← The Neuro Experience
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- [00:00]
A
We actually did a podcast on the extreme exercise hypothesis. And if you had to define what that is, the sort of definition is, like, folks doing greater than somewhere over 1500 MET minutes of exercise per week, that might be, like, too much. And then you go look at, like, data on their hearts, data on their sort of health trajectories. And in general, those folks live longer, have less incidence of disease, but a lot of the adaptations that you see in their cardiovascular system, for example, mimic or look like at just face value, some bad things.
- [00:34]
B
Jordan, welcome to the show.
- [00:36]
A
Hey, thanks for having me. I'm excited.
- [00:37]
B
What's happening. How are you?
- [00:39]
A
I'm great. Just another. I know we're not supposed to date the podcast, but just another standard Wednesday. And happy to be here. Excited to see where the conversation goes.
- [00:47]
B
So you're the epitome of every medical student, like, doctor, you're living, I guess you're living near the beach, you're podcasting, you're. You're lifting barbells. Like, completely different to what you learn in medical school, right?
- [01:00]
A
Oh, yeah, no. My DM's overflow with. With med students and people in residency, and they're like, how do I. How do I do what you do? And I'm like, that's a great question. I'm not sure that that's opportunity for most folks, but I do enjoy what I do and feel so grateful that I have this opportunity.
- [01:18]
B
Yeah. So I want to talk about the word barbell medicine. So you and I, I think this is why I really wanted to bring you on. I think we. We adapt the same type of the very. You know, no matter what I know about clinical medicine, neurology, I still believe that exercise is the elixir in terms of preventative medicine. Right now I'm about to publish a systematic review on resistance training and cognitive impairment and dementia. There's just so much happening in that space. And so that's my space. And I kind of feel like you've adapted the same mindset in terms of medicine and weights, in terms of exercise and weights and the correlation between, I guess, health and all cause mortality.
- [02:09]
A
Yeah, that's. That's probably a pretty good synopsis of it. And, you know, my background was I started out as a strength coach. I've been doing that before I went to medical school. I was doing that for, oh, I don't know, seven or eight years. And then I had a gym and was the director of education for a large, like, strength conditioning coach company. So I was in charge of kind of educating Them. And when I got into medical school, it was cool, like learning all the medical science, different disease processes, pathophysiology, things of that nature. And I'm like, and there was lifestyle at every, at every step. There was always, you know, one slide on the lecture, like, and for this particular, you know, lifestyle modifications involving dietary pattern change and exercise, those would be good. And I'm like, okay, well, at least they're paying some sort of attention to this. But there was no sort of formalized training on how to not only recommend that, but to deliver those recommendations, get people to do it. And then I was more interested in, well, what are the actual effects of exercise on different disease processes, particularly resistance training. And I kind of just went down this rabbit hole because coming where I came from in the, you know, strength conditioning world, I could see the effects, right? But as far as characterizing them more accurately and kind of seeing what it, what are the effects of exercise and in particular resistance training on, on health, health trajectory and quality of life and things of that nature, I was just more curious, like, well, where is there a compendium, for example, of like, for this disease, exercise can modify it this way. And it just, it wasn't there. And so I was like, huh, this is a niche I could probably occupy. Cause I'm interested. But I agree, I think as far as, like, what is the biggest lever to pull for, like, if you want to say longevity, or if you want to say, like, optimizing health trajectory or improving health trajectory, I think exercise is it. And then if you further kind of specify, well, what are people not really doing? And it, it, you know, when you compare aerobic training or endurance training rates to resistance training rates, more people engage in aerobic training than resistance training. Very few people do resistance training, period, globally. And so I'm like, well, this is my space. That's what I'm into anyway. So it kind of worked out if it was flipped, like most people lifted weights and like, didn't do endurance training, I'd have to expand my, my preferences, I think. But yeah, I agree with you a hundred percent. It's people don't do enough resistance training. But if you had to pick a lever, a lifestyle lever to pull for optimizing health trajectory, it would be lifting weights for sure of that.
- [04:29]
B
I'm so excited we're going to start on that. And I wanted to give you a statistic which you probably know, but did you know that 76% of US adults don't exercise?
- [04:39]
A
Oh yeah. And actually I think that's a probably charitable. That's a probably a charitable statistic, right? So because most of the data comes from like self reported activity levels, right? You just ask people, you're like, hey, on average, how many days a week do you exercise or do some sort of activity? It's called like the physical activity is a vital sign. It's two questions. It's like, hey, how often do are you active and for how long? And it sort of, then you can stratify people and oh, they are exercising versus not. And then there's usually a third question that's do you lift weights? And if so you just check in the box. So people self report this, right? And yeah, it's about 75% or so report they're not meeting the current guidelines. Not doing much activity at all. Insufficiently active is what we'd call them. Uh, interestingly, when you strap like an accelerometer to people and say like, okay, and see how much aerobic activity or, or endurance training they're doing, less than 5% of folks will actually meet the current guidelines, which is being active for at least 150 minutes per week for, for conditioning. And then if you further layer on top of that resistance training, at least lifting weights twice per week, it goes down to probably about 1%, 2%. The data is mixed on this, but because it's like, how do you actually track whether or not people are lifting weights? You can't like strap a device to them and say, yeah, you know, are, are you, are you lifting weights? But yeah, I think even that statistic that oh, 25%, one in four people are actually meeting the guidelines for exercise, I think that's pretty charitable. Um, I think the most recent meta analysis we've seen on this in adults and youth suggests it's closer to 15%. But even that I think it's an overestimate. And, but we, we all know that to be the case. If you, if you think about a hundred friends that you have and our, you know, sample is select, you know, there's a lot of selection bias there because who we hang out with, but I still think it's pretty charitable to think that, you know, one in every four people that I know is actually meeting the current guidelines.
- [06:28]
B
Yeah, it's funny that you said selection bias, right? Like the people that we hang out with. When I read this statistic, and this is actually the cdc, you know, from the physical activity guidelines.
- [06:39]
A
Yeah.
- [06:39]
B
I think to myself that I was so shocked because in my world everyone exercises. I don't see physically I just, I don't, I'm like, oh, and, and you start to get into this world and you, but that's with everything. You know, I like, I go deep on blood work, right. And when I hear that like someone's not doing like regular and I'm like, you don't know what a lipid panel is. You don't know apo beat what you haven't done your lp. Like I get so deep into it that I actually forget that there is a huge population out there that is just not looking after their health. And exercise is literally, to me it's free, it's underappreciated. But here's my, here's my current thesis, right. I, in 2019, my father had a, he had a stroke and I saw, you know, there's been a decline there evidently from there. But we, I, you know, I went, I flew to Australia, you know, he did his care and then I put him with a physical therapist who was also a post stroke personal trainer, if you will.
- [07:43]
A
Sure.
- [07:43]
B
And I was like, I actually got kicked out of the gym. Right. Every time I go back to Australia I get kicked out of these gyms because I take my parents health really serious. I'm like, what is he doing? Like he had absolutely no idea. And then I started thinking, in order for us as a society to shift this percentage and get more people exercising, it's not about just go out and just exercise. You've also got to know what you're doing in the weight room. Right. And many people you can probably imagine don't really know what they're doing. So then it really comes down to educating these so called personal trainers.
- [08:19]
A
Totally. Yeah, I know. There's a number of different specialized certifications in the US I'm more familiar with than globally for sure. There's like clinical exercise specialists, there's cardiovascular rehab specialists, there's all sorts of different specialized certifications you can get that effectively credentials people to work with folks post heart attack, post stroke, post, you know, whatever. And so what you would hope is that those certifications would empower these fitness professionals to not only recommend the correct dose of exercise, but also be able to deliver that effectively. But that has not necessarily been my experience. To me it's more just another piece of paper. And what's happening in practice is that exercise continues to be under prescribed and underdosed, so the people aren't really doing enough to make them better, to get them back to not only their previous functional level, but also surpass that. And it's Like I don't want to, you know, harp on, on, on fitness professionals too much because I don't necessarily know that it's their fault per se, but I think it is their responsibility, it is their responsibility to be a professional in that space to kind of know not only the literature but also how to like practically deliver that. And yeah, that was my same experience with my father at post mi. You know, he had multiple stints placed or whatever and he did the. Fortunately he was able to do some cardiac rehab, go to that sort of program. But I remember when I asked him, I was like, what are you actually doing? And he kind of told me and I go, yeah, so you should probably double that. And again, I do understand from a fitness professional standpoint, like you want to be risk averse, the last thing you'd want is somebody to have a bad outcome. So I understand that sort of perspective, but at the same time I think there are a lot of well characterized risks for insufficient activity. So if the dose isn't high enough, if you're not actually improving things like cardiorespiratory fitness, muscular strength, muscular size, in many cases it's like, well, you're doing something which is better than nothing. But if we had to pick, you'd want to do enough to sort of improve these not only metrics of performance, but they that also correlate well with health trajectory. And so yeah, your experience was the same as mine.
- [10:25]
B
Yeah, well, going back to the physical activity guidelines, it states that we should be doing at least 150 minutes to 300 minutes of aerobic physical activity. I would lobby this and argue against it saying that we should actually be doing a minimum of 300 minutes per week of moderate to vigorous, not just, you know, aerobic physical activity. I think the evidence is there to show that, you know, moderate to vigorous physical activity is actually better than just aerobic based training at 150 minutes per week.
- [10:57]
A
Yeah, there's some nomenclature problems in the guidelines. So like when you read them, they're like, yeah, you can do 100, any combination of 150 to 300 minutes of moderate to vigorous aerobic activity or, and, or 75 to 150 minutes of vigorous intensity sort of activity. And, but they, they always call it aerobic activity. And to further special specify, they call it, they say you need to do 500 to a thousand MET minutes of aerobic activity per week. And then it's like from a public health standpoint, it's like how many people know what a MET minute is like? Even in the fitness space. Like if you ask most professionals what is a Met minute, they're like, uh. And so yeah, it, it, there's problems with sort of the specific application of those guidelines. And I would agree with you that if you had to come up with like a public health recommendation for, you know, what is a sort of optimal target for in this case and just we'll call it conditioning. Right. Cause it could be aerobic, it could be anaerobic interval training, it could be, you know, doesn't necessarily need to be purely aerobic. It would probably be closer to 300 minutes per week and you would want people to be active on most days and you would want those activity, those sessions of exercise to be fairly long. Although again the current scientific consensus, the supporting document for the physical activity guideline says pretty much any type of activity at any duration is going to be helpful. That is true. But again, you're really trying to figure out, well, what are the optimal targets that we're looking for? And I would agree that more is better. There seems to be this dose dependent relationship between the amount of exercise volume that people do and the sort of disease modifying process. So for example, there's a dose dependent relationship between exercise volume and resting blood pressure lowering effect. It's like the more you do, the better. Same thing for blood sugar control, same thing for reduction in heart disease risk or incidence of major adverse cardiac event. And so yeah, the 150 minutes per week is a target that still most people aren't hitting. If it was 300 minutes, even less people would be hitting it. And so I guess, you know, I, I kind of feel for the people making up these guidelines because they're like, they probably want more too, you know, but they're like, well, what can we actually recommend that people are going to do? You know?
- [13:07]
B
Yeah. And I think they also don't want to scare people off because what I think as well might be happening, this is just my observational data, is they see the word 150 minutes and then they think to themselves, there is no way I'm going to hit that. So I'm just not going to do anything at all. So there's that side, but then there's also the word physical activity example. My mother and I fight a lot about this. I'm like, did you go? I bought them weight vests, they haven't got them yet. So that's what we're going to be. That's the next fight in December when I head home. But I said to mom, did you Exercise. And she's like, louisa, I did the gardening, I put the clothes on the line. What more do you want me to do? I'm like that, that's not exercise, that's just, you know, daily productivity.
- [13:45]
A
Sure, yeah, yeah.
- [13:46]
B
And so that's as well. Do you think that there is a problem there?
- [13:49]
A
Yeah, I think. And again, this comes down to like wording and verbiage and again, just public sort of health campaigns. They, you know, the guidelines do recommend again for the conditioning component, the 150 to 300 minutes of moderate to vigorous aerobic activity, which again we should just call conditioning. But they effectively don't delineate between physical exercise, like physical activity and exercise. Exercise being a sort of specialized form of physical activity that is purpose driven, tends to be repetitive, tends to be designated to improve aspects of physical performance and physical health. Whereas physical activity is more just movement. Right. And so gardening would be, it's movement, it's, you know, it is physical activity, but it's not exercise. And the, the biggest part, the biggest issue with gardening, if we, I don't want to harp on gardening too much because gardening seems like a fun activity.
- [14:37]
B
Right though, by the way. Therapeutic activity.
- [14:39]
A
Yeah, yeah. It's just that the sort of rate limiting steps of how, like as far as how much you can garden or how hard you can garden doesn't necessarily drive the fitness adaptations that we know share and overlap with disease modifying processes. So for example, any type of conditioning that actually improves cardiorespiratory fitness, those underlying processes that actually lead to an improvement in like VO2 max, for example, those things, it's the same underlying processes that reduce resting blood pressure, reduce your resting heart rate, reduce your sort of fasting blood glucose. Whereas activity, any sort of activity does have a little bit of benefit, but it's not to the same magnitude or same degree. And so I think, you know, even when you look at like the metabolic compendium chart. So again, if you were hard up on the 500 to a thousand minutes per week of physical activity, you'll find gardening in there. You'll find, you know, all sorts of different activities. But I think there should be a better sort of designation between all right, here's generalized physical activity, which is good, great, do it, but you also need to do formalized exercise. Um, on the other hand, that could create a barrier to folks if they're like, well, this is an exercise, should I do it anyway? It's like, well, you should do it all. I mean, that's kind of what I'm.
- [15:54]
B
Thinking, what's your take on VO2 Max? We're currently doing it right now. And you know, in my practice we're doing VO2 max. We're doing many other different metrics to measure physiological performance. I love it when done correctly, by the way, because I think that even with equipment I still see a lot of people just getting a mismatch in numbers. Maybe the, it's, the validity is off. I'm not sure with some type of equipment that people use. But I really love it as like a baseline proxy to measure. This is where you're at, this is where you should be for your age group. And then we can work up from there.
- [16:30]
A
Yeah, yeah. We kind of joke around about this idea of having a predictive composite score of like, okay, these physical elements. If we had data on these particular parameters, we could predict how you're going to do health wise. And it would be some sort of strength test, you know, whatever. If it's a leg press 1 RM or something like that, you'd also have like a VO2 max and then you'd have like a waist circumference and then maybe like a dietary fiber intake. We'll call that like a gains score. Right. So you just have this composite score and that would predict your outcome. That's mostly a joke. But with VO2 Max, it's a pretty good indicator of someone's cardiorespiratory fitness. And you can track that over time. It does tend to reliably change with changes in cardiorespiratory fitness. Where it sort of falls off is at the margins, particularly the upper, the sort of limit. So if you're an athlete and you're like, I want to get better at running a 5k, 10k marathon, something like that, you may not actually see an improvement in VO2 max that tracks well with performance because at that point your VO2 max is already so well developed that other sort of adaptations occur to improve performance in addition to like environmental considerations, pacing, motivation, things of that nature. And so I think that's more of a distraction to the utility of VO2 max in predicting how people do. There's reams and reams and reams of Data showing that VO2 Max sort of predicts people's sort of heart disease risk, for example. So the higher the VO2 max, the higher their card respiratory fitness, the lower the risk of, of all cause mortality and heart disease related mortality, for example. It just tends to be less predictive as people get really, really high VO2 maxes, especially for performance, but at that point you're like, you've already checked the box. It's like your cardio respiratory fitness is good. We don't need to like prioritize an improvement in VO2 max per se. For a person who's really, really well conditioned, they need to really focus on other elements of performance that are modifiable. So again, pacing strategy, environmental stuff that you can may be able to control. Running economy for runners, cycling economy for cyclists, things of that nature. But VO2 max might not actually change. Yeah, the other big thing is that VO2 max is modality specific. So if you're like, like Lance Armstrong, for example, had one of the highest VO2 maxes ever recorded on a bike, but then when he went to the treadmill, his VO2 max was significantly lower, only because again, most of his training was done on a bike. And so going mode to mode, different types of exercises, difficult. But I, I think VO2 Max is a pretty useful metric to track, particularly when it's underdeveloped to begin with. And then if you tracked it over time, you'd expect to see an improvement as somebody's cardiorespiratory fitness increases.
- [19:02]
B
Yeah. And have you, did you ever hear about, like, this is probably like 10, 20 years ago now, like the people who are just so fit, even Tour de France guys, high VO2 max but just dropping dead of heart attack.
- [19:15]
A
Yeah, yeah, There's a couple things going on there. It actually sort of generated this extreme exercise hypothesis, right, that, oh, you could actually over exercise to a point where that would be deleterious to your health. And there's been multiple sort of hypotheses like, oh, you're getting athlete's heart, for example. So some like left ventricular hypertrophy, that is a maladaptation. It might compromise LifeSp. When looking at those data sets, however, you don't really see that. You see folks with sort of either congenital or sort of acquired, we'll call them like channelopathies, for example, in their heart. So issues with different electrolytes and ions moving across the heart itself, and so that can cause arrhythmias. You'll also see people with other sort of underlying conditions that are exacerbated when stressed under the exercise. And also polypharmacy is a big problem, particularly at the highest level of sport. So you get people, you know, on epo, erythropoietin, for example, and there's just a lot of complicating factors. We actually did a podcast on the extreme Exercise hypothesis. And if you had to define what that is, the sort of definition is, like, folks doing greater than somewhere over 1500 MET minutes of exercise per week, that might be like too much. And then you go look at, like data on their hearts, data on their sort of health trajectories. And in general, those folks live longer, have less incidence of disease. But a lot of the adaptations that you see in their cardiovascular system, for example, mimic or look like at just face value, some bad things. So are you familiar with the coronary artery calcium score? A CAC score? Yeah, should be zero, Ideally should be zero. Although in young people it's less predictive. But for example, people who are marathoners, ultra endurance athletes or whatever, their CAC scores are significantly higher. And so it's like, wait, is this causing calcification in their arteries? Is that like a heart disease risk, for example? What it looks like is that exercise causes adaptations to actually stabilize any sort of existing plaque and also just tends to improve blood flow to the heart itself. And so it seems to be a feature and not a bug because they end up having less heart disease overall than folks who are less active, who have lower CAC scores, statins, for example, which we have, again, mountains of data showing benefit for a reduction in major adverse cardiac event, particularly in folks with elevated atherogenic lipoproteins that increases CAC score. And so it kind of depends how you got there as far as whatever parameter you're measuring, whether it's coronary artery calcium score, whether it's the size of your heart, for example. And so I don't know that there's an upper limit to how much exercise is actually beneficial. My current stance on this is that the more active somebody can be in general, the better. There are other modifying factors, but, yeah, that's kind of my general stance.
- [22:09]
B
Do you think there's conflicting evidence on plaque in the arteries and exercise? You know, on the one hand it's like, okay, it doesn't have any effect at all. And then I just read a study that was released, I think maybe like two weeks ago, saying, like, there's, you know, now correlations between exercise and lowering plaque. It's like, what?
- [22:29]
A
Yeah, yeah, I think there's a lot of interesting, like, mechanistic data surrounding exercise and how it can either modify plaques, modify lipid levels, modify, you know, atherogenic potential. And all that stuff to me is interesting, right? It's like, I want to think about that, roll it around in my brain a little bit. But I keep coming back to, well, what are the actual outcomes? Because I honestly am less concerned with what somebody's uninflammatory marker, like C reactive protein, for example, does, or what somebody's CAC score is compared to. Well, at 10 years, 20 years, 30 years, 40 years, does their risk of heart disease increase or decrease on average? That's the outcome I'm more concerned with than the, than the mechanism. The mechanism is interesting, but we're only getting like a snapshot in time of like, okay, this is happening immediately post workout or after a 12 week intervention of exercise. What I want to, I don't really care about that unless there was some sort of signal that an actual outcome was modified. And so to this point right now, I'm just more like any sort of maybe deleterious adaptation that we think based on a mechanism. It means we don't really understand the mechanism as well as we'd like to, or there's there's something else going on there.
- [23:42]
B
Yeah. As with so much in science, I've been told many times that's the whole thing. Yeah. And my mentor, who, Dr. Tommy Wood, who's, you know, one of the co authors on this paper, he's like, Louisa literally said this to me yesterday. He goes, you need to be okay with saying that exercise may or may not reduce the risk of dementia. I'm like, I can't sleep at night.
- [24:03]
A
Yeah.
- [24:03]
B
And he's like, that's it.
- [24:05]
A
I'm like, okay, yeah, just be okay saying it. I mean, even something as simple as like blood pressure. Right. So we, you know, very well established that elevated resting blood pressure is a risk factor for all sorts of cardiovascular disease and cardiovascular related outcomes. However, all exercise increases blood pressure while you're doing it. And you're like, would that increase risk of these things? But then you look at actual outcomes on exercise and not only blood pressure in general. Exercise lowers resting blood pressure and all of the sort of related outcomes to elevated blood pressure. Exercise seems to improve. And so it's like, again, what happens in the short term is I'm relatively unconcerned with unless there's some sort of outcome based sort of thing that that's important. The sort of mechanisms seem to be more squishy than a lot of people appreciate.
- [24:54]
B
I want to really separate aerobic and resistance training and I want to talk about what's actually happening in your body for both. I know you've dedicated an episode of this on your podcast. I love your podcast, by the way. It's super informative and it's straight to the point. And you really just get rid of the bullshit that's, you know, infiltrating social media right now. I share that passion as well, and I want to deconstruct it. And many people hear me say the word constant constantly Myokines, because it comes up in my work a lot. So everybody has, you know, everyone knows what that is in terms of resistance training. We'll get there. But let's just talk about what's actually happening when you are training aerobically.
- [25:35]
A
Yeah, yeah. In general, for something to be considered an aerobic form of exercise, mode of exercise, really the rate limiting step in sort of doing the task, completing the task is not necessarily muscular force production. Rather, it's more so delivery and removal, delivery of oxygen and energy to the tissue and removal of fatigue byproducts and buildup products, things like that. So it's mostly related to the cardiovascular cardiorespiratory system. And so once the task becomes challenging enough where it's more based in muscular force production and the actual delivery of energy and oxygen to the tissue is not sort of that rate limiting step, then it becomes, you know, it kind of shifts from, all right, this is aerobic or this is conditioning based, versus this is more resistance training. And so because of the different, we'll call it limiting reagents, to use like a chemistry sort of term, you get different adaptations. Yes, there's some overlap. You can think about it as a Venn diagram. Conditioning exercise, for example, can make people stronger, can increase muscular hypertrophy, just like resistance training can increase VO2 max. But the magnitude of adaptation is much, much smaller compared to doing like resistance training and its effects on strength and muscle mass. It's just that, again, whatever the limiting factor is in doing the task tends to determine the types of adaptations that you get. And so, yes, there's some overlap in the middle, but in general, you can think about resistance training improving the function and structure of the muscle tissue. And then aerobic training or conditioning training, which I think we. You should probably use that term, tends to improve sort of the energy supply and ability of the muscle to repeatedly produce some sort of locomotive force or something like that. And so that's kind of the way I think about it in my brain. One improves the function and one improves the sort of energy supply.
- [27:34]
B
The way I describe it is I usually bring in stroke volume.
- [27:40]
A
Right.
- [27:40]
B
And I bring in. Have you, have you ever used the term cardiac remodeling?
- [27:44]
A
Yep.
- [27:45]
B
Yeah. What do you, like, what do you think in terms of like, improving Stroke volume and like literally remodeling your entire cardiovascular system.
- [27:54]
A
Yeah. And in fact, this is actually an interesting topic because there was a lot of thought for a long time that resistance training had sort of unique adaptations to the heart itself. And so, for example, when you're lifting heavy weights, challenging weights, particularly when you're using like a Valsalva maneuver, right? So you're holding your breath, bracing or whatever, the afterload, so the, the sort of pressure that the heart has to push against is much, much higher. And the thought was that in resistance training you could get this left vent, this remodeling of the left ventricle. So cardiac remodeling of the left ventricle to make it thicker, stronger, and be able to better, again, eject blood against this high pressure system. And so it was thought, well, dang it, resistance training, particularly heavy resistance training, could have sort of untoward outcomes on the heart. You'd have this big left ventricle and it looks the same as having high blood pressure. That was all based on 2D ultrasound, sort of. So two dimensional ultrasound, sort of imaging. With three dimensional ultrasound and cardiac MRI, we actually now know that the adaptations to the heart are similar between resistance training and aerobic training. So you don't get in this, like, disproportionate type of cardiac remodeling between the two. And in fact, if you had to sort of rate the magnitude of cardiac remodeling that occurs, it's more profound with endurance training. But again, that's all an interesting mechanism. Right. And then it's like, okay, well, does resistance training in general increase the risk of cardiovascular disease or major adverse cardiac event? And no, it doesn't. It reduces them. Same thing with endurance training. Doesn't increase rates of like, having heart attack, stroke or whatever tends to reduce them. But yeah, a lot of cardiac remodeling happens in response to sort of any type of activity, even if it's insufficient activity. So it's just always, it's a dynamic tissue, just like bone, just like muscle, just like pretty much every other organ system that we have.
- [29:43]
B
Yeah. And it's true, right? They, I mean, who did I interview? I interviewed, you know, a Harvard cardiologist and she was describing.
- [29:52]
A
Yeah, that's a flex.
- [29:54]
B
I had to say that. She was describing the, you know, she's deep into the lp, but she was describing, you know, left ventricular, like the way that the ventricles, obviously they've got muscles around them. The, the stronger they are, the stronger they are in terms of like, Fighting off the plaque that may or may not build up on the artery wall.
- [30:17]
A
Yeah, I don't know that. I, I'm definitely not an expert in sort of vascular remodeling at the level of the heart tissue. I do know that the biggest sort of, you know, if you, if you go back in the literature 20, 30 years ago, they would say that, oh, resistance training calls, causes concentric left ventricular remodeling, for example, the vascular system, it's, you know, intimal thickening, so the muscles of the large vessels gets thicker. And all of that is true. And it was thought that that was like a resistance training specific adaptation to the cardiovascular system, whereas an endurance training specific set of adaptations would be eccentric left ventricular hypertrophy. And you didn't really see that intimal thickening in the vessels. Again, all of that seems to be awash based on modern imaging techniques. And further, yes, it is true that the vascular tree, the blood vessels in the body, do tend to get a little thicker with resistance training, but they also increase the amount of elastin content, so they actually get a little bit more pliable, which seems to be beneficial for reducing sort of atherogenic potential because the stiffer that you're and less compliant that your vessels become, if that happens due to elevated resting blood pressure, for example, that can cause an increase in plaque formation or turbulent blood flow. All sorts of things that you don't necessarily want. But again, the body is smarter than we are. It has multiple redundant homeostatic sort of mechanisms that it's like, yeah, we want to be able to thrive in the sort of environment that we're in. And that includes the tasks that you regularly expose the body to. And so if you lift weights, the body adapts in a way that gets you better prepared, better suited, better tolerant of lifting weights. Same thing with endurance training. And so I think the biggest issue in the fitness field is people want to say one is better than the other. Endurance training is better than resistance training or resistance training is better. Yeah. And it's like, no, you need both. You want some from column A, some from column B. The. I think the biggest reason why you and I maybe push resistance training a little bit more than endurance training is that far less people are engaging in resistance training than aerobic training or conditioning. People will go for a run, go for a bike ride, go for a brisk walk or whatever. That's, you know, everyone's like, yeah, I'm doing that. That's good. But when you ask somebody to lift Heavy weights, heavy ass weights. They're like, is that safe? Like, am I going to become injured and is this actually good for me? There seems to be more questions around that than like, is going for a run good for me or is going for a brisk walk good for me? Nobody questions that. But people, when you tell somebody they need to squat, you know, a heavy set of five, they're like, I don't.
- [32:54]
B
Know, it's the miseducation. It's also, you know, I still can't believe that women still are scared of lifting weights as well. So it comes down to that population group as well.
- [33:03]
A
Yeah, that'd be a really interesting podcast to take a deep dive in. And unfortunately, I think we'd be just opining eloquently based on our sort of, I don't know, conditioned responses. But I do wonder, yeah, women are in general discouraged, or maybe a better way to say this, less encouraged to lift weights or to be involved in strength sports than men from like a social perspective. And I wonder kind of where that comes from and like, what the knock on effects of that are. Because if you stratified people who aren't lifting weights right now, and you did like a sort of sex, stratified it by sex, it'd be far more women that are not engaging in resistance training. And you could make the argument that if there was, if there was a population group that stood to benefit the most, it would probably be women, particularly from like an osteoporosis standpoint, sarcopenia standpoint, because they're going to have less muscle mass, less bone mineral density at baseline than men, um, due to a number of factors. Yeah, exactly right. And so you're like, man, we really should have like a public health campaign to like get women lifting weights. I, I, I, yeah, you can do that.
- [34:09]
B
I can't exactly. You know, I can talk about things like menstruation, everything, because it's fine. But when a man starts talking about this stuff, it's like, listen, although I have been, although I have been known on Instagram to talk about like testicular size and like things like that, so totally.
- [34:27]
A
I know every time that I have a topic where I have to discuss, like, you know, changes that happen in menopause or postmenopausal stuff, I, I am very cognizant that I am not sort of the, I'm not the champion that they want. Right. But I'm the messenger that they get. And so I've had some run ins on social media where someone's like, well, you're not a woman. You haven't had a kid. You don't know. You don't know. And I'm like, I mean, that's true, but I have delivered a couple hundred kids and I've cared for a couple thousand women going through this. So I have experience, just not any personal experience actually doing the thing.
- [35:01]
B
Yeah, I mean, I even get that because I evidently don't have kids yet. And I still get. Well, Louisa, what do you know about sleep? You don't have kids. I'm like, okay, that's true.
- [35:11]
A
Yeah, there's some sort of learned experience there.
- [35:13]
B
I'm like, that's true.
- [35:14]
A
I can appreciate. I can appreciate that. But.
- [35:16]
B
Okay, so we talked about. We did touch on, you know, what resistance training does as well. Is there anything else that you wanted to add in there in terms of what resistance training is doing for health specifically?
- [35:28]
A
Oh, I mean, the list is endless. We actually wrote this. There's, like a repository of information for physicians. It's up to date, is the actual, like, collection of information. And they have effectively, articles, clinical practice guidelines, new treatment guidelines for every medical condition that we currently know about. And we were tasked with writing the article, you know, the Effects of Strength Training on Health. And it's just a massive compendium of like, here is the. Here's the effects on exercise with respect to depression, with respect to heart failure, with respect to heart attacks, with respect to stroke, with respect to diabetes. And so, effectively, exercise of any sort has a systemic effect. Every tissue, every organ, every sort of formed element in the bloodstream is affected by exercise. And in general, they tend to be very, very positive, again, to better suit the human, the organism, to the environment that they're in and the tasks that they require required to perform. And the sort of default status of humans is to be active. And so the biggest problem occurs, or the biggest series of problems that occurs in humans is due to insufficient activity. And we need to lift weights in order to sort of manifest our highest self. And so we could go through organ system by organ system. But I think a better way to conceptually think about it is that that exercise in general positively affects every organ system, every tissue, every sort of biomarker that you could potentially evaluate. And the risks of exercise are far, far, far, far, far lower than the risks of insufficient activity. And so when people go, should I exercise? The answer is almost always yes. And if it happens to be no, that means that you're on your way to the hospital for some sort of emergent or urgent action. That needs to be taken by a healthcare professional. Otherwise exercise would be better.
- [37:24]
B
Well, since you wrote this, this manuscript, if you will, this document.
- [37:28]
A
Sure.
- [37:29]
B
Do you remember anything that you wrote in terms of strength training and dementia?
- [37:35]
A
Yes.
- [37:35]
B
Or Alzheimer's disease.
- [37:37]
A
Yeah. So that's the thing, right. So when you say dementia, it's like, all right, there's a. Obviously so many different types. And in general, what you're going to see in the literature is that resistance training improves quality of life and functional sort of scores. So, like, people are able to better again, interact with their environment because they have strength, they have more sort of physiological reserve, they have more capability to do that. Whereas the big risk in most forms of dementia is due to insufficient activity. When we talk about function, like just actually being able to do stuff as far as modifying the disease trajectory, does it actually improve cognitive function? Another big problem that arises in the literature is, well, how is cognition actually being assessed? How reliable is that metric? And then how long was the follow up? Because again, you don't really care what happens at 6 weeks, 8 weeks, 12 weeks. You care what happens at a year, 5 years, 10 years. And to my knowledge, there's only been a few data sets kind of trying to investigate this, but even then you're now you're looking at like case control type type data sets rather than randomized controlled trials. It'd be very difficult to ethically do like a randomized controlled trial where like, you guys get to exercise and you guys can't.
- [38:47]
B
Yeah.
- [38:48]
A
But in general, the results are favorable. Resistance training seems to be a pretty powerful lover as far as not only improving functional scores, but also perhaps attenuating some forms of dementia and cognitive decline. And again, I think when people, you know, patients that either you've interacted with or neurologists that they would interact with in their practice, people aren't necessarily. They don't care what their score is on a moca, for example, to like evaluate their sort of cognitive performance. They care about what's their day to day life like, are they better able to do the tasks that they need to in order to remain independent, for example. And resistance training tends to be very, very powerful. The mechanisms are super interesting. Right. Myokines, as you alluded to earlier, and other changes in various biomarkers that sort of contribute to the disease processes involved. Various forms of dementia. Totally, yeah. Memory, I mean, all sorts of, you know, all sorts of stuff. Vigilance. Yeah. In general. The way I like to conceptualize it though, is the better your sort of physical 401k is the more deposits you've made throughout the life, the more you can withdraw when you need to, the better physiological reserve you have. If your 401k is empty and you happen to develop some sort of medical condition or have an issue where you're in the hospital and it's. Your balance is zero now, you're in a precarious position because you can't really tolerate any sort of insult to your person. So, yeah, I think we're going to find out more as we get better, better and better data sets. But I think in general, my opinion on exercise and cognitive sort of not only performance, but also, like, if you wanted to use the term cognitive health in general, beneficial. I don't know that it's, you know, the elixir. I don't. Yeah, I mean, you know, people ask us all the time, like, well, I have a test coming up, like, should I lift, should I lift weights? You know, is it going to improve my functional, my working memory? Is it going to improve my performance on the test? It's like, I mean, I think you need to study adequately too. Literally. Yeah. But there is good data showing that if you studied and you exercised, that's probably going to lead to a little bit better benefit and you might perform a little better on the test than studying and not exercising. So do both.
- [41:04]
B
Yeah, the way I concluded this is you're really providing the environment for an enriched learning experience. So cognitive performance, it doesn't just. You can't just get better at episodic memory if you don't practice, you know, memory. You can't just. We can provide the, you know, the blood flow and the nutrients and the oxygenation and the myokines to a specific area in the brain, but when it's there, it's provided, like the soil. I, I explain, you know, but you have to also plant the tree. This, you can't just put the soil down and then a tree. You have to plant the tree first. So you people think with learning as well. It's like, oh, I heard on Huberman that if I, you know, exercise, you know, 20 minutes after I learn something, I'm going to learn it more. It's like, yes and no. Like, you really have to want to learn that thing and you have to keep repeating it and knowing it. You have to learn it and then the exercise can help as a booster.
- [41:59]
A
Yeah, I think that probably the best sort of data we have on any sort of cognitive impairment or neurological process that results in cognitive impairment is with Parkinson's disease. And I think that kind of speaks to the general relationship between resistance training and function. It's. It. Because Parkinson's in general is the big. Most of the signs and symptoms are related to function. Resistance training tends to have like the biggest impact on, on that particular disease process compared to something like frontotemporal dementia. Right. Where you're like, all right, the function. Yeah. The functional changes aren't necessarily the hallmark of the disease process itself. People don't necessarily notice like, oh, I have a little bit of weakness or my gait speed has decreased or my, you know, whatever. That's not, Those aren't the main signs and symptoms. Whereas in Parkinson's, people have slowed movement. People have, you know, movement that's not smooth or coordinated as well as it should have been. And resistance training seems to have a bigger effect on that than something just like working memory, for example. But again, to, to use your example. Yeah, this is like resistance training is like the fertilizer to your soil. You're, you're, you're enriching the soil. You're making the environment better. Yeah. Maybe for. We could re. We should workshop that. We should.
- [43:10]
B
I actually wanted to just state here quite openly that I'll be stealing the 401k analysis because I'll tell you why I always say, you know, in terms of like doing small efforts every day I say that Albert Einstein said that compound interest is the eighth wonder of the world. And you know, you have to do small amounts every single day and deposit into your bank. But I've never used the 401k because I didn't know how to like tie it in. So I'm going to add that in. I might even trademark and steal it from you.
- [43:38]
A
There you go. Yeah. I feel like every workout I do is just a little deposit into my retirement account and hopefully I don't have to withdraw too much later on. But I like to think that having all that banked away is going to be useful should I ever need it.
- [43:51]
B
Yeah. Okay. So I want to now, just for a short time, just focus on. And we're going to get away from now like pathology and physiology and focus on what your thoughts are on the current state of this so called scientific education that is happening now, or lack thereof, on TikTok, on Instagram, on various different platforms.
- [44:16]
A
Oh, man.
- [44:16]
B
Long pause.
- [44:17]
A
I mean. Yeah, well, so I think the thing is there's almost perverse incentives for people to put out not only polarizing content, but maybe, maybe even just content that is, elicits some sort of visceral reaction from folks, positive or negative. Right. People are rewarded for doing that on, on X, on TikTok, on Instagram, you get more clicks, more views, more engagement, whatever. Whenever you say something that pisses people, some people off and that other people like, really, it really resonates with them. And it almost doesn't matter whether or not what you said was accurate. Right. It matters more like how controversial it was. And so I think that, yeah, now, now there's, there's this kind of question that you have, is like, are people doing this with nefarious intent? Meaning that do they know what they're saying is either completely incorrect. Right. Or not totally correct before they put it out there? And I fail to believe that most people have nefarious intent. I rather, I think they're just unaware of the limitations of their own fund of knowledge and they think, hey, this could be beneficial and it serves, you know, my interests as far as getting me engagement, getting me clicks, views or whatever and ultimately monetizing this sort of thing. But I fail to believe that people aren't. I fail to believe that people are trying to hurt people, you know, like with misinformation or disinformation in some cases. I just think that the scientific training required to have an adequate fund of knowledge to speak intelligently about a lot of these complex topics, that requires a lot of sacrifice and a lot of, you know, direct, directed, formalized steps to go through. You have to get your undergraduate degree, you have to do graduate training, you have to do some clinical, sort of have some sort of clinical training. And Stu, that's a long road that's not accessible for everybody. And so I get it. But at the same time, I would hope that most folks would sort of realize where their fund of knowledge ends and where uncertainty sort of begins. And I think that's just, just a lack thereof. And again, why people speak on this, it probably is due to again, being incentivized and conditioned to say things that are polarizing. And those things tend to be less true, I think, than how scientists speak. You hear a scientist say something, they're like, in general, we think this is the case and correlate. Yeah. But not always. May, sometimes could be, or whatever. And that's not sexy. Yeah, people want, people want a concrete sort of thing, right? A practical take home that's concrete. And they prefer terms like always, you know, or, and especially things that make folks feel like a better person than others. Right. And it's like the more interesting thing. And I'll get your take on this. I know you're supposed to ask the questions, but here's a question for you. What do you think the actual benefit is of communicating like science or health related information on social media is? Because my, my personal opinion is that we have this sort of parasocial relationship with folks like our followers and people who interact with us. I don't know that we're actually modifying their behaviors significantly. I think people who like, read something you post, you're like, resistance training is good. Everyone should resistance train. And the people who are already lifting weights are like, yeah, go Louisa, I love you. But people who aren't, they're not like empowered to resistance train or like motivated to start necessarily, I think. I don't know. What's your take on that?
- [47:47]
B
Interestingly, I, I get a lot of women reaching out to me saying, because of you, I started taking creatine. So I'm like, really? And I really like that because I really believe in it for several reasons. And I'm trying to make people aware of the brain health benefits of creatine, especially for, and women as well. You know, I've got my mother taking, I've got my father taking it. So I, I don't post too much. I hate the nutrition world on Instagram. I'm so happy I'm not in it. I am so happy I'm not in the nutrition space. The only thing I'll post about is omega 3 fatty acids, which I listen to your podcast on. And creatine. Right?
- [48:24]
A
Yeah.
- [48:24]
B
I won't say anything. I won't even say don't eat chocolate or don't eat sugar. It's not my field. But I do know that women are, and men like, because of you, I have started taking creatine. No one's really said to me, because of you. I've, I've worked out more. I personally, you know, I work out every single day. I don't post myself working out because I don't think people want to. I'm not an influence. People don't, I don't, I don't think people are like, oh, I want to see what Louise is doing today. Like, I don't wear pretty close to the gym. I don't wear makeup to the gym. I look quite hideous probably at the gym. So I'm like, I'm not going to put myself like working out. I look horrible. And I don't know how some women do it. I'm like, how do they look so hot working out? And I'm like, it's got, that's got to be stage. I don't have time for that.
- [49:08]
A
Yeah, the new gym, the new gym that I go to, these people, the women there, I mean, I'm impressed because they show out at the gym every single day. I'm like, well your outfits are very well coordinated. You got the camera situation. And then I mean I do video myself working out and I do post them and I'm like. And I'm like, is that really my face?
- [49:25]
B
Yeah.
- [49:26]
A
Did that happen?
- [49:27]
B
Yeah. But by the way, guys can do what you can just wake up in the morning and just end up at the gym. If I'm meant to like film, it's like I have to get up, I have to do my makeup, my eyebrows alone, like I comb them. I'm Greek. It's just like, it's a whole thing. It's like that's not happening at 6:00am.
- [49:42]
A
Yeah, I think, I think we'd like in a best, in the best case scenario we'd prefer that the information that we're transmitting on social media helps some people. Right. And is neutral to other folks. Right. It's not hurting anybody. That's sort of like best case scenario, right. It's helpful to some, not hurtful to anybody. I think that's where the, when people promote information that is not correct, whether or not they know that it's. That's incorrect. That's a totally different sort of discussion. But I think when it is potentially harmful to folks, I think that's where I have the problem. And the reason why I think that's so rampant is because of the overall low level of scientific literacy.
- [50:23]
B
Correct.
- [50:24]
A
Particularly, particularly outside of those with formalized training and then again being incentivized to post things like that. And so if you were an influencer, right, that was your whole source of revenue, just being an influencer, you would have to continually come up with content that is that people want to engage with and some of that stuff's going to be polarizing and you at some point run out of ideas and also probably get encouraged to stop saying things like maybe sometimes correlates, whatever you'd want to. You'd get encouraged and incentivized to say things more confidently and then it's a slippery slope.
- [51:01]
B
So the one thing I have a problem with is the, you know, I believe anyone can go on PubMed. I don't know if people are doing that. But it's about, do you understand the difference in, you know, the hierarchy? Like do you understand what, what actually makes just because it's like printed doesn't mean that it's a great study. That's the first thing. But you also raised a point earlier in terms of a clinical setting. I was seeing like, like clinically, like I'm seeing these, these patients and so it's, you can't, you know, I'm seeing them like today and sometimes maybe there's not a study on this. Like, I see it, I know it. I've seen thousands of these patients and somebody who's just putting up just a random study, it's like, that's, that's not true. You have to marry the both. Yeah. I believe you have to marry the scientific literature with what you're actually seeing clinically.
- [51:50]
A
Yeah, yeah. The clinical practice is a totally different beast than just like, what does the scientific evidence say? Yes, you want to marry them together, but like applying that practically, that's a, that's the next step. Right. And so, yeah, people without clinical experience who are posting, you know, PubMed related stuff, they found that usually they just read the abstract or maybe in some cases just the title. I appreciate, I appreciate the thirst for scientific knowledge. That's the kind of thirst that I, I'm after. But, but as far as, like, if it's more of like a clapback like, oh no, check this study out. It's like, yeah, so in clinical practice, here's where things change. But I get, I get it all the time. People will send me PubMed links. They're like, look at, I'm like, well, so this is an editorial. It's not actually a study, like, but it's on PubMed. I'm like, yeah, so not everything on PubMed is an actual study. Sometimes it's just an op ed that was published in a scientific journal. That doesn't mean that it's bad necessarily. But as far when you're trying to answer a question that you feel like can best be answered using empirical data, you have to go look at the empirical data, not an op ed. But you know, to your point, there are limitations to what we can that we know currently based on empirical evidence. And so a lot of clinical practice guidelines are just consensus opinions, a bunch of people sitting in a room and it came up with, hey, we should probably do this based on the available evidence or lack thereof, and kind of what we've been doing for years. And in, in many cases that's kind of all we have. But it doesn't mean that we, you know, if again, empirical evidence came out that we wouldn't modify those Things that's. That's the other thing that people get pissed off about. They're like, you changed your opinion. Why? It's like, well, new evidence came out and that's just kind of how this whole process works. But people don't like that. They want. You can't be a flip flopper, but science kind of requires you to be a flip flopper, as it were.
- [53:39]
B
So you're coming to Sydney or going. I'm not there yet. But you're going to Sydney. January, February.
- [53:44]
A
Yeah, we're going. Okay, so we've been. I've been to Brisbane, which. Okay, you've been to Brisbane a few times. They call it. They called it Bris Vegas. Right. So I thought, oh, it's going to be like Las Vegas. It's just a joke. It's not nothing there. Yeah, Sydney's excellent. I've been to Melbourne a number of times. But, yeah, this year we're going to Sydney and then we're going to Perth, which I am so excited about, to see the west coast of Australia. I heard the beaches there.
- [54:07]
B
Yeah, you should go to Rottnest Island.
- [54:09]
A
That's the thing. I heard there was Rottnest Island. I could see Koakas. I'm. I'm pumped. So it's going to be a fun time.
- [54:15]
B
The fact that you said Melbourne, right, and you didn't say Melbourne is amazing. Okay, so I like that. I was going to say I'm going to come and see you in Sydney.
- [54:24]
A
Yeah, we're gonna meet up. You know, it's funny, the pronouncing the name correctly. This is something that my whole life that I've been struggling with with just different places that I've lived. I went to med school in a place called Norfolk. Okay, so it's N O R, F O, L K. And the way that they stratify people who either grew up there, have lived there, or have just seen it on a map is based on how you pronounce the city name. So if you say Norfolk, we know that you're a casual. You've never lived there. You're not from there. You've just seen it on a map. If you say Norfolk, like I said, you've lived there, but if you're from there, you say Norfolk. And it's like the whole. You can just tell somebody's familiarity with the area based on, like, how. How long they've lived there or whatever. Same thing with Missouri. So, like, that's where I'm from is Missouri Midwest people in the Southern part of the state say Missouri. And then other people from outside of the area, they say Missouri. And you're like, missouri. Okay, well, misery. Yep. Which is. Which is accurate. So. But, yeah, Melbourne. When I went there, I. First time I did, I said Melbourne. And people like, sir, that's.
- [55:28]
B
Yeah, yeah. You'll get a huge kick up the butt for that. Well, I'm so excited. We're going to post the links to that. And you hang out on Instagram, too. What's your handle, Jordan?
- [55:38]
A
Underscore Barbell medicine. If you search barbell medicine anywhere across the Internet, you'll find our stuff. Hopefully nothing bad, but, yeah, we're everywhere.
- [55:46]
B
I have to say, whoever's your photographer, like, great photos, by the way. Like, right, camera. Yeah. Sleep camera. Unless it's just me doing it. Yeah. But whoever it is, I love it. I appreciate that.
- [55:58]
A
Yeah. The good aesthetic quality. It's funny, he. One of our very first seminars, he took a picture. He is a professional photographer. To be clear. Tom can tell he's our media guy. He is a professional photographer. He used to shoot for CrossFit. He's done, like, commercials and ads for a lot of, like, fitness brands or whatever. And he took a picture of me and I go, tom, wow. It's like, you're a professional photographer. He's like. Like a professional photographer. He's like. And then I said, the worst thing you can ever say to an actual professional photographer. Afterwards, I go, what camera is that? He's like, the camera doesn't matter, dude. I'm a pro. I could shoot this on an iPhone. I'm like, all right. Sorry, sir, you're fine.
- [56:35]
B
Anyone can buy a stethoscope, but it's like, who's actually behind that? So I love that.
- [56:40]
A
Yep.
- [56:41]
B
I'm going to post everything. Jordan, thank you so much. I'm considering this part one. I reckon we'll do a part two sometime in the future.
- [56:47]
A
I hope so. I'd love to be back. Yeah.
- [56:49]
B
Awesome. Thank you.
- [56:50]
A
Yeah, thanks.