#145 - AMA #19： Deep dive on Zone 2 training, magnesium supplementation, and how to engage with your doctor
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Summary
In this episode of the Ask Me Anything podcast, Dr. Bob Kaplan and Dr. Ron Tugnut discuss exercise, magnesium, and colonoscopy. They also discuss how to talk to your doctor about some of the things you should ask your doctor before getting a colonoscope.
Transcript
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Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
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I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can
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access the AMA episodes in full, along with a ton of other membership benefits we've created,
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or you can learn more now by going to peteratiyahmd.com forward slash subscribe.
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So without further delay, here's today's sneak peek of the ask me anything episode.
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Welcome to ask me anything. I'm once again joined by my head of research, Bob Kaplan in this episode,
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AKA Ron Tugnut. In today's episode, we go really deep on zone two. We touch on exercise a little
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bit more broadly than that. And we get into a few other tangents outside of zone two, like what is
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FTP zone five, you know, some of the anaerobic stuff, but mostly this is a super deep dive into
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zone two from a practical level. So if you heard the Inigo San Milan podcast, you'll have obviously
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an understanding of what that is. If not, don't worry because we revisit it. But more importantly,
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I think we kind of get into the how to do it. What's the dose, what type of exercise, what type
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of machines, the frequency, what if your numbers look like this, you know, all of that kind of stuff.
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So I hope by the end of this episode, you'll really understand how to bring zone two in as one of the
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four pillars to your exercise program. The other two things we get into in this episode are a kind
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of lowdown on magnesium. So we had a great question about, Hey, Peter keeps talking about
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this type of magnesium, that type of magnesium, this type of magnesium. Can you give us the skinny
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on that? And so we get into that and then we close it out with a short discussion on the,
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how do you actually talk to your doctor about some of the stuff that we're getting into here?
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A couple of weeks ago, actually a couple of months ago now, we had a newsletter that talked about
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early screening or more aggressive screening on colonoscopy, which is a sort of point of view
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that I have. And there were many questions from listeners saying, Hey, look, sure. That'd be one
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thing. If you were my doctor, we could have this discussion, but having this discussion with my
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doctor was actually much more difficult. And so I try to offer as many insights as I can into how
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one would go about doing that without being off putting and obviously trying to get the best care
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you can. So without further delay, I hope you will enjoy. Hey, Peter, how are you doing? Ron
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Tugnut. How are you? The one and only I'm doing pretty well. I feel like our AMAs have turned into
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basically a game of hockey obscurity, where every time we meet on video, you've got a different 1980s
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slash 90s goalie as your ID. That's right. Growing up, just loved the Bruins and hated every other
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team, but I had a lot of respect for Ron Tugnut. Boston Bruins saved 70 shots in a 3-3 tie. It's
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just absolutely unbelievable. It's on YouTube. Check it out. Just some of the saves that he was
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making was just unreal. It's a great game. Yeah. Mr. Tugnut actually is from my home borough of
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Scarborough, Ontario, the little crappy outpost of Toronto. I remember that. We've got a nice Easter
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egg if anybody cares to look in the Studying Studies series. If you go to, I think it's Studying
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Studies part two, and I think it's figure two. It's about chimney sweeps. Check out that figure
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caption. It's pretty impressive. I forgot about that. Thanks for reminding me. Yeah, you approved it.
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So, it's there. What do we have on my docket today for Ask Me Anything?
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We have a lot of questions related to exercise and zone two. We also have a few questions around
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magnesium, and then we got a lot of follow-up questions on a couple of weekly emails, which
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were, I think the earlier one was how to find a good doctor and the questions that you should ask of a
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doctor. And then we also had a weekly email on colorectal cancer and colonoscopy and a lot of
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questions that you should ask your GI doc before getting a colonoscopy. And we had a lot of questions
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around how should I approach my doctor with these questions? Is there a way to do that that's most
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effective? If we can get through all of that in one episode, I'll be delighted, but let's see how far
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we can. Absolutely. Okay. Zone two in exercise questions. First, type of exercise. One of the
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questions we received is, what is the best device to buy if you want to do zone two in your home?
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Rower, stationary bike, or treadmill? Bob, or should I say Ron, may I take a step back from this before
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answering it and create a bit of a broader context if there's a listener who's not familiar with exactly
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what zone two is? I'll allow it. I think it'll be helpful. Thank you. As you know, in our practice,
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we have kind of a framework for how we think about exercise and it has four components. Those
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components are stability, strength, aerobic efficiency, and anaerobic performance. Now I will
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focus on one of those today. I just want people to understand that when we talk about zone two,
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it doesn't mean at the exclusion of these other things, stability, strength, and the anaerobic
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piece. But it is the way in which we think through the aerobic piece. So you don't want a table that
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stands on three legs or two legs or God forbid one leg any more than you want a root canal. And
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therefore, one has to be very clear that when you think about zone two, you understand that it is
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but one component. In subsequent episodes of both the podcast and AMAs, we'll get much deeper into
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these other things. When you understand that, you understand, okay, well, zone two, it's got a very
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clear definition. And this was covered in a previous podcast with Inigo San Milan. I don't remember what
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number that is, but obviously we'll link to it, 85. So it is defined as basically your highest metabolic
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output, the highest amount of work that you can sustain while keeping your lactate level below
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two millimole or two moles per liter. So what does that mean in English? To understand that,
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you have to think about what's happening biochemically as you exercise or frankly do
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anything. The process of respiration, which is central to our existence, is the process of using
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substrate. And for the purpose of this discussion, let's just think about glucose and fatty acids
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and oxygen to make ATP and carbon dioxide. So let's just restate that. We use glucose. We use
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fatty acids. We use oxygen. We undergo a chemical process. So we take the chemical energy that is
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stored in the bonds of those molecules. We turn that into electrical energy. People have heard of
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something called the electron transport chain, which is the bulk of where that takes place. And then it
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gets turned back into chemical energy as we borrow from that energy to make ATP. And then ATP becomes
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our currency for how we do everything. And just again, to put this in perspective, any interruption
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in that system is fatal. So when you think about a toxin like cyanide, why does a microscopic dose of
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cyanide kill somebody instantly? It's because it actually stops that process. Now, people may already
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appreciate that there are a couple of different ways that we can go about making ATP. And it basically
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comes down to how quickly the body is asking for it. So the first step, and let's just limit ourselves
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to the discussion of glucose to make this really simple. The first step is turning glucose, which has,
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it's a six carbon ring into two smaller molecules that are each made up of three carbons called
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pyruvate. And that process doesn't yield a whole heck of a lot of ATP. It yields a little bit,
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costs a bit, makes a bit. But when you stop there, the body kind of has a choice. And the choice is,
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do I continue this process outside of the mitochondria where I make another by-product called lactate,
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and I can generate a little bit more ATP, by the way, or do I take that pyruvate and shuttle it into
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the mitochondria and undergo a separate chemical pathway and a separate process called the Krebs cycle
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where I can make many, many more ATPs. So we'll obviously link to sort of figures that make this
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much more clear graphically. But if you need to make ATP really, really quickly, you'll take that
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former pathway and make lactate because you don't need oxygen to do it. So you're not limited by the
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amount of oxygen that is being taken up by the muscle. If you have time on your hands, you'll take
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the latter pathway, which means you will utilize oxygen and actually take that substrate into the
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mitochondria and you will be able to make tons of ATP. Now, all people are not created equal,
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both genetically, but more importantly, through training. And one of the biggest things that
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differentiates the highly trained from the untrained, the metabolically fit from the metabolically
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unfit, the flexible from the inflexible is that ability to, under a greater and greater array of
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metabolic demands, make that input of substrate into the mitochondria. So mitochondrial health then
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can be somewhat estimated and proxied by the ability a person has to do this. So how would you measure
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this? I mean, shy of doing muscle biopsies and things, which obviously we're not going to do,
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how can we get an estimation of this? And it turns out one of the most valuable ways to do this is to
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measure lactate levels, because we can measure this. This lactate, if you start producing too much of it,
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will actually escape the muscle and get into your circulation. And you can measure it very easily
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with a finger prick, just as you would measure glucose or ketones or some other metabolite.
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A healthy person, when they're sitting there at rest, has a lactate level of about one millimole.
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If they get up and move about their day and walk around and have breakfast and watch TV and get in
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the car or do whatever they're doing, their lactate really shouldn't be changing. They're actually
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demanding more ATP than if they were sleeping, but a reasonably metabolically flexible person and
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healthy person, those activities I just described shouldn't at all be pushing you to generate higher
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levels of lactate. So in other words, you're not accumulating lactate. Now, what happens if we
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ask you to start doing something a little more strenuous? At some point, you're going to start
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generating lactate. It doesn't matter how fit a person is. If you push the fittest person on the
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planet, at some point, they're going to have to start generating lactate because you're basically saying,
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I need you to make energy or ATP faster than you're able to deliver oxygen to your muscles.
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And at some point they can't clear that lactate. So at some point the lactate begins to accumulate
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in excess of what is cleared and we can measure that. Now it's a bit more complicated because the
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organ that is primarily responsible for clearing lactate is the liver and it does so via gluconeogenesis
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and that takes longer. So there's a big time lag there. The other thing is different people have
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different amounts at which they clear lactate from the cell. So everything I'm describing is taking
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place in the cytoplasm of the cell. It still has to escape the cell to get into the circulation.
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And it does so via transporters called MCTs. So different people can have different levels of
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MCT expression. But if you put that aside for a moment, it's crystal clear that the fitter a person
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is, the healthier a person is, the more work they can do with less lactate. And therefore for a given
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individual, we use this metric of zone two as a place to say, how metabolically healthy are you?
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How good are your mitochondria? And that means how much work can be done while you keep your lactate
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right at about two millimole. We kind of use a slight range. We'd say about 1.7 to two millimole.
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So how does one do this? So if I'm walking down the street and I run into you and I say,
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hey, Bob, what's your zone two? And we were both in the know on this. You could literally spit out
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a metric. You could say, oh, my zone two is 200 Watts. That would assume that you're riding a bike.
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And that would mean you could hold 200 Watts for a very long period of time because you're never
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really going above two millimole. And two millimole is a very, very sustainable level of lactate
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production. People have probably heard the term lactate threshold. This is well below lactate threshold.
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Lactate thresholds for most people kind of in the four millimole area. And at lactate threshold,
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an athlete is really only able to hold that pace for, depending on their level of fitness,
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we're talking tens of minutes, if not less. And obviously peak output is going to produce lactates
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easily over 10. And in some cases over 20, those are, you know, efforts that can be sustained for
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seconds. Sort of all out two minute effort might produce that in a very fit individual.
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But zone two is functionally thought of as your all day pace, but there is an enormous variability
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between what some can do and what can't. In the podcast with Inigo, we discuss one of the studies
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that he did, I believe with George Brooks, where they compare people with type two diabetes to people
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who are normal fit people to world-class people, world-class athletes, I believe cyclists.
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And the difference in the zone two, meaning the amount of power that they could put out on a
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bicycle while keeping lactate at two was staggering, especially once you normalize for weight, which is
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really the way you want to normalize these things is not just how many Watts, but how many Watts per
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kilo. So I know that was a bit, maybe more information than people wanted upfront, but I don't
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think you can understand everything. You're probably going to want to ask me without that. So now your
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question, if I recall was, if you want to do your zone two training at home, what's the best type
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of device to do it on? Thank you for listening to today's sneak peek AMA episode of the drive.
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