#304 – NEW: Introducing quarterly podcast summaries - Peter shares his biggest takeaways on muscle protein synthesis, VO2 max, toe strength, gut health, and more
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Summary
In this episode, Dr. Peter Atiyah takes a look back at the last quarter's episodes of the Ask Me Anything (AMA) podcast, and shares what he's learned from each of them. In addition, he makes a case for why you should go back and listen to those episodes if you haven't already listened to them.
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 access
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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. So without
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further delay, here's today's sneak peek of the ask me anything episode.
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Welcome to a special AMA episode of the drive. We know that at times our interviews can be quite
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technical. And one of the most common requests we hear is that listeners would love to hear
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summaries of episodes we've done. As such, we are testing out a new style of AMA for this episode.
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Before I get to it, I want to sort of explain to you how I interact with my podcast. As you all know,
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I'm sure we have an amazing team of analysts who helped me prepare for each and every episode of
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the drive. So I'm typically going into an interview with anywhere from 10 to 20 pages of single spaced
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notes that have me very familiar with the topic of discussion and lay the groundwork for where
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we're going to go. During the interviews, of course, you might not be able to see this because
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hopefully the camera is on the guest and not me. I am typically feverishly taking notes because I'm
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learning as the podcast is going. At the end of every podcast, I typically take the most important
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things that I have learned and I transcribe them onto five by eight inch cards. Any podcast might
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have somewhere from one to three or four of these cards filled out. And you can imagine someone doing
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this back in the way that you would make a crib sheet in college, very small writing, but nothing
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that's on there is wasted. And sometimes there's diagrams, tables, et cetera. Well, it kind of occurred
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to us that people might want to see what my takeaways are from a podcast. And so in this episode,
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what we're going to do is look back at the last quarter's podcasts, and I'm going to share my notes
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from the podcast. In other words, I'm going to share what I learned personally and what I think were the
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most important insights. In addition to that, I'm going to comment where applicable if any of these
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learnings have led to a behavior change in me and or with my patients. In this particular summary AMA,
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we cover the following podcasts, Luke Van Loon, Courtney Conley, Olav Alexander Boo, Alex Arovinas,
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Colleen Cutcliffe, and Mark Rosekind. And through these episodes, we speak about topics such as protein,
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building muscle, VO2 max, the importance of toe strength and lower leg strength, liquid biopsies in
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cancer, the gut microbiome and probiotics, and how to mitigate the risks of automotive deaths.
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I want to be clear. I don't think that this podcast is even remotely a substitute for having
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listened to those podcasts. In fact, if you were only listening to this, having not listened to that,
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the information that I spit out will be kind of jarring and might lack some context. So my real hope
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is that this is viewed as an adjunct to being able to listen to the podcast. Furthermore, it might serve
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as a reason to go back and listen to a podcast, especially if you haven't listened to it and what
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I talk about piques your interest. As this is a new episode style for us, if you like it and if you
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find value in this conversation, please let us know because I think we'd continue it. Obviously, if
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people don't find this interesting, there's no need for us to do it and we could go back to regular
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AMAs. But our intuition is that if this is indeed valuable, a once quarterly summary might be of
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value to you as well. If you're a subscriber and you want to watch the full video of this podcast,
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you can find it on the show notes page. And if you're not a subscriber, you can watch the sneak
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peek of the video on our YouTube page. So without further delay, I hope you enjoy this special episode
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summary AMA of the drive. Peter, welcome to a special AMA. How are you doing? Very well. Thank you.
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Before we get started, there's a question I've been forgetting to ask you, but now that the McLaren
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Senna Lego is officially available, how many have you put together? I'm actually really embarrassed to answer
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that question. I have not put any together, but I have bought four. So I don't know which of those statements
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is more ridiculous. You're building the fleet when the time comes. Exactly. I'm creating a generational
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supply of McLaren MP44 Legos. And of course, I'll build a few along the way. But the goal is like to have
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one to build with every child, every grandchild, every random kid that comes to my door when I'm 80 trick-or-treating.
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Hey, you want to come in and build an MP44 with me? Like a creepy old man.
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I love it. He had such a specific request for the trick-or-treaters.
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I don't have any candy for you, but let me tell you what I got.
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But I got some Legos. You can also build them with the police who then show up about 30 minutes later.
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So just keep an extra few in the back. Yeah. I'm just accumulating.
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I love it. So for today's AMA, we're going to do something a little different.
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And it kind of stems from one of the things we hear a lot is we know sometimes our episodes can
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be technical. And with that, people love to kind of understand not only like summaries of the
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episodes, but also what you take away from them. And so with that said, do you kind of want to walk
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people through how this style came about and how we're thinking about it?
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Yes. So I appreciate the fact that our podcasts are long and obviously quite deep and that's by
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design. And I personally don't even have time to go back and listen to most of them, which is a bit
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of a shame because despite what people might assume, I'm not capable of assimilating everything
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that comes out of a podcast. So, you know, in the past year or so being cognizant of that,
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I have got into a habit, which is during the podcast itself, I am feverishly taking notes when
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the guest is speaking. Luckily, I'm able to do this off camera. So you generally don't see
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that I'm doing that, but that seems to me the best time for me to get the insight out of the episode.
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What I then do is immediately following the podcast, almost always on that day,
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maybe letting it go one more day, but usually on that day, I take out these five by eight cards I
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have, and I then re-synthesize everything from my prep and the notes that I took during the podcast
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onto five by eight cards. And here the goal is to really minimize the cards because I want the cards
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to be the highest yield thing imaginable that six months or six years from now, I would go back to,
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and that captures the salient essence of what I learned. And in particular, it's always with an
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eye towards something that I didn't know before or something that maybe I knew, but didn't realize
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how important it was. And obviously I'm always looking for something that's going to change my
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mind or change my practice. Okay. So fast forward to a month ago, we were sitting around with the
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podcast team and I don't know, I almost just mentioned in passing that I did this and I think
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you guys decided, well, can you read a couple of your cards to us? I remember we sat there on a
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call and I just rattled off a bunch of cards and I think your eyes kind of opened up like saucers and
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you thought, why would we not share this with people? This is valuable. So I think that's what
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got us here. Yeah. And I think for the listener viewer, how we're going to kind of break it up is we'll
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look at some recent episodes we've done and kind of look at it from two realms. One of what you
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think are the most important takeaways, insights, your biggest learnings. And then the second is if
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you've changed your mind, change your behavior, how you work with yourself, work with your patients,
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anything of that nature as well. And so we'll kind of hit those two prongs for each.
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The last thing I'll say is I think we're excited about this type of episode because we thought it was
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really interesting during our conversation, but for listeners and viewers, if you like it or don't
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like it, let us know because it's one of those we can always continue to do in the future because
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we clearly have no shortage of episodes coming up. I would like to reiterate that point. I mean,
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it's a bit of work to put this together. It seems to me that it's worthwhile. So if folks like this,
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they should let us know because I could easily see doing this quarterly. And if folks think this
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is not valuable enough, then I'll keep my notes to myself and I'll still be doing it because it's
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valuable to me. Yeah. You can put the notes by the McLaren Legos you haven't built yet.
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Perfect. So the first episode we're going to hit was just an awesome episode with a great guy,
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Luke Von Loon. So do you want to walk through, I mean, that was an action packed episode on a topic
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protein, which I know you're very passionate about. We've talked a lot about, but I think some of the
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insights that came from there were very interesting. And so I think let's just start with Luke's episode
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and kind of go through what were some of the biggest insights, takeaways, learnings that you
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had from that conversation. Yeah. Again, please don't confuse what I'm about to say with any sort of
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substitute for listening to the episode. In fact, if you haven't listened to the episode, it will feel
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very out of context and maybe even jarring for me to just give you my bullet points. I will preface
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that by saying one thing with respect to Luke's episode, which is this wasn't the first or even
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the second or even the third episode we did where we focused very heavily on protein. And yet, despite
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that, the richness of this episode surprised me. So with that said, we talked a lot about something
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called the fat athletes paradox. And by fat, I mean fat slash athletes paradox. So there's this idea
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that when you look at the muscle of an athlete and you look at the muscle of someone with type 2
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diabetes, so you're looking at two opposite ends of the metabolic spectrum, you're going to see large
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stores of intramyacellular lipids. You're going to see large stores of lipid within the muscle.
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I remember hearing this before, but I think what came into focus for me was the idea that this is one
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of the limitations of static information. Because in the case of the person with type 2 diabetes,
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that intramyacellular lipid store is indeed just that. It is a depot. It is a place where excess
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energy is seeping out of adipose tissue and remaining stored in the muscle. And in fact, as we saw in our
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podcast a couple of years ago with Gerald Schumann, that's one of the hallmarks of the cascade of events
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that leads to insulin resistance. So the question is, why aren't athletes not insulin resistant?
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They're the exact opposite of that. And it comes down to the fact that for athletes, that is less
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a storage depot and more a state of flux. So for the athlete, the intramyacellular lipid is indeed
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a fuel source and it's being turned over rapidly. So that's the key takeaway there that's really big.
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Just because you have triglyceride in the muscle on a biopsy, if you biopsy the muscle of an athlete
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and of the diabetic, you're going to see high amounts, much higher amounts of fat than you would
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see in a non-elite athlete, non-diabetic. But it's important to understand one is a constant flux
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that's being used to prime the pump. And the other is obviously a pathologic finding. That's the other
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point there as well, which is that the reason the athlete has that storage of fat so readily available
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is that it's an immediate access at that low end aerobic fuel point. So if you, again, think about
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zone two, we talk about that a lot. The idea is the minute you jump into that energy system,
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you want to make sure that you're burning lipid and not burning glucose.
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So moving on from fat and that athlete's paradox, the next thing I made note of here was the idea
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that amino acids are signaling molecules in and of themselves. Now this is relevant because it speaks
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to the fact that the ingestion of protein by itself stimulates muscle protein synthesis, even in the
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absence of activity. So how does this work and why is this relevant? So the amino acid signals mTOR,
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we understand that. Of course, mTOR is the master nutrient sensing molecule. And the activation of
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mTOR signals muscle protein synthesis, even in the absence of activity. Now, when you combine protein
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intake with exercise, you're going to get more muscle protein synthesis. But what I remember,
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and I made note here is Luke made this analogy of it's like the bricks calling the brick layers.
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I thought that was very clever. Another point, and this was actually brought up by Lane in one of our
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first podcasts where Lane talked about sort of the isotope labeling of amino acids to understand
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the flux of amino acids, talked about how there are about 300 grams of amino acids being utilized per
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day. And most of this is actually recycled endogenous amino acids. So what do I mean by that? So if
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300 grams of amino acids each day are being utilized, you're not eating 300 grams per day. So what's
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happening? You might be eating 150 grams per day. So that's the exogenous input. The muscle itself
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is turning over and part of what's being turned over is being reincorporated. So that much I knew,
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I don't think I knew that it was 300 grams or if I did, I'd forgotten. But this is what was really wild
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to me, was that it takes somewhere between 50 and a hundred days for the complete turnover of a muscle.
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In other words, if I look at a muscle on my body today, I look down at my bicep. It's a little bit
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interesting to think that a hundred days ago, it was made up of completely different amino acids.
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So in other words, in two to three months, you are completely turning over every muscle in your body.
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Luke mentioned later in the podcast that that turnover is even more rapid in the brain
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to the tune of about 30 days. Try to let that sit with you in your brain that 30 days ago, a month
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ago, the actual structure, the proteins that make up your brain were a totally different set of amino
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acids. We talked a little bit about the difference between bodybuilders and endurance athletes. So
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bodybuilders, when they are undergoing muscle protein synthesis, obviously based on the nature
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of the training stimulus, you're seeing more myofibular protein synthesis in the type two
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fibers. Whereas endurance athletes, obviously based on the nature of their training stimulus,
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you're seeing an increase in two things, mitochondrial protein synthesis and capillary density. Again,
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this is occurring in the type one fiber. So I'll restate that. Bodybuilders are getting bigger
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muscles, more contractile force, myofibular protein synthesis. This is occurring in the type two fiber.
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The athlete is increasing mitochondrial protein synthesis and capillary density in the type one
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fibers. An editorial comment on top of that, we want both of those things to occur. Both of those
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things should be the desired outcome. And therefore that's why we want both types of training.
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Another very interesting discussion we had was on the idea of what drives muscle protein synthesis.
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So he listed four things. And I think this is a very helpful guide as you start to think about
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protein choices you're making. So the first is what is the digestibility of the protein? So here we make
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a big contrast between plant protein and animal protein. This is where animal protein has an enormous
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advantage over plant protein and that it is far more digestible. Now, there are things that you can do
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about that. We've talked about this, right? So if you want to eat or get the majority of your protein from
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plants, that's fine, but you will need to accommodate that by, for example, cooking it, making sure it's cooked
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and or eating sources that have higher amounts of certain amino acids, which we'll get to in a second.
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The second is the rate of digestion. So not just the digestibility, but now what's the rate of digestion?
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So here, let's take perhaps the most potent type of protein, which would be, say, beef protein or
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something like that. There's a significant difference between ground beef and steak. So the rate of
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digestibility is obviously greater for ground beef than steak. Similarly, whey versus casein. They're both
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milk proteins, but whey has a much higher rate of digestibility than casein. Again, here's where you'd
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see cooked versus raw. Amino acid composition is now the third factor here. So an example would be
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collagen versus whey. Whey has a much higher quality amino acid composition than collagen. Collagen tends
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to be rich in a handful of amino acids. If my memory serves me correctly, I think it's glycine and
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proline. And whey, of course, has a more distributed wealth of amino acids. And then, of course, the fourth
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and final component here is what's the total amount of protein that's being consumed. The more protein
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that's being consumed, the more muscle protein synthesis. Quick primer on the milk proteins. We
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did talk about this, right? So milk protein is about 80% casein and 20% whey. So whey, much more rapid
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casein, much slower digestion profile. Both are valuable. We spoke about this. There was a study that
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Luke was a part of, I think we've written a newsletter on it, talking about how much, much
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larger doses of protein could contribute to muscle protein synthesis in a study that was using casein
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because of this long lag in which it was dragged out. He mentioned that plant protein is specifically
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low in lysine and methionine. And so if you're going to eat plant protein, you're going to have to
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probably look for ways to supplement those if you want to maximize muscle protein synthesis.
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Okay. We have more notes from this podcast. This is a bit longer than normal, truthfully,
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but again, there was so much here. A very powerful image in my mind from this podcast was the idea
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that when you look at the graphs that describe loss of muscle in the elderly, everybody's familiar
00:19:00.740
with what these graphs look like, which is they start out here and they drop down here. And for those
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listening to me, it's kind of like a smooth curve that drops like a stone. Usually once people
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are in the eighth decade of life in their mid seventies. And he made such a fantastic point,
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which is if you look at this at the population level, which is always how the data are presented,
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it appears to be a physiologic phenomenon. What does he mean by that? A physiologic phenomenon is
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an inevitability. It's physiologic. You're going to lose muscle as you age and it occurs on this nice,
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beautiful, smooth curve. And he said, but if you actually look at it at the individual level,
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that's not at all what it looks like. It's actually a graded step function. So again,
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if you're watching me, this is easier to see it's here's your muscle mass and then boom,
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a big drop. And then you stay there for a little while and then boom, a big drop and away you go
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and away you go. And he said, what it really comes down to the individual level is a series of discrete
00:20:01.360
periods of inactivity that result in sudden, relatively speaking, meaning over a period of months
00:20:08.400
or weeks, big drops in muscle mass that are never recovered. And I'll tell you, it's been a while
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since that episode. I think about that every minute of every day and I'm only in my fifties
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and I keep thinking, what do I need to do to make sure I don't experience one of these two week or
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two month episodes that's going to result in an irreversible loss of muscle mass. And again,
00:20:34.180
really comes down to how do you not get injured? And even if you don't have an injury, how do you
00:20:40.020
make sure you're staying active? Well, this gets to another important thing we discussed, which is
00:20:44.380
the idea of anabolic resistance. Again, this has come up over and over on various podcasts that I've
00:20:51.020
done on this topic. And basically we talked about the two drivers of this, which are aging and
00:20:58.060
inactivity. So it's crystal clear that inactivity and age drive this. So the question is, is it one
00:21:06.920
or the other? Is one simply a proxy for the other, et cetera? He offered great ideas for why maybe both
00:21:13.480
of these things play a role. So let's start with inactivity. This is the easier one to test because
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you can actually do an experiment. So you could take young people who ordinarily would not experience
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anabolic resistance and you can render them inactive. And there's very elegant experiments
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done where you take young people and you put one leg in a cast for a period of time. And the
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experiment he talked about was one week. So this is beautiful because each person is their own
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control. So young person, one leg in a cast, one leg not. And just in one week, there was a 35%
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difference between the active and inactive leg in a young person with respect to muscle protein
00:21:52.200
synthesis and therefore anabolic resistance. So again, that very compellingly says inactivity
00:21:58.200
plays a huge role, but that doesn't mean that aging inherently doesn't also account for some
00:22:04.500
of this. And there are lots of hypotheses that he put forward. Is there a decrease in amino
00:22:08.940
acid uptake, a decrease in gut absorption, a decrease in the circulation of amino acids, something
00:22:15.480
called splanchnic sequestration going up. So basically losing amino acids to the splanchnic
00:22:22.660
system in the GI tract, reduction of perfusion. Of course, that's true elsewhere in the body. So
00:22:27.720
maybe it's true here and lower muscle uptake. Finally, lower mTOR signaling. It certainly is listed
00:22:34.220
as one of the hallmarks of aging that nutrient sensing goes down. Boy, I've got even one more set
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of notes here, but I'm going to just go for it because I think it is pretty important. I made a table
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while we were talking about the difference between myofibrillar muscle protein synthesis and muscle
00:22:52.560
contractile tissue protein synthesis in response to the following stimuli. Exercise, dairy protein,
00:23:00.900
so whey and casein, and collagen protein, which again, you may recall a second ago, I said, look,
00:23:06.160
collagen protein is not a complete protein. It's mostly just got a couple of amino acids in it.
00:23:12.120
And when you look at exercise, you see that it gives a huge increase in both myofibrillar
00:23:20.500
muscle protein synthesis and muscle contractile tissue. When you look at dairy protein, you get a
00:23:27.300
big increase in myofibrillar, but not in contractile. And I think that's not surprising.
00:23:33.360
And when you look at collagen protein, it's relatively small on both. So what this highlighted for me and
00:23:38.980
the reason I made these notes was total protein quality plays a big role in myofibrillar protein
00:23:46.360
synthesis and exercise plays the biggest role in generating contractile tissue protein synthesis.
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So at the risk of maybe doing a bit more, but I apologize, I probably took more notes on that
00:23:58.640
podcast than most others. Those were the salient points that I took away from the podcast with Luke.
00:24:04.980
You hinted at a few things there in terms of like behavior changes or what you're thinking about.
00:24:10.800
One of which is just consistently thinking about the importance of always training and not taking
00:24:16.740
time off, whether that's by choice, meaning you're going on a trip or life gets in the way and you
00:24:22.180
decide not to train or by not choice, which is like an injury and you're not able to train. So
00:24:27.120
if you think about any behavior changes that you've made in either your training protein consumption,
00:24:33.660
how you look at that throughout the day since that episode, what's jumped out to you?
00:24:39.040
Yeah, a few things you've already mentioned a couple. Another one is for really long endurance
00:24:44.400
activity, which I still do some of maintaining dietary fat matters in that pathway that we talked
00:24:51.200
about at the outset where you want to maintain intramyocellular lipids. So again, not an issue for me
00:24:57.760
personally, because I've never ever been a fat, a low fat diet guy, but it's worth keeping in mind
00:25:04.440
for athletes out there who tend to be lower on their fat consumption. You are depriving yourself
00:25:10.340
of a pump prime. Obviously we talked a lot about the need for activity. I guess the two other things
00:25:16.520
I'd say before we leave this are, I have been using time restricted feeding a little bit more lately
00:25:23.160
in myself, but I'm always making sure to get protein while I'm in that non-feeding window.
00:25:30.340
Because again, I don't believe there's like a particular magic to not eating for 18 hours a day.
00:25:35.740
It's just a tool to calorically restrict. And so I don't care if I get another couple hundred
00:25:41.500
calories of protein during that window. I guess the final point here was really for my wife who is
0.94
00:25:47.840
really adamant about her collagen protein drink in the morning. And I think I feel a little more
00:25:52.440
comfortable telling her, Hey, there's nothing wrong with drinking your collagen protein.
00:25:56.100
And if you happen to really love that formulation or whatever, knock yourself out,
00:26:00.540
but it's also not a very complete protein. So maybe at a minimum supplemented with something else,
00:26:05.260
but clearly consuming a collagen protein is not a superior protein. I think that is definitively true.
00:26:13.000
One last piece on Luke before we move on is there was one quote he said, which I thought was just
00:26:18.700
really, really good and succinct and I'll read it. And then it's, you know, we can talk about it,
00:26:23.140
which is he said, I've had a lot of people in my life asking me how important is it, whether I take
00:26:27.680
my protein shake before or after the training session, but I never had someone come up to me
00:26:32.220
and say, look, how important is it if I skip one training session or miss one training session?
00:26:37.720
Consistent training is the benefit, consistent training so that every meal is a greater impact
00:26:42.420
on your muscle protein synthesis. And I thought that was really good because we see a lot of
00:26:47.360
questions come through and sometimes people may overthink potentially protein and when to take it
00:26:52.500
and when not to, but for him to say, whether you consume before or after the biggest thing is just
00:26:59.000
always be training, always be consistent and never take time off. I thought was a really good point for
00:27:04.980
people to kind of remember. Yep. Yep. All right. Let's move on to the podcast with Courtney Conley.
00:27:12.420
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