibility and I want to be able to, like, lift my kid from the crib because it's sort of not exactly from. It's actually almost a deficit, and he's fine. Like, it's. It is a way to do it if you want to.
- [81:35]
Dr. Jordan Feigenbaum
Yeah. People say, oh, you can't live with the rounded back. You're gonna explode a disc or whatever. You know, it's like you could do it with no weight, right. You just like bend over round your back and stand back up. And they're like, yeah. And I'm like, could you do with the PVC pipe? And they're like, yeah. And I'm like, do you think you could do it with an empty barbell? You know, and your back when exploded. Like, well, yeah. And I'm like, okay, so what you've told me then is the technique itself, the form itself is not the injurious agent, it's the load. Not necessarily just the weight. But how many reps of that weight do you do and how well prepared are you for the task that you're being asked to do? And then that kind of clicks for them. They're like, oh, shoot.
- [82:13]
Dr. Rena Malik
So you can do it. Just.
- [82:14]
Dr. Jordan Feigenbaum
We're not a car.
- [82:15]
Dr. Rena Malik
Don't overdraft.
- [82:16]
Dr. Jordan Feigenbaum
Yeah, don't overdraft. Well, look again, we're not a car. We're not like brake pads that wear down. You got to replace them every now and again, you know, in fact, it'd be like you'd be driving around in a car and your tires would get thicker as you drive. That's how we respond to exercise. We get better at tolerating the things that we've been exposed to. But we just have to start with a moderate or conservative type of dose. And I think to Jordan, the other Jordan, OJ's sort of. Maybe we don't use that for. In LA. To. To his point. Yeah. Like, if he thinks he's going to be bending over the round, it's fine. Do it. Do it rounded. I think when people on the Internet see somebody deadlift with a cat back, you know, rounded back, and they're like, injury waiting to happen. Some of that's like, aesthetic to them. Like, I don't like the way that looks.
- [83:00]
Dr. Rena Malik
Yeah.
- [83:00]
Dr. Jordan Feigenbaum
The other thing is, like, plenty of people deadlift like that. No pain. Other people deadlift perfectly have pain. Right. It's more complicated than that. It just depends on how well you are prepared for that. From a coaching standpoint, I'm like, it's probably not the most efficient way to lift. And to that I feel relatively confident outside of very unique cases. Constantinov, I think he recently passed away a few years ago. He held at the time one of the highest deadlifts ever done. Conventional. So feet inside of his hands, nine hundred and something pounds and deadlifted on purpose with a rounded back.
- [83:33]
Dr. Rena Malik
Wow.
- [83:33]
Dr. Jordan Feigenbaum
And people were like, what, what do you do? Is your skeleton made of adamantium? Whatever. He goes, he goes, no, it's an advantage for me. And I'm like, oh, interesting. So, yeah, some people will find, yeah, we'll find different strategies to do the task, but the, the premise remains humans are very adaptable. Don't let your knees go over your toes. Like, well, what if you're a catcher?
- [83:51]
Dr. Rena Malik
There's that. There's that, that YouTuber. Knees over toes.
- [83:54]
Dr. Jordan Feigenbaum
Yeah. It's like if you have to get into a position where your knees are over your toes for sport, for life or whatever, you prefer to be prepared for it. Right. If you have to pick something off the ground, you prefer to be prepared for it.
- [84:05]
Dr. Rena Malik
So really there's no, like, strict rules. It's about efficiency and. And essentially just not overdrafting, not overdoing it.
- [84:12]
Dr. Jordan Feigenbaum
Yeah. I think the biggest takeaway is, like, making sure that the dose of training is well suited to you. So my goal, if I put on, like, my personal trainer or strength coach hat, is how do I get the person to do the most amount of exercise possible? Right. The highest training load, two biggest bottlenecks. Time. And the second one is what can they tolerate right now? Their physiological tolerance or recovery capacity. I can't out kick that second one. Right. I can't out kick that second one. Because that's when I think injury risk starts to go up. Not because of how they're doing the exercise, but just the amount of exercise that they're doing. So I think that's a nice way to frame it.
- [84:46]
Dr. Rena Malik
Are weighted vests useful?
- [84:48]
Dr. Jordan Feigenbaum
First? I think all exercise is good. Big fan. You like it? I love it. Scratch, you know, fitness kink. Let's go. The thing with weighted vests are that they are billed to be a replacement or supplement for resistance training. Right. And so they would load the skeleton in such a way that prevents bone mineral density loss. They load the muscles, or to force the muscles to work hard enough to prevent sarcopenia and increase strength and hypertrophy. And this, that and the other, when study doesn't do any of that. And we've had, like, pretty robust studies on this using far heavier weights than people would be otherwise wearing from either her particular weighted vest. I'm gonna talk about 50% body weight people are wearing, right. For, like, eight hours a day, for example. This goes back to a research group out of Gothenburg, Sweden. Are you familiar with the Gravitostat theory?
- [85:38]
Dr. Rena Malik
No.
- [85:39]
Dr. Jordan Feigenbaum
There's a bunch of theories about how we regulate body weight like humans. And so this gravity stat theory is that, look, the bones sense how much you weigh.
- [85:46]
Dr. Rena Malik
Yes, I've heard the theory. I didn't know that was the name of it.
- [85:48]
Dr. Jordan Feigenbaum
Yeah, yeah. And so then if you gain too much weight, the bones will start releasing this unknown chemical that causes you to eat less, move more, whatever. And this was thought because they implanted weights inside of a belly of a mouse of rats, rather and the rats who had the implanted weights lost the proportional amount of weight otherwise. So they were like, all right, there's our rodent data, let's translate this to humans. We're going to make humans wear weighted vests for eight hours a day, 12 hours a day, and see do they lose weight, does their bone mineral density increase or whatever. So a number of studies have been done. None of that happens. Weighted vests can be useful for a few things. One, if you are trying to target a particular heart rate zone during some conditioning, like walking, running, whatever, adding load certainly can do that. The problem is if it's not, you know, it's not a very structured program, most people, when they add a weighted vest, won't exercise for as long.
- [86:39]
Dr. Rena Malik
Right.
- [86:39]
Dr. Jordan Feigenbaum
And so like while the increased pace or the increased intensity of the certain exercise that you do is maybe good or maybe just, you know, different, you're gonna do less of it. So that's, that's problem one, but doesn't always have to be trade off. Could be, yeah, potentially. Potentially could be. That's thing one. Thing two, it's not heavy enough for people to generally use for resistance training as a resistance training replacement. On the other hand, if you were at stuck at home, it's Covid time and you're like, look, I gotta find a way to exercise my legs in a way that's challenging to me. So I'm like, all right, well what if you did split squats with a 30 pound vest on? Maybe that gets you somewhere near failure in the 10 to 15 or 10 to 20 rep range, whereas normally without the vest you could have done 50. Right, right. So potentially use potential use case there. Right. But it doesn't burn more calories really, because again, people will end up exercising for a shorter period of time or doing less total work. And to the extent that exercise has an effect on weight management anyway, it's pretty modest. So like you can kind of put that to the side. Doesn't really increase bone mineral density, although
- [87:44]
Dr. Rena Malik
that's what people say. That's the, that's the whole, the calorie thing. No. The bone mineral density.
- [87:48]
Dr. Jordan Feigenbaum
Oh, yeah. No, like definitively no. Like hard. No. And, and, and I say that relatively confidently because even like heavy resistance training, we think it does its best work at when people do this early in life, really maximizes that sort of mountaintop of bone mineral density, which is going to go down as you age. And then the secondary effect after you do early in life is later in life, it makes that decline slower. All Way heavier than weighted vests. There's this thing, it's called osteogenic index. Basically refers to how much strain is placed on the bone to cause it to increase bone mineral density. Heavy resistance training, Very high plyometrics where you're landing. High impact jumping. Yep. Very, very high. Weighted vest, not high because it's not heavy enough is the problem.
- [88:36]
Dr. Rena Malik
Because I noticed when I don't, I'm not good about wearing it because I just forget. But if I go for a walk, I have to come and take it off after my like one circle around the neighborhood because I know I'll keep walking but like I would not be able to continue as long as I normally would.
- [88:49]
Dr. Jordan Feigenbaum
Yeah. And so, you know, there are maybe some unique conditioning benefits to be had by working in different intensity ranges. Right. Zone two versus zone three, Zone four. Mostly performance related, not health related. Right. But for bone mineral density. Yeah. I feel pretty confident in saying, like it's not enough. And I actually don't know if it's beneficial in any real meaningful way. And my fear is that people will buy the weighted vest and then not do the stuff like lift weights, for example.
- [89:18]
Dr. Rena Malik
I think, I think most people are doing it just to add something when they go for a walk, at least to my knowledge, which I don't think is harmful as.
- [89:24]
Dr. Jordan Feigenbaum
Nope.
- [89:25]
Dr. Rena Malik
You know, totally fine and may be beneficial potentially.
- [89:28]
Dr. Jordan Feigenbaum
Yeah. Yeah. I would suspect if people are going to use it for conditioning, assuming they're doing the same total amount of work, whatever, maybe more work. Yeah. Neutral effect to potentially beneficial bone mineral density. Relatively confident saying no effect to date, based on available evidence. Muscular strength really no effect, particularly compared to actually lifting weights or even calisthenics.
- [89:47]
Dr. Rena Malik
Not the expense of those things.
- [89:49]
Dr. Jordan Feigenbaum
Yep, agreed.
- [89:51]
Dr. Rena Malik
How does calisthenics differ from like, I know that people who resistance train are like, calisthenics is not as good, but is that true? Is calisthenics not sufficient for muscle building?
- [90:02]
Dr. Jordan Feigenbaum
Sure. It really, it really depends what your, you know, the extent of the outcomes that you're looking at. If you're talking about just generally improving muscular strength. Right. So muscular force production, increasing muscular size, calisthenics, you can accomplish a great deal of that. The problems are similar to what we talked about with working out at home. If you don't have the requisite strength, mobility, coordination to do some of the, to do the exercises, it's going to be challenging to do them at an appropriate intensity. So for example, how many push ups could you do from your toes unbroken?
- [90:32]
Dr. Rena Malik
I don't know, like 10.
- [90:33]
Dr. Jordan Feigenbaum
Yeah, we'll hype it up. 20. Let's say 20, whatever for the Internet. That represents a hard enough challenge for you from a strength perspective and from a muscular hypertrophy perspective, you're getting close enough to failure in a rep range that's not totally governed by just conditioning. Great. Me, I can do. We'll just say more than, more than 20. Right. So I would have to pick a variation of the push up that is more challenging where I'm at a mechanical disadvantage. So is it a narrow grip push up? Is it a deficit push up? Is it a pause pushup handstand push up? Sure. Right. Is it a one armed push up? Right. So there are options, but at some point I'm either going to run out of mobility to do that exercise or, you know, it's otherwise going to be inaccessible for me just because I'm either not well suited for that or less well trained. And so the problem then just becomes how do you keep progressing?
- [91:28]
Dr. Rena Malik
Right.
- [91:28]
Dr. Jordan Feigenbaum
And there are calisthenics people out there who have solutions for all these things. Like, look, you can't do a squat, do this. Or you can do a squat, but it's light, do this. And there are seemingly, you know, nice progressions and regressions. I'm aware of all that. I think it can't. Calisthenics can be a powerful tool if again, somebody has the coordination and the mobility to access all of those. Conversely, you go to a gym a lot easier.
- [91:51]
Dr. Rena Malik
Right.
- [91:52]
Dr. Jordan Feigenbaum
A lot more loading, a lot more options. Right. And so when we talk about strength, strength is specific to how it is developed and how it's tested. Right. So when you say strength, we talk about hand grip strength, we're talking about, you know, isotonic, isometric leg extension strength. We talk about one rep max squat. If we're talking about a one rep max squat, well, you gotta, you're gonna have to squat. Yeah, that's, that's the best way to improve that sort of outcome. Right. But as far as muscular strength goes with respect to health, you could do a lot with calisthenics provided again, that somebody has the mobility to access all those things, regressed versions and progress progressions. That's just the biggest problem is that for folks who like, I don't get around so well, or I don't have the coordination or the balance or like the mobility, then it's like, well, it'd be nice to have some machines.
- [92:35]
Dr. Rena Malik
Yeah, you could start there, but you probably will not be able to progress as much. Right. Hand grip strength. I Always like, I know this is used as a surrogate for, for overall strength in many, many studies, but I have a hard time understanding why hand grip strength is so powerful.
- [92:52]
Dr. Jordan Feigenbaum
Yeah. So yes, the data on this is really interesting to me. You see a pretty powerful predictor of people's mortality trajectory when in respect to you're in the highest quartile, highest 25%, or the middle versus lowest. So you see that. What you don't see, and I think what's maybe introduces the problem with the research here, is that it is very challenging to improve hand grip strength through most strength training methods. Meaning, like, I could put you on a powerlifting program. And if there's any program in the world that's designed to get you stronger, it's powerlifting program. Right. It's the sole focus your hand grip strength may not change. And it's like, well, you got stronger, right?
- [93:34]
Dr. Rena Malik
That's right.
- [93:35]
Dr. Jordan Feigenbaum
And we know that muscular strength is generally a good marker or a good metric or involved in your health trajectory, but your hand grip strength didn't change.
- [93:45]
Dr. Rena Malik
Yeah.
- [93:46]
Dr. Jordan Feigenbaum
You're only testing the, obviously the intrinsic and extrinsic muscles of the hand. It just seems like to me it's more like, more like a pasco, you're fine test until it's not so. Meaning that if you have a normal hand grip strength, I'm like, okay, I know right now that your musculoskeletal system is intact. You're neurologically intact to a level where I'm not worried for you, but once it's low, I'm like, ooh, got it.
- [94:08]
Dr. Rena Malik
But getting more like you, like, it's
- [94:11]
Dr. Jordan Feigenbaum
harder to get more.
- [94:11]
Dr. Rena Malik
Right? It's hard to get more. And should you be doing like hand grip strength, is there any benefit to like just working on your hand grip?
- [94:17]
Dr. Jordan Feigenbaum
The biggest difference we see in like very strong individuals who have a lot of history in strength training versus untrained individuals is actually they have less asymmetry in hand grip strength between their dominant and non dominant hand. So you actually don't see a significant increase most of the time in their dominant hand hand grip strength compared to an untrained individual. I'm stronger than you. Why is my hand grip strength not, not as, not, not significantly higher, but my non dominant hand is much stronger than theirs and so there's less asymmetry.
- [94:45]
Dr. Rena Malik
So maybe there's some like, predetermined plateau.
- [94:48]
Dr. Jordan Feigenbaum
Like a ceiling.
- [94:49]
Dr. Rena Malik
Yeah. For, for people where their natural hand grip strength will be. So their, their dominant hand reaches it and then their non dominant Catches up.
- [94:56]
Dr. Jordan Feigenbaum
Could be. Yeah. The way I think about drops in hand grip strength is that it kind of identifies a problem after it's already happened. So it doesn't seem like a great screening tool outside of, like identifying folks that we've already missed. Do you see what I'm saying?
- [95:08]
Dr. Rena Malik
Yeah. So you don't think there's, like, value in getting a good dynamometer at home?
- [95:12]
Dr. Jordan Feigenbaum
I don't know. Unless it like. Yeah, you could argue it. Like, well, look, if you take it as normal, like, great, now you can just give it to somebody else because you don't. Because you don't need it. But if someone were to get it and they otherwise were unaware that they were maybe at risk for sarcopenia, already had sarcopenia and it identified that they were low. Yeah. Even if it's a false.
- [95:28]
Dr. Rena Malik
It would be a wake up call.
- [95:29]
Dr. Jordan Feigenbaum
That's what I'm saying. So even if it's a false positive, I'm kind of like, maybe that would be net good. And they're relatively cheap and they are like 20 bucks. Yeah, yeah. It's just the idea of training your grip strength to improve that because it would otherwise increase your health. No, I don't. I don't think so.
- [95:43]
Dr. Rena Malik
You run barbell medicine and you guys are working on creating some guidelines. Tell us about those.
- [95:49]
Dr. Jordan Feigenbaum
Yeah, well, as you know, the.
- [95:50]
Dr. Rena Malik
And the company, of course.
- [95:51]
Dr. Jordan Feigenbaum
Yeah. Barbara, I started this back in medical school. It was supposed to be like a. Just a blog because I owned a gym prior to going to medical school. I was instructed some personal trainers. That was kind of an educational role. And I was like, I was really into strength conditioning, coaching people, educating folks. Get to medical school. And as you know, most courses you go through, they talk about diet, they talk about exercise, but it's mostly lip service. They're like, look, that would be beneficial for folks. And you're like, yeah, but it's no. Like, here's how you counsel patients on that. Here's how you refer patients appropriately for that. You really have to have a self interest to kind of take that further. All well and good. Maybe a second podcast we do is on the medical education system system, but
- [96:30]
Dr. Rena Malik
it's a whole discussion.
- [96:31]
Dr. Jordan Feigenbaum
So I started this. It was just like a. Yeah. A casual interest. I'll just write stuff on here. Bringing these two worlds together. And ultimately it kind of took off, got some attention, did some consulting, built a team. And yeah, now we do a lot of education stuff in the space. We do some telemedicine and we do some injury rehab. Stuff with folks. Yeah, a little bit of everything. Anyway, I feel like sometimes we're the adults in the room, in the influencer space, not because we, you know, are just doctors or because we come from the lifting community more so I think it's a confluence of factors. Right. You have some clinical experience and clinical training, and so, you know, your empirical evidence, you get some sense there. Right. Risk, benefits, that sort of stuff. Clinical logic, that's all there. And then you have the experience in the gym and so you're like, melding,
- [97:15]
Dr. Rena Malik
you know, the community really well.
- [97:16]
Dr. Jordan Feigenbaum
Yeah, exactly. So it's a unique position. So. But sometimes I do feel like the adults in the room were like, look, everyone's talking about peptides. I'm like, where's the data? Right. Anyway, so the new food guidelines came out. Food pyramid, scientific consensus.
- [97:29]
Dr. Rena Malik
Yeah.
- [97:30]
Dr. Jordan Feigenbaum
You know, for all of the polarization around them, they're mostly the same and, like, fine with some odd choices regarding, like, beef tallow, butter, putting a big steak at the top corner.
- [97:41]
Dr. Rena Malik
Right.
- [97:41]
Dr. Jordan Feigenbaum
Like, I think if you remove imagery. Yeah. If you remove the steak and you remove the cheese thing, you move them down, you put a big bean up there. That'd be fun. And then like, take the butter and beef tallow thing out and maybe say, yeah, you keep drinks, you know, alcohol one to two, like, they keep that. I probably wouldn't. We probably would not have been charged with making these guidelines. Right?
- [97:59]
Dr. Rena Malik
Yeah.
- [98:00]
Dr. Jordan Feigenbaum
But all this polarization, all this discussion seemed like a nice opportunity to say, look, we don't have any industry influence. Right. Nobody's paying us to make these things. And further, because we have this established maybe legacy of being the adults in the room, maybe it would be useful if we came out with some dietary guidelines that would not only appeal to maybe the lifting community, but also just our gen pop audience as well. And so the most interesting thing about, in coming up with these guidelines is that you're forced with going through the history of the dietary guidelines in America and seeing, like, where do we start and how do we get here? You go back all the way to 1977. Senator George McGowan, he had this committee in the Senate that he was ahead of. And effectively this committee was designed to reduce food insecurity. Nobody's going hungry. And then they pivoted in the late 70s to say, well, look, there's a cardiac disease epidemic coming. We got to get in front of this. And so their guidelines were pretty good. It's like, eat more fiber, eat less processed food, less added sugar, you know, alcohol intake. You know, minimize it all these sorts of things. Eat lean proteins, a lot of plants and fruits and vegetables. I'm like it's pretty good, pretty good. So what we're adding to that is more specific protein recommendations which I think the new guidelines got right. Right. So you would want any 1.2 grams per kilo per day up to 1.6. That's kind of like a protein floor. I think that's reasonable. The difference from the current food guidelines to ours would be try to make some of that plant based protein, whether it's legumes or whatever. Doesn't look, you can eat meat fine with that. Can be red meat, that's fine. But like plant based protein intake, particularly high fiber plant based protein can be useful too. So put that together. We would probably push back on beef tallow and butter as like healthy cooking fats. Would generally advise against that and instead pick more monounsaturated and polyunsaturated fats. And for the carbohydrate section, fruits and vegetables section, the current guidelines are like you need at least 3 servings of vegetables and 2 servings of fruit per day. Seems reasonable, we want more, would encourage generally more. And again if you want to replace some of your protein with plant based protein like legumes, lentils, etc would be great. And then we added a supplement line to this. Mainly because if you look at survey data, 75% of the American population has taken a dietary supplement in the past year. 35 billion dollar a year industry. Yeah, exactly right. Look at big pharma, look at big wellness. Right. So because people are going to use these anyway, we thought well let's come up with some guidelines around that. And generally we want somebody to pick a supplement that has is made by a manufacturer that is certified to meet the good manufacturing processes. Looks like a little shield on their label. CGMP is third party tested so NSF informed for sport, usp, handful of other ones again on the label. That means that what's on the what your bottle? Yeah, what you. Yeah, exactly. What you think is in the bottle is actually what you're getting and the right amounts. And then it has a good amount of evidence for doing what you think
- [101:01]
Dr. Rena Malik
it's supposed to do and there's a purpose for it.
- [101:03]
Dr. Jordan Feigenbaum
Correct? Yes.
- [101:04]
Dr. Rena Malik
I will say I see so many people come to me like I'm on this line of supplements. I don't know why someone told me to just take it.
- [101:10]
Dr. Jordan Feigenbaum
Yeah, yeah. And then you just have to ask, well, is there good evidence in humans that it does this thing. What are the risks? How long am I supposed to take it? Do I ever come off like, you know, it's the same thing you would want applied to a medication. So, yeah, we put all those together and the thought is like, look, we don't think that anybody at the Dietary Guidelines for America, that committee is going to read our stuff and like, update their position. But if it can be a counterfactual to, you know, to what's out there, that's gonna be useful, it's gonna be free. That is my current writing project, mainly because I'm optimistic that many people will download it and if they catch a typo or spelling error, it's gonna be the end of me. And I can't. I can't do it. I can't do it.
- [101:47]
Dr. Rena Malik
Yeah. Hopefully that won't happen.
- [101:49]
Dr. Jordan Feigenbaum
Yeah.
- [101:51]
Dr. Rena Malik
What supplements do you think as a general population people should consider?
- [101:57]
Dr. Jordan Feigenbaum
Great question. Yeah. Somebody else sitting in this chair would say something like, well, you should take a multivitamin, you should take vitamin D. You should take fish oil, you should take protein and creatine. Somebody might say that. I wouldn't. I would just say you should only use a supplement if there's a purpose for it. So, for example, I don't think everyone needs to take a multivitamin. But if you are an individual who's experiencing food insecurity, if you have a very restricted diet, highly likely that a multivitamin is going to do some good for you or have a neutral effect. But for most people, a multivitamin doesn't do much. Relatively safe, provided it's CGMP accredited on the label, third party tested. But just to take it, most people probably not going to do much. Vitamin D. I, relatively confident, has minimal to no effect for most folks if you're not deficient. Correct.
- [102:46]
Dr. Rena Malik
Yeah.
- [102:46]
Dr. Jordan Feigenbaum
Yes. And that goes in, like, when should you be tested? And there's some new guidelines operating around that. So people are like, oh, I just take it and, you know, I don't think about it.
- [102:55]
Dr. Rena Malik
There's harm, too, to hypervitaminosis. D. Yeah, I see it. Right. Kidney stones and other things.
- [103:02]
Dr. Jordan Feigenbaum
We just did a mystery case on this guy. He was a dude at the gym, told him that vitamin D was anabolic and that it would increase his testosterone level.
- [103:10]
Dr. Rena Malik
Not true.
- [103:12]
Dr. Jordan Feigenbaum
Not true. So he was taking 10,000 IUs of vitamin D3 per day for six months. And he came in, his calcium was close to 15. Yeah. Hypertensive, severe jaw pain. Had some areas of active remodeling going on, acute kidney Injury. Anyway, so vitamin D can be very useful for people with various pathologies, especially those involving the gut. Right. So a malabsorption sort of risk or for people that are vitamin D deficient but otherwise would not just routinely recommend. Everyone's gonna take vitamin D, so that's not on my list.
- [103:40]
Dr. Rena Malik
Yes, if you're deficient.
- [103:41]
Dr. Jordan Feigenbaum
Correct. Same thing with fish oil. People like, oh, you should take fish oil. Well, there seems to be a risk of atrial fibrillation. That's thing one, Thing two doesn't seem to be doing much for folks who have not already had existing heart disease. And for people with existing heart disease, the synthetic versions like Vexipa and I forget the other one, it seems to be more effective not only for lowering triglycerides, but actually for preventing further major adverse cardiac events alongside with their other medications that they're taking. So I don't recommend any of those routinely. I recommend.
- [104:09]
Dr. Rena Malik
Do you rec. Sorry? To fish oil, do you recommend people get an omega 3 index?
- [104:14]
Dr. Jordan Feigenbaum
Oh, the test.
- [104:15]
Dr. Rena Malik
Yeah.
- [104:16]
Dr. Jordan Feigenbaum
I don't really know how it's going to change my management.
- [104:18]
Dr. Rena Malik
Well, because if it's low or less than ideal, which, you know, again, that's a controversy.
- [104:23]
Dr. Jordan Feigenbaum
Right.
- [104:23]
Dr. Rena Malik
If it's less than ideal, then do you then supplement?
- [104:26]
Dr. Jordan Feigenbaum
Yeah, so that's a good point. Right. So it's like if you test it and you find this thing and you're like, well, shoot, now I'm deficient of an Omega 3, should I take it? And I'm like, you could. I mean, that's why you did the test in the first place. Right. If it's going to affect your management, to me, I'm less confident that that index tells me, wow, this person would really benefit from a fish oil supplement versus addressing their dietary pattern. Otherwise, it's unlikely.
- [104:49]
Dr. Rena Malik
People don't all eat fish or have access to fish.
- [104:51]
Dr. Jordan Feigenbaum
Totally.
- [104:51]
Dr. Rena Malik
And that's an issue. Right?
- [104:52]
Dr. Jordan Feigenbaum
Yeah. So that's my. That's the active area of controversy where it's like, if you don't eat any
- [104:56]
Dr. Rena Malik
fish or it's too expensive. Totally.
- [104:59]
Dr. Jordan Feigenbaum
Should you take, should you take a fish oil supplement? I'm of the opinion no. But other people feel differently and that's fine too. I just think it's an active area of, of debate and I'm happy to say that I don't feel super confident about that.
- [105:11]
Dr. Rena Malik
Yeah, I think the data, I think it's controversial. I do agree with you. I don't think that there's one size fits all, but I do think most people don't get enough fish in their diet. Probably the large majority people eat too
- [105:21]
Dr. Jordan Feigenbaum
much red meat, not enough fish, not enough fiber. Yeah.
- [105:24]
Dr. Rena Malik
And walnuts and other plant sources of omega 3.
- [105:26]
Dr. Jordan Feigenbaum
100. Yep. And then so finally now we're in a protein. If somebody is not eating enough protein, a protein supplement can be very, very useful for them. Also if somebody's trying to consume an energy restricted diet, trying to lose some weight, protein can be very, very useful as a meal replacement. We think that protein is more satiating, more filling. But the other thing it does when people adopt a higher protein diet and sometimes that involves using a protein supplement is it displaces other foods which is probably its biggest effect on like total calorie intake. So you'll notice I didn't say a whey protein supplement or a soy protein supplement. Or matter doesn't matter.
- [106:01]
Dr. Rena Malik
Right.
- [106:01]
Dr. Jordan Feigenbaum
I just care that it's third party tested, CGMP approved. And then creatine can be useful if you're trying to get every possible benefit out of your resistance training. Seems to be pretty useful. It's very, very safe. Right. To the extent there are cognitive benefits or other sort of effects, maybe.
- [106:18]
Dr. Rena Malik
But it is very higher doses, right?
- [106:20]
Dr. Jordan Feigenbaum
It seems like it. But again it's like it's not, it's
- [106:23]
Dr. Rena Malik
not as rigorously studied as the muscle benefit.
- [106:25]
Dr. Jordan Feigenbaum
Not yet. But the whole thing is it's very safe. Right. So I'm like. So in contrast to peptides where we have very little research on safety and further efficacy, we have great data on safety and efficacy in creatine. And so I have minimal concerns with people taking it. And yeah, so if somebody's again trying to optimize creatine would probably be part of that stack. Other than that I don't have a lot of supplemental fiber. Supplemental fiber would be interesting. So we think we. Well, we know that supplemental fiber does not have the same effect effects on non lipid related health outcomes as dietary fiber does. That's a long way of saying this, that your diet is more important for what the health outcomes you get related to fiber than the actual fiber content of your diet.
- [107:09]
Dr. Rena Malik
Well, I guess, yes, absolutely. But soluble fiber does have some lipid benefit.
- [107:13]
Dr. Jordan Feigenbaum
100.
- [107:14]
Dr. Rena Malik
Yes.
- [107:14]
Dr. Jordan Feigenbaum
Yeah. So that's the whole thing. Right. So. So I see supplemental fiber use primarily when we're trying to get somebody's either LDL and or triglycerides down. And there seems to be a dose dependent relationship. There's. But as far as the other effects of fiber, we think they're related to the food matrix effect. So there's other stuff that's in the food that contains the fiber, whether it's flavonoids or polyphenols or otherwise displacing other foods. Unclear, but it seems like fiber supplements aren't super good for lowering blood pressure or reducing cancer. We think that's mostly from the dietary pattern, but yeah, it can be useful for triglycerides and other lipid sort of outcomes.
- [107:52]
Dr. Rena Malik
I do think that most people are fiber deficient.
- [107:54]
Dr. Jordan Feigenbaum
6% of the population right now is hitting the 25 grams a day for women.
- [107:58]
Dr. Rena Malik
Right. It's even higher.
- [107:59]
Dr. Jordan Feigenbaum
Yeah, correct. So more. Yeah, more. Again, put that big bean up there in the food pyramid.
- [108:04]
Dr. Rena Malik
Yeah. Chia seeds. I love chia seeds. Great way to get your fiber.
- [108:07]
Dr. Jordan Feigenbaum
We are fiber replete here in this studio.
- [108:11]
Dr. Rena Malik
I will ask you about protein. There's been a lot of Consumer Reports studies about lead in protein.
- [108:17]
Dr. Jordan Feigenbaum
Totally.
- [108:18]
Dr. Rena Malik
I know that there's lead in lots of foods, but how do you tell people to look like, decide what protein is right for them?
- [108:25]
Dr. Jordan Feigenbaum
To your point? Yeah. Every food that starts in the earth is going to have some amount of lead in it. If there's lead contamination after the fact is when we think it becomes a problem, particularly when it gets to high amounts. Now, yeah, that Consumer Report article came out and there's been multiple actual studies published assessing how much lead or other heavy metals are found in some of these protein supplements. And some of them do exceed the limits. There are various limits, some set as like a concern, like, we don't want it to be above this amount. And you ask why and they're like theoretical harm. And then there's the actual, like, threshold, like toxicity, sort of. Right. Those are two different, and they're very far apart. Well, we're not. What we're, we're trying to do is identify people or identify supplements or companies or protein sources that have a bunch of lead that's added in afterwards contamination. And so an easy way to do this is ask the supplement company for their heavy metals testing report. We publish ours, for example, on our website. And a lot of other companies do the same and it just shows you the amount. And if a company doesn't do that and if you ask them for it and they don't provide that to you,
- [109:29]
Dr. Rena Malik
well, probably they don't do it and put it on their website. That's a red flag.
- [109:32]
Dr. Jordan Feigenbaum
Yeah, yeah. In fact, so this is a relatively new practice for us because we had somebody write into us and they're like, hey, look, you guys sell a protein, you Guys don't market it. You don't do anything. You just. It's just there for people to use, which is great. I appreciate that about you. I'm like, thank you. Also easier on the marketing budget. But he's like, where's your heavy metals testing report? And I'm like, oh, I got it right here. You see it? I sent it to him. He goes, this should be on your website. And I was like, genius. Genius. Yeah. So I think a lot of the problems that came out around the lead toxicity was that the consumer report article used a threshold that was where there's a theoretical risk of harm if people were to eat that product every day, you know, And a lot of it, in fairness, that was, like, from a California statute from the 80s. Most vegetables that we consume have more lead than that. Yeah.
- [110:16]
Dr. Rena Malik
Yeah.
- [110:17]
Dr. Jordan Feigenbaum
So I don't know that they should have used that level, but that's the level they use, and that's why there was this sort of, like, spark of interest and debate around it. In any case. Yeah. Ask the. If you're. If it. If you're looking at a protein supplement or any supplement in general, just ask the manufacturer for their heavy metals testing report. It's not proprietary information. And like. Yeah, to your point. Probably should be on the. On the website.
- [110:36]
Dr. Rena Malik
Anyway, I will tell you an interesting story. I was speaking to a supplement company. I asked them for their lab report. They sent it to me, and I was like, this doesn't make sense, because I worked with a different company that had a. You know, that had showed me something different. So I went back to the lab, and I. Because I knew the person who ran the lab.
- [110:52]
Dr. Jordan Feigenbaum
Oh, okay.
- [110:53]
Dr. Rena Malik
And I went to the lab and I said, is this an accurate lab report? And she said, no.
- [110:57]
Dr. Jordan Feigenbaum
They just, like, made it up.
- [110:58]
Dr. Rena Malik
They made it up.
- [110:59]
Dr. Jordan Feigenbaum
What?
- [110:59]
Dr. Rena Malik
Yeah. It was the craziest thing. And that was the moment in my head when I was like, look, this is so the wild wild west. The supplement industry is the wild wild West. And. And, like, that's scary.
- [111:10]
Dr. Jordan Feigenbaum
Yeah. I will tell you. So we're small. Supplement. And again, it's mostly because people kept asking us, like, what would you recommend? And, like, here. Here you go.
- [111:18]
Dr. Rena Malik
Yeah.
- [111:18]
Dr. Jordan Feigenbaum
I stay up to date on the research anyway, so I feel fine about that. Not a huge moneymaker for us, but, like, I feel fine that it's there. On the other hand, when I interface with physicians, I'm like. I kind of feel embarrassed. I'm like. They're like, oh, you're just a supplement guy. And I'M like, I wish I was living that lifestyle.
- [111:31]
Dr. Rena Malik
I should at least you know what you're putting out there is safe.
- [111:34]
Dr. Jordan Feigenbaum
Yeah. So I just feel like I'm doing a service, but at the same time, like taking some heat for it. Anyway, we have to pay a lot of money for every batch of our supplements to be tested, not once, not twice, but through the entire life cycle. That supplement lives in our distribution facility. I know what that, that number is, and it's not insignificant. And we're small. Right. So I suspect for a larger company that's got more product to test, it would be even larger. So it's got, it's got to be financially, like they're disenfranchised from doing it. And then two, the public doesn't care. Because if the public was demanding it, they're like, well, we can't get around this cost. Yeah. So that's, that's the only way. There are large companies right now that are not third party tested, don't do any of this stuff.
- [112:14]
Dr. Rena Malik
They're just really good at marketing.
- [112:16]
Dr. Jordan Feigenbaum
It goes to the marketing budget.
- [112:17]
Dr. Rena Malik
Yeah. Last question I want to touch on is you said that the protein recommendations of 1.2 grams per kilogram to 1.6 is sufficient for most Americans. Now is this also sufficient for someone who doesn't, who's sedentary?
- [112:32]
Dr. Jordan Feigenbaum
Yeah, that's a great question. So everybody got excited about these protein guidelines. Like, look, more protein. Yes. Average American, average American adult eats 1.07 grams of protein per kg body weight per day. Now, obviously there are people lower than that and there are people higher than that. I'm certainly contributing to the higher end, whatever. And most Americans do not exercise. Right. So right now most Americans are in no danger of being protein deficient.
- [112:58]
Dr. Rena Malik
Yes.
- [112:59]
Dr. Jordan Feigenbaum
No danger. Adding more protein to their diet would move them even further away from that risk. Would it instill any health benefits, though? Going back to the earlier point, if they were adding minimally processed or unprocessed sources of protein that displaced other foods. Like, I think one of the most common ways that we get our protein is our hamburgers, for example. No hate comments against hamburgers. Big, big fan of hamburgers, generally speaking, but like, probably not all the time. So that can be useful. It's. Adding protein might be beneficial for weight management if it does that for a person who's insufficiently active, but it would be way better if they started lifting weights. And so if I had the opportunity to again wave my wand overnight, 10% of America now is eating 1.6 grams of protein per kilogram body weight per day or 10% of America is now meeting the physical activity guidelines. I pick the latter every time.
- [113:50]
Dr. Rena Malik
And ideally both.
- [113:51]
Dr. Jordan Feigenbaum
Ideally both. But if we're already eating like kind of almost enough protein, like let's exercise, that's a far bigger lever to pull eating more protein. If I can wave two wands, maybe three wands. One wand for the exercise, the other one for the protein. The third wand make that protein come from a plant based source for. To get the fiber benefit too. I'm like, that's my. Yeah, maybe, maybe that should be in the guidelines. Just the three, the three wand rule.
- [114:15]
Dr. Rena Malik
Yeah. I think it missed on the fiber. I mean they mentioned fruits and vegetables, but you know, I think, I think we need to really focus in on fiber.
- [114:23]
Dr. Jordan Feigenbaum
It was a retreat. Yeah. Like the my plate stuff that came out in 2011 to replace the original guidelines from 92. Original pyramid, rather from 92 were heavily plant focused, lots of beans, more fiber. More fiber, more fiber.
- [114:35]
Dr. Rena Malik
It's quite evidence based.
- [114:37]
Dr. Jordan Feigenbaum
Told. Yeah. And in fact, if you read the 20 to 25 consensus, scientific consensus for these new guidelines, they're still plant based, protein, more fiber, whatever. And then when they put together the newest food pyramid, I think somebody just went into Canva, they might have been a little drunk and they were like, put a steak up there. Hell yeah, brother. Right.
- [114:56]
Dr. Rena Malik
Just because the average person is going to see that and be like, steak is at the top.
- [115:00]
Dr. Jordan Feigenbaum
Yeah. And cheese.
- [115:01]
Dr. Rena Malik
I can eat as much steak as I want. Which is, you know, and if you look at the data, and again, not all red meat is treated the same in data, but if you look at the data, ideally less than two servings a week.
- [115:13]
Dr. Jordan Feigenbaum
Yeah.
- [115:13]
Dr. Rena Malik
You know, in terms of inflammation and fat and the other negative consequences of eating red meat.
- [115:19]
Dr. Jordan Feigenbaum
I love a good steak. I think people can eat red meat as part of a health promoting dietary pattern. I don't think it should be the sole base of your dietary pattern. And I think that's where us as science communicators get into trouble. And you know, because if somebody's carnivore or keto, whatever, they're like this idiot. They think red meat is like uniquely harmful. I'm like, well, it's just a dietary pattern that it normally comes with.
- [115:42]
Dr. Rena Malik
Correct.
- [115:43]
Dr. Jordan Feigenbaum
Can be. But if it's high fiber, otherwise correct amount of calories, you know, and the saturated fat intake is not too crazy. I'm generally a fan of it, you know, but it probably shouldn't be the base of your pyramid.
- [115:54]
Dr. Rena Malik
Right. Anyway, Exactly. All right, so we. Where can people find out more about you?
- [115:59]
Dr. Jordan Feigenbaum
Yeah, everywhere on the Internet you can search Barbell Medicine. You'll probably see my face. So sorry about that. If you don't want to do that, you go to a podcast platform, search Barbell Medicine. You won't have to see my face. But yeah, everywhere on YouTube, TikTok, Instagram, Facebook, our website, Barbell Medicine dot com. And thank you so much for having me. This was fun.
- [116:18]
Dr. Rena Malik
Awesome. We do end our podcast with four questions we ask everybody.
- [116:21]
Dr. Jordan Feigenbaum
All right, I'm ready.
- [116:21]
Dr. Rena Malik
They don't have to be about your career. They can be about anything. Okay, what is something you know now that you wish you knew earlier?
- [116:28]
Dr. Jordan Feigenbaum
Nvidia.
- [116:31]
Dr. Rena Malik
It's a good one. That's a good one. What is a non negotiable something you have to do every day?
- [116:37]
Dr. Jordan Feigenbaum
Ooh, coffee.
- [116:38]
Dr. Rena Malik
Yeah, me too.
- [116:39]
Dr. Jordan Feigenbaum
Also, just as an aside, if you're a K cup person, you're not a Keurig person, are you? Okay, thank God. Just it's not. It's not real coffee. Right. We all agree. Okay, yeah, fair enough.
- [116:47]
Dr. Rena Malik
It's convenience, but active. It doesn't taste great.
- [116:49]
Dr. Jordan Feigenbaum
Yeah.
- [116:51]
Dr. Rena Malik
What's a life hack or health hack you'd share that you haven't already shared?
- [116:54]
Dr. Jordan Feigenbaum
Ooh, put a scale in your kitchen. Like, if you don't have one already. Like, easy way for portion control. Like, not in a disordered way for most folks, but it's like you need to weigh things out occasionally and it's right there. Super easy to use. Can be useful for portion control because sometimes our eyeballs don't work very well.
- [117:10]
Dr. Rena Malik
Yeah. Also, when I started weighing out my food, I realized how little meat was actually being given to me. Like, on, like, you know, if I wanted to get enough protein, I was actually eating less than I thought I was.
- [117:19]
Dr. Jordan Feigenbaum
Yeah, that's exactly the hack, too. Not only you see the visual representation and you're like, oh, well, this restaurant has given me this. It's actually, here's how much I'm getting. So. Allows you to ballpark stuff a little more easily. Not to say that you have to get neurotic about it, but having a visual representation of this is 6 ounces of chicken, for example. This is a cup of oatmeal or rice or whatever can be very, very helpful at your own sort of dietary pattern.
- [117:41]
Dr. Rena Malik
If you couldn't be a physician or a powerlifter or a personal trainer, because they're all sort of of your line, what would you be?
- [117:48]
Dr. Jordan Feigenbaum
Radio host.
- [117:49]
Dr. Rena Malik
Yeah.
- [117:50]
Dr. Jordan Feigenbaum
Yeah. Look, I understand no one listens to the radio anymore. But that that was the whole reason why we started the podcast is because I always wanted to be like a dj.
- [117:56]
Dr. Rena Malik
Not like you've got a good voice for it.
- [117:58]
Dr. Jordan Feigenbaum
Well yeah, I have a face made for radio. That's what my mom said. And so, so I always thought I would be like, you know, welcome back to KSDK 93.7. We play the greatest hits from yesterday, Today and Tomorrow I'm your, you know, something like that. Turns out we're just talking about medicine and other nerdery. But that's fine.
- [118:16]
Dr. Rena Malik
It's great. I love being nerdy. Well, thank you so much.
- [118:19]
Dr. Jordan Feigenbaum
Thanks for having me. I appreciate it.
- [118:20]
Dr. Rena Malik
Thank you guys for joining me on today's episode of the renamelic, Maryland Podcast. If you're enjoying this content, please please please subscribe on your platform. It is a huge favor to me and to everyone listening, really, because it helps other people find the podcast. And as always, take care of yourself because you are worth it. Two Good Company Coffee Creamers are made with farm fresh cream, real milk and contain 3 grams of sugar per serving. That's 40% less than the 5 grams per serv serving in leading traditional coffee creamers for a rich, delicious experience. Whether you enjoy your coffee hot, cold, bold or frothy, two good coffee creamers make every sip a good one. Two Good coffee creamers Real goodness in every sip. Find them at your local Kroger in the creamer aisle. My dad taught me a lot, including how easy it is to forget to cancel things. So I downloaded Experian, my bff. Big Financial Friend Experian could help me cancel my unused subscriptions and lower my bills, saving me me hundreds a year. Get started with the Experian app today. Your Big Financial friends here to help you save smarter. Results will vary. Not all bills are subscriptions eligible, Savings not guaranteed. $631 a year average savings with one plus negotiations and OnePlus cancellations. Paid membership with connected payment account required. See experian.com for details. Experian.