The Peter Attia Drive - #307 ‒ Exercise for aging people： where to begin, and how to minimize risk while maximizing potential

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:58.040 head over to peteratiyahmd.com forward slash subscribe. Welcome to a special episode of

00:01:06.700 The Drive. This is an episode that is like an AMA where I'm the one answering the questions.

00:01:12.420 However, it is an episode that will be available to all. One of the most common questions that we

00:01:17.900 receive through the site is from people who are quote-unquote older, we'll define that as my

00:01:24.120 cohort and up, 50 and up, who realize the importance of exercise but are wondering if it's too late for

00:01:30.180 them to start. This could be because they've never trained or they're worried about injury, they have

00:01:35.160 no idea how or where to start, or they used to exercise when they were young but they've kind of

00:01:39.920 got away from it and they're just trying to figure out what to do. As such, we wanted to create an

00:01:44.420 episode for these people. People above 50 who haven't been exercising at least recently want

00:01:51.380 to start but don't know where to begin. In this episode, we speak about exercising in that age

00:01:55.840 range as it relates to all four pillars of exercise and dive into not only why it is not too late but

00:02:02.420 what one can do to start exercising, minimize injury risk, and maximize potential. This conversation

00:02:09.420 will be a little less technical than some of our AMAs. I wanted to try to keep it a bit more

00:02:13.480 conversational and what we've done to accommodate that is included many of the studies that support

00:02:20.580 the observations and points that are being made in the show notes. Even if you're not in this quote

00:02:26.200 older slash 50 and up age category, most of you likely know someone who is like a parent and you

00:02:32.760 may find this hopefully something that you can share with them and help them to start exercising. So

00:02:37.300 without further delay, I hope you enjoy this special episode of The Drive.

00:02:46.900 Peter, welcome to a special episode. How are you doing?

00:02:50.020 Very well, thank you.

00:02:51.300 So today's episode is special in that it's kind of shot like an AMA, but it's going to be available

00:02:56.720 to everyone. And what we're going to cover is one of the most common questions that we see come

00:03:03.380 through day in, day out to the website is whether people who are quote unquote older, let's say just

00:03:10.720 for general purposes for this conversation, 50 plus who realize the importance of exercise, but are

00:03:16.980 wondering if it's too late for them to start. And this could be whether they've never trained or worry

00:03:22.280 about injury, they don't know what to do or how to do it, or they just think, you know what, it's too late

00:03:28.000 for them to really make a difference. And so we wanted to create an episode for that group, 50 plus

00:03:33.580 who have not been exercising, but want to start. And although much of what we'll talk about applies

00:03:39.260 to anyone in that age category, it also can apply to anyone of any age who is deconditioned and looking

00:03:45.020 to start slow. With that said to anyone who's younger, most likely has parents who might be in this

00:03:51.220 position. And this could be a good episode to send to them to encourage them to start. And so how we're

00:03:57.400 going to structure it is a little less technical than some of our AMAs and much more conversational as to

00:04:04.820 how you would speak to these people if they were your patients and came to you and were asking you these

00:04:10.400 questions. In the show notes, we'll have the studies that you talk about. We'll link to them. We'll link to

00:04:15.960 other content that goes much deeper, but this will be a little bit more on that conversational side. So with all

00:04:23.660 that said, anything you want to add as someone who is now in the quote unquote older category as well.

00:04:31.080 Yeah. My wife likes to refer to me as an older gentleman now. So that's right. I'm in the over

00:04:37.180 50 category, not just 50, but over 50. So a couple of things. One, as we thought about putting this

00:04:43.100 together, the goal initially was to have no figures, no studies, just really put all of that in the show

00:04:50.540 notes, but let us talk. And I've sort of begged to have a few figures because I do think that there

00:04:57.140 are times when a picture just says a lot. So for folks who are listening to us, there's going to be

00:05:03.040 a few times when I'm going to reference some figures from studies that I think really do a lot.

00:05:08.540 A couple of things to state is that we'll talk about this in detail, but we talk about 50 being a

00:05:14.920 turning point. I think another really big turning point is 65 plus. And again, we'll get to some of

00:05:20.200 these things, but we really start to notice reduction in strength at about that age. We

00:05:25.640 start to see vestibular changes that occur around that age. And that probably contributes significantly

00:05:30.220 to something we will talk about, which is the risk of falling. So while I think everything we're going

00:05:34.400 to talk about is going to be relevant to anybody who's over 50 and untrained, I will probably call

00:05:40.500 out specifically areas where when we get into that 60 to 65 year old camp, we want to be even more

00:05:46.720 mindful of things. And so I think to start, you've spoken at length about the importance of

00:05:51.860 exercise for longevity. So I don't think we need to start there, but let's say someone heard that

00:05:56.360 message is in that 50 plus 65 plus category hasn't been exercising and they come to you and say,

00:06:02.640 is it too late for me to start doing this? Is it too late for me to worry about this and start

00:06:08.400 making changes? I think it'd be helpful for people first to hear, how would you even respond to that?

00:06:13.080 I've had the same response largely for many years now. So I realized that some people will have

00:06:18.560 already heard me say this, whether it's on another podcast, but truthfully, I haven't come up with a

00:06:23.200 better analogy yet. And it's really the analogy of saving for retirement. So if you could be talking

00:06:30.800 to somebody who's in high school or college and you were talking to them through the lens of being a

00:06:36.400 financial advisor, their fiduciary, what would you say? Well, you would say, listen, there's this really

00:06:42.140 magical thing called compounding that Einstein basically said was the eighth wonder of the world

00:06:46.860 and you want to use it to maximum advantage. And to do that, you should start saving immediately.

00:06:52.760 When you get your first job, you should be saving. If not, certainly by the time you get out of college,

00:06:58.480 you should be saving. And if you do that, you don't really have to be that brilliant about it.

00:07:04.620 If you put all of your savings into an index fund at the age of 22, the probability that you are not

00:07:12.260 going to be set when you retire is so low. So that's great. But what happens if you're talking

00:07:19.160 to somebody who's 45 and due to life circumstances, like they just haven't been able to save? They

00:07:25.820 haven't made enough money to even have some disposable saving income or they've saved and

00:07:29.780 lost or invested badly or something like that. Would you say, well, too bad? No, of course you

00:07:34.500 wouldn't. I guess the point here is it is never too late to start saving for retirement, but you must

00:07:40.200 understand something, which is the longer you wait to start, the more you're likely going to have to

00:07:46.260 save, the greater return you're going to need, and therefore probably the greater risk you're going to

00:07:52.840 take. So it's never too late to start saving and it's never too late to start exercising. But I want

00:08:00.160 the message to be, don't wait because of some reason and say, well, I'm going to wait until I'm

00:08:05.860 older because. So anyway, to me, that's the best way to think about this. I think it will be helpful

00:08:10.660 for this conversation because we'll touch on these various aspects as it relates to exercise in this age

00:08:17.180 population. But can you just remind people of your four pillars and kind of how you think about each

00:08:23.060 of those pillars individually as someone is aging? Yeah. And sometimes I think of it as three or four,

00:08:29.840 but I think I'd write about it as four. So I'll stick with that. But it's basically stability, strength,

00:08:35.580 aerobic efficiency, and peak aerobic output. And you could argue, well, those are just kind of a

00:08:40.180 continuum. And so I would say, sure. But let's not get lost in the semantics. Those things, if you

00:08:47.280 define them the way I do, kind of constitute everything. Again, stability is kind of a broad

00:08:51.580 term, but embedded within stability is everything that enables you to dissipate force safely,

00:08:58.420 everything that enables you to have balance and flexibility, because believe it or not, those come

00:09:03.220 from stability. If you have balance, by definition, you have stability. You can't have balance without

00:09:09.400 stability. You can't actually have flexibility without stability. We think of training as having

00:09:15.560 a purpose. And of course, different types of training factor into these different activities.

00:09:22.200 So there are some types of training that really kind of myopically hit one of these things. So if

00:09:27.220 you're riding a bike like I do for your zone two training, well, first of all, riding a bike is a very

00:09:34.860 one-dimensional activity. There are basically no degrees of freedom outside of you

00:09:39.040 pedaling the crank. And if you do it at a fixed power output that meets the criteria for zone two,

00:09:44.960 then you're very narrowly targeting that. You're doing very little for any of the other systems.

00:09:49.540 And then conversely, there are other types of training, like rucking with a heavy weight on hills,

00:09:55.480 where actually you're targeting all four of those elements. It requires tremendous stability,

00:10:01.500 moments of strength, large segments of aerobic base or aerobic efficiency, and moments of peak

00:10:07.540 aerobic output and even anaerobic output. So that's just something to keep in mind.

00:10:13.660 You mentioned at the outset, there's a few graphs that you think will be important. I think it's

00:10:17.560 be a good spot for us to pull them up, which is one looking at the decline of muscle as we age. So

00:10:23.780 people can visually see what that looks like. And then one looking at VO2 max across different age

00:10:29.720 brackets. And so I'll share my screen here and pull them up, but I think it will be helpful for

00:10:33.780 people if you kind of talk through them and how you look at it through the lens of this conversation.

00:10:38.740 So this is a figure that I fought like crazy to include and outlive, and I got overruled and just

00:10:46.960 kicked in the groin. No way this figure was going in the book. So it really makes me happy to be able

00:10:51.360 to show this figure here. The figure for those who are not watching, it's basically four graphs and

00:10:58.880 two of them are for men, two of them are for women, two of them demonstrate fat-free mass,

00:11:04.260 which is a great proxy for muscle mass. And two of them show spontaneous or deliberate physical

00:11:10.520 activity. In that sense, you can think of it as a two by two male by female versus activity and fat-free

00:11:17.000 mass. And then each of these has kind of an X axis that shows age. Okay. So what one notices when

00:11:25.180 they look at this is that fat-free mass rises up, so i.e. lean mass kind of rises pretty significantly

00:11:36.360 from birth till about the age of 25. And then it slowly starts to go down. By the way, this is true

00:11:44.460 for males and females. Males are on the right, females are on the left. So you'll notice that from

00:11:50.760 age 25 to 75, there is indeed a gradual reduction of lean mass. But then something happens at the age

00:11:57.900 of 75, which is the fall-off in lean mass becomes much more significant. It's actually even more

00:12:04.220 noticeable in men, presumably because they're starting from a higher baseline. But this is clearly a curve

00:12:11.420 that has three segments. Birth to 25, where you're gaining, gaining, gaining. 25 to 75, where you're

00:12:18.240 slowly losing. And by the way, we know the numbers. We know that that's actually happening at 8 to 10%

00:12:23.780 per year. And then 75 and on, where you fall off a cliff. So now let's look at the lower figures. The

00:12:30.180 lower figures show physical activity level. And you can see that a very similar trend occurs. It tends to

00:12:37.520 peak a little bit earlier. So it's probably peaking in late teens and early 20s. And interestingly,

00:12:42.480 it doesn't have a huge fall-off between the ages of roughly 20 and 75. It actually stays

00:12:49.720 relatively constant. If anything, it probably dips a touch in middle age. That might have to do when

00:12:55.100 we're at sort of peak work and therefore not as busy physically. But again, you notice what happens

00:13:00.400 at the age of 75, which is physical activity level drops like a stone. And of course, this begs the age

00:13:09.440 old question, which is, which is the chicken and which is the egg? Because again, there is an

00:13:14.600 unmistakable relationship here between physical activity and muscle mass and age. And something

00:13:21.600 very noticeable happens at the age of 75. Of course, data like these cannot give us causality. In other

00:13:29.040 words, can't tell us which one's causing the other. But I think anybody who's observed people at this age

00:13:34.000 would come to the conclusion that there is bidirectional causality here. In other words,

00:13:38.740 as we lose muscle mass, we become less active. And as we become less active, we lose muscle mass.

00:13:45.720 And there's one point that I will make in addition to this, which actually came from a very recent

00:13:52.980 interview I did with Luke Van Loon. So that's an episode that you can go back and listen to in great

00:13:58.240 detail if you haven't already. But Luke made a very interesting point. So interesting that I was

00:14:04.520 scribbling it down as he said it, which was that data like these were replete with these sorts of

00:14:10.340 data that show population-based reductions in activity of aging individuals always make it look

00:14:17.420 like it's kind of a gradual, continuous curve. Even if it happens precipitously, it's still a continuous

00:14:24.800 curve. And what Luke pointed out is, well, actually, that's true at the population level. It's not true

00:14:30.580 at the individual level. At the individual level, it is a series of big, discrete drops. And so when

00:14:39.200 you smooth out thousands of people with big, discrete drops, it looks like a smooth drop. And what it

00:14:46.380 really comes down to is once you reach a certain age, even minor setbacks become permanent setbacks.

00:14:53.200 And that's the thing we're going to talk about, but we have to be able to avoid that situation.

00:14:58.300 So I'll give you one example. People have long heard me talk about the idea that once you reach

00:15:02.420 a certain age, like 65, and if you fall and break your hip or femur, the probability of death is

00:15:07.460 really high. I mean, it's in the order of 15 to 30%. What often gets forgotten there, even though I try

00:15:12.840 to always mention it, is of the survivors, meaning the people who don't go on to die within 12 months,

00:15:18.400 50% of those people never reach the same level of function again. That's an example of why these

00:15:26.280 curves are probably not smooth, but in fact, have these discrete step-offs.

00:15:31.900 And now, do you want to talk in the same way about how you talked with

00:15:35.120 the muscle and activity decline by looking at VO2 max?

00:15:38.960 Yes. So again, apologies for those not watching, but rather listening. Again,

00:15:45.180 please take a look at the show notes. But here you can see a table that shows exactly what is

00:15:53.380 happening to VO2 max as we age. Now, the purpose of this table, of course, is to show you something

00:15:59.080 else. The purpose of this table is to show you basically the quartiles of VO2 max by age. So the

00:16:06.600 way this table is broken up is that low, below average, above average, and then high and elite

00:16:12.580 combined represent the four quartiles of VO2 max. The difference is that elite peels off the top 2.3%

00:16:21.100 for each respective age and sex. And so we could talk about what that looks like, but I think a more

00:16:27.220 important point, and the purpose of, I think, showing it here, is to give you a sense of how every

00:16:32.980 one of these categories falls. In fact, what I think is most illustrative is to just look at the elite

00:16:40.220 category. So again, these are the top 2.3% of the population. So for example, if you look at a woman

00:16:49.520 in her late teens, the top 2.3% would have a VO2 max greater than 53 milliliters of oxygen per kilogram

00:17:00.400 per minute. And you can see that that will fall such that by the time a woman is 80 to be in the

00:17:06.620 top 2.3%, she would have to be greater than 30 milliliters per kilogram per minute. But what's

00:17:13.180 interesting is 30 places her in the bottom quartile for the late teens. It would place her at about the

00:17:20.940 25th percentile for someone in her twenties. So the implication here is that regardless of how fit you

00:17:30.140 are, you can still expect to see a precipitous drop here. And as I've talked about many times,

00:17:37.100 and certainly my patients are probably very sick of hearing this, the reason we want to see people,

00:17:43.840 if they want to live a completely uncumbered life into the final decade of their life, and that's a

00:17:48.920 big if, not everybody necessarily has that type of an aspiration, but if your aspiration is indeed

00:17:54.600 to basically be able to do what you want without limitation, climb a flight of stairs, carry a

00:18:00.280 luggage up a broken escalator, go for a hike, you pretty much need to be two decades younger at the

00:18:10.640 elite level if you're thinking you're going to live to be about 90. So anyway, this hopefully provides

00:18:15.900 some illustration of why that's the case. Yeah, Peter, I think that's really helpful for people to

00:18:20.840 kind of see and hear, and it's almost the why. So the why you should care about this and why,

00:18:26.140 no matter what age you are, no matter how quote unquote old you are, you really do want to continue

00:18:31.320 to think about this. And so now we'll get into a lot of what people are probably really curious on

00:18:36.800 is the how. So you've convinced me I need to care about this and I should do it, but how? And so I think

00:18:43.360 the first question that would be helpful here is, you know, what are the most important aspects

00:18:47.460 of training if you're starting or even returning to exercise in later life? So this could be people

00:18:53.460 who have never exercised, or this could be people who exercise all the way until they were 40,

00:18:59.120 family, life got busy, they took 10, 15, 20 years off, and now they want to get back into it.

00:19:03.820 I mean, I think there's a lot that one could say here, but I think you would want to start from the

00:19:08.080 principles of exercise variability and movement quality will always trump volume, load,

00:19:17.180 and intensity. So I would say that I think most people listening would agree that that's an

00:19:23.340 obvious statement to make for someone who's new to the game. But this is an example of something

00:19:28.340 where I would say that's even true for someone like me. I mean, I have a very high training age.

00:19:34.700 That's the term that we use when we're assessing patients to understand how much volume they've done

00:19:39.400 and over what period of time. So basically, with the exception of one very bad injury,

00:19:44.420 zero interruption in very high volume of training since the age of 13. And yet, as I'm now in my

00:19:52.780 50s, I realize I need to be much more attentive to these principles of exercise variability and

00:19:59.140 movement quality. The reason is quite simply, I'm much more prone to injury today than I was before.

00:20:04.960 And so I have to think of ways to challenge myself that are not just load dependent. And that doesn't

00:20:13.360 mean that I don't still push load in complex movements like a deadlift I do, but I'm clearly

00:20:19.380 not going to do nearly as much load or volume in those regards. And I am going to want to challenge

00:20:27.080 myself. And by saying this of myself, what I'm really saying is everybody should be thinking about

00:20:31.300 this, especially at this age, in terms of circuit training exercises where you're doing more than one

00:20:41.000 thing at a time. So an example of this might be that if someone were just starting out,

00:20:47.960 I would want to see them doing more body weight exercises that are slightly more complex movements.

00:20:53.800 So for example, a step back lunge is an important thing for them to be doing, even if it's just body

00:20:58.640 weight versus just working on a leg press with heavy weight. So again, there's a time and a place

00:21:03.200 for using machines. And I think we'll talk about why I think machines are a very good thing

00:21:07.780 for someone starting out because they control the range of motion, but we must be able to mix that

00:21:13.420 in with more complex movements that are variable in more than one plane. And for those movements,

00:21:19.420 we obviously want to deload them so that we just begin to do the neuromuscular training.

00:21:25.060 With that, let's say potential patient over 50 coming to you and saying, I want to start exercising.

00:21:31.080 How are you going to start to think about the structure of the programming that you give them?

00:21:36.020 Because again, you mentioned like the four pillars and there's different areas you could

00:21:39.260 start. So how do you think about that person just taking that first step to exercise?

00:21:45.180 You know, it always starts with a question that is obvious, but it sometimes is overlooked.

00:21:50.660 And I have to be honest with you, this is something that even I think I overlooked a lot

00:21:55.360 years ago. And that is, you have to come up with something that is realistic for a person

00:22:00.880 because the most important goal when you're returning someone to exercise or when you're

00:22:07.380 starting someone from scratch is you want them to be able to look back in three months

00:22:12.700 and view this as a positive experience. Nothing else matters if that is not true.

00:22:18.620 If in three months you've improved them by every objective metric and they hated it or they're

00:22:24.680 injured, well, I just don't know how to view that as a success. So people are going to be

00:22:30.580 very different in terms of what their appetite for beginning is. But because we're focusing

00:22:37.040 this discussion on people who are not like me, they aren't lifelong exercisers and therefore

00:22:42.820 by definition, they're either starting from scratch or maybe coming back to it after a long

00:22:46.460 hiatus. You have to assume that their appetite for training is not going to be seven days a

00:22:51.680 week, two hours a day. And therefore what I really want to focus on is the habit of doing

00:22:58.000 something active daily. And that doesn't mean training every day, but it means at least

00:23:01.900 walking or doing something active. So you're going to evaluate them based on their fitness

00:23:09.400 level, their level of conditioning. And again, at the most extreme level, if it's a person who's

00:23:14.380 never done anything and is completely deconditioned, it's really going to be about walking and that's

00:23:19.820 about it. And it could be as little as 5,000 steps per day, every day on relatively flat

00:23:25.740 ground. And of course, there's so many ways to progress this. If a person is a little bit

00:23:30.320 more conditioned, I do like to put weight on them out of the gate. I'd like to have them

00:23:33.700 do some rucking. We're not talking about putting 60 pounds on their back. It could be 20 pounds

00:23:38.180 on their back, but getting them moving under a little bit of load. Again, there's lots of

00:23:43.940 other things to consider here. So again, if a person is open to starting with some body

00:23:49.080 weight exercises, that's a very helpful way to begin doing things. It doesn't have to

00:23:54.720 be complicated, right? It could be box squats, wall sits. Isometric things are much safer

00:24:00.300 for individuals who haven't done conditioning in the past than isotonic movement-based, meaning

00:24:06.560 strength movements where the muscle is changing length. I don't know if you want to talk about

00:24:10.640 more now versus later. But again, I have strong thoughts on how to begin cardio training. We've

00:24:16.740 spent a lot of time talking about the importance of VO2 max. When we're working with a patient

00:24:21.380 who hasn't done training, we do not do VO2 max workouts. I do not believe in starting people

00:24:28.240 with interval training without building an aerobic base. And the aerobic base, of course, that zone

00:24:33.480 too, you want to start building that in a manner that's consistent with where they're coming

00:24:37.680 from. So that might just be, again, walking. That could be incline walking. That could be

00:24:42.080 riding a bike. And then even within riding a bike, how do you do that? Well, if a person doesn't have

00:24:47.560 the lower back flexibility and strength, it might even be on a recumbent bike as opposed to just a

00:24:52.720 regular stationary bike. So all of these things are considerations. But again, if you forget everything

00:24:57.360 else, remember the following. You want to make sure that in three months they feel better, they notice

00:25:03.360 that they are fitter and their appetite to exercise has grown. That's the most important thing if you're

00:25:09.960 viewing this both as a participant or as a trainer. Let's continue down that aerobic path that you kind

00:25:15.500 of mentioned there. And so I think the first thing people are curious about is what do we know about

00:25:20.720 the ability to improve aerobic capacity? Is that something that can be improved in someone who is

00:25:27.280 older and untrained? Yeah. And that's to me, the most amazing part of this is how malleable that

00:25:33.780 system is. In fact, I think you could make the case that the physical system, so aerobic capacity

00:25:41.160 strength is even more malleable than our cognitive systems. And we know that our cognitive systems are

00:25:46.520 quite malleable. Again, I didn't want to load this with too many stats and studies, but I think this one

00:25:52.140 is worth mentioning. And obviously we can, in the show notes, give you all the granular detail, but

00:25:57.280 one study that really jumped out to our team here was looking at percent improvement in healthy older

00:26:06.340 people and healthy younger people. So there was a study that did a six-week aerobic exercise, they use

00:26:14.680 cycling, training program to assess changes in VO2 max, oxygen consumption, of course, workload and

00:26:23.840 endurance. Now in the older group, these people averaged 80 years of age. In the younger group,

00:26:30.380 the people averaged 24 years of age. Couldn't be further apart. And yet in both groups, there was

00:26:37.820 about a 13% improvement in VO2 max, a 34% improvement in maximal workload. So that's basically how many

00:26:48.240 watts could you hit. And then a 2.4 fold improvement in endurance capacity. I found this staggering and I

00:26:57.960 would not have predicted this prior to seeing this study. Now, of course, I want people to understand

00:27:03.100 that the absolute levels of all of these things were significantly higher in the 24 year olds.

00:27:08.860 That's a given. They put out more watts, they have a higher VO2 max, et cetera. What we're talking about

00:27:13.800 here is the malleability of the system. What we're talking about here is how much could individuals

00:27:18.680 improve in six weeks? And the answer is they both improved dramatically. And I should point out

00:27:26.320 something else. This particular study followed the six-week training cycle that I just described

00:27:33.620 with an eight-week deconditioning period. And what's worth pointing out here is that the older group

00:27:39.720 declined much faster than the younger group. So both groups were able to see significant gains,

00:27:48.580 but the older you were, the quicker you lost those gains with inactivity.

00:27:53.880 Yeah. And so that speaks to what you mentioned earlier, which is the consistency. So if someone

00:27:58.700 starts and they do something for three months and they don't enjoy it, and so they drop off again,

00:28:04.480 it's not like they're just going to stay at that level. That level is going to drop back down. And so being

00:28:08.640 consistent is almost more important than how high you start. That's right. You can't overstate this

00:28:15.460 analogy of compounding. If anybody really just wants to understand how compounding works, just

00:28:20.020 pull open Excel and build a very simple formula that shows what happens if something compounds at 2%

00:28:28.480 per month or 1% per month or something like that. I mean, it becomes so nonlinear, our brains can't

00:28:36.280 comprehend that. And of course, I'm not suggesting that the gains in exercise will compound at that

00:28:41.700 intensity, but the idea of how much fitter you can be after years of doing something. This is another

00:28:49.020 point I want to make, which is if you look at a lot of the literature in VO2 max training, you know,

00:28:54.560 it suggests that people are capable of improving their VO2 max by 13%, like that study I just quoted.

00:29:00.200 And so a lot of people hear that and they look at the table that I showed earlier and they say,

00:29:05.160 well, I just had my VO2 max tested and I was at the 50th percentile. There's no way I'm going to

00:29:10.420 get to the top 2% of someone two decades younger. That would require literally increasing my VO2 max

00:29:16.160 by 80%. And this study showed that it could only happen 13%. To which I say, yeah, that study was six

00:29:23.500 weeks long. When we give our patients these audacious goals, we talk about these as two and

00:29:29.420 three year goals. So it's very important to understand that whatever we're talking about

00:29:34.800 here, we're talking about over a very long period of time. What I was going to say too, with that long

00:29:39.620 game on VO2 max, as we saw earlier, that elite category also drops. So if you're 40, it's not like

00:29:47.200 your elite category is the same when you're 70. So if you are making that progress and you are

00:29:52.460 increasing, just as you age, the categories are also going to decrease. So you're just

00:29:56.800 naturally going to move up as long as you're maintaining. So it's an interesting way to think

00:30:01.200 about it. I have all of these crazy goals, as you know, and one of them is like, what's the

00:30:05.960 oldest I can be such that my VO2 max in milliliters per kilogram per minute exceeds my age. Clearly

00:30:13.140 at some point that will cease to be true. There's no 80 year old whose VO2 max is 80. So the question

00:30:20.400 is like, where does that happen? And I think that's a really great heuristic for the health

00:30:26.100 of a person is, does that happen when you're 30? You hope not. If a 30 year old's VO2 max falls below

00:30:31.960 30, there's a huge problem. Does it happen when you're 40? That's probably where it happens for most

00:30:38.620 people. Can you push that to 50? Can you push that to 60? So again, the only way to start to play

00:30:44.640 that game is to basically get in shape and stay in shape. So on that, let's look at cardio training

00:30:52.400 first and say, how would you put someone on a program to help on the cardio side? Once we've

00:31:01.660 established that a person has the basics, they're not immediately injured. They've got the ability

00:31:07.020 to start doing some cardio training. I like to really start with base building. Even for someone

00:31:11.680 like me who trains a lot, remember 80% of my training volume is at zone two. Only 20% of my

00:31:18.760 training volume is in that VO2 max range. And again, I've said this before, but it's always worth

00:31:24.020 reiterating, understand that I am not training for anything other than the sport of life. If I were

00:31:31.120 still training to be an athlete, if I were still training to be a cyclist, I would have to do something

00:31:36.860 very different than what I'm stating. What I'm stating is far less intensive than someone who's

00:31:43.260 trying to be a master's level athlete in pick your endurance sport. So now we're talking about a person

00:31:49.240 who's new to this. What are we going to do? I would be really happy if I could get them to start

00:31:55.240 two days a week, 30 minutes a time. If I took a person who was relatively fit and we did two times a

00:32:01.640 week at 30 minutes per session, they're not going to improve enough. They're going to experience no

00:32:06.200 improvement. If I reduced my training volume to that level, I would probably go backwards.

00:32:12.180 But you have to remember when you're starting with a person who's very deconditioned,

00:32:16.100 they will actually see a training benefit at such low volume. So I'm not going to throw them in

00:32:22.700 three hour, four hour a week training. We're going to start them much lower. Now, the question I get

00:32:28.580 asked all the time is how do you help that individual calculate where their zone two is? And this is

00:32:34.260 worth spending some time on. Again, for folks who want a bit of a primer, when we talk about zone two,

00:32:40.900 we are not talking about the same zone two that shows up on your polar heart rate or your Apple

00:32:45.940 watch or whatever other device you're talking about. We're talking about a very specific

00:32:50.260 mitochondrial level of zone two. And it's referring to the highest level of work that you can do

00:32:57.280 while keeping lactate at effectively in indefinite steady state, which for most people tends to be

00:33:03.860 below two millimole. So once you're exercising and lactate gets above two, you're probably not going

00:33:11.980 to be able to sustain that for a couple of hours, which is effectively what we're talking about here,

00:33:17.600 because metabolically you are going to move to an area where you're generating too much hydrogen along

00:33:24.880 with too much lactate and the muscles are going to be compromised. So if you really want the gold

00:33:29.820 standard for measuring zone two, you got to be kind of checking lactate levels. And I don't really

00:33:34.440 advocate that for people, especially if they're starting out. I do it, but I'm probably an outlier

00:33:39.460 here because I enjoy that level of precision. So what I do recommend is two ways to be thinking

00:33:46.880 about this. The first is on the rate of perceived exertion, which I've talked about at length in the

00:33:51.600 past. And that is the talk test. So, and I've even posted a video, I think somewhere that we can

00:33:56.420 probably link to in the show notes, showing people what I look like when I'm in zone two and what my

00:34:02.100 difficulty in speaking is. We'll link to that. So people understand, but because I know that people

00:34:07.900 really like a little more guidance than that, I think using Phil Maffetone's MAP formula, maximum

00:34:14.700 aerobic performance, I think is what MAP stands for, but it's one 80 minus your age is a target

00:34:21.320 heart rate. And then if you're really new to the thing, which again is the audience we're now talking

00:34:26.360 about, you might even subtract 10 from that. So a 60 year old is going to potentially be as low as

00:34:32.780 110 beats per minute at a target. And as they get fitter, that's probably going to go a little bit

00:34:38.300 higher. Now I want to point out that you don't want to be too wed to this as you get more and more

00:34:43.960 involved in your training because the fitter you get, I think the more variability you'll experience

00:34:49.580 based on recovery. So my Maffetone formula would have my heart rate be 129. Okay. Well, I can tell

00:34:59.880 you 129 is never in zone two for me, except on the worst day, maybe once every two months, I might

00:35:08.100 have a zone two based on lactate where my actual heart rate ends up being 129. It's almost always

00:35:13.960 going to be in the high one thirties and sometimes in the low one forties. So as you get more

00:35:18.980 conditioned, the formula may be less and less valuable and you will rely more and more on RPE.

00:35:25.140 Or if you really want to take it to the next level, you might even start using lactate.

00:35:28.880 Final point I say on this, even if a person is deconditioned, we will not use lactate on them

00:35:33.420 because an individual that's coming in who's metabolically unhealthy tends to have very high

00:35:40.220 arresting lactates. In fact, there were people walking around with a lactate of two millimole at

00:35:44.960 rest. Clearly in that person using lactate provides no value and you should rely on heart rate and RPE.

00:35:51.740 In that person, let's say they're doing two days a week, 30 minutes a day. How long do you like to

00:35:57.460 see that consistency before you slowly increase either the duration or the number of days?

00:36:03.080 In part, it comes down to what we talked about, which is how do they feel? I almost want to

00:36:08.720 inspire within them an appetite to do a little bit more. I mean, this sounds silly, but when you're

00:36:13.800 starting out some of this stuff, a lot of it is just the growing pains of being able to sit on a

00:36:17.960 bike and your butt doesn't hurt or being able to walk on a treadmill and making sure that their

00:36:22.300 knees aren't aching or things like that. I would say within eight weeks to 12 weeks, I would want to

00:36:27.960 start pushing frequency and or duration. And I don't think there's a right answer here. And if

00:36:32.760 there is, I'm sure someone will comment. I like to push frequency before I push duration. So I'd

00:36:38.660 almost rather go from two to three to four sessions at 30 minutes before we start going to 45. But

00:36:44.020 eventually I'm going to want the sessions to be at least 45 minutes each. On the other side of

00:36:49.080 cardiorespiratory VO2 max, before we get into how you start to build that in for people, we do have a few

00:36:55.940 other graphs here that I think are insanely helpful and looking at why VO2 max is so important

00:37:02.560 as people age. And so I'll pull them up here, but do you want to kind of talk viewers and listeners

00:37:07.520 through this side of it as well? Yeah, this was a graph that I was able to get into the book.

00:37:13.160 I fought hard for this one because boy, nobody wanted this one in a book and I can understand why

00:37:18.140 it requires some explanation. So this is a figure that shows the hazard ratio of various

00:37:25.660 comorbidities and performance subgroups. So again, what's a hazard ratio? Well, it gives you

00:37:31.880 an estimate of relative risk. So let's start with the comorbidities because I think that's easier to

00:37:37.640 understand. So if a person is a smoker, are they at increased risk? And in this case, the risk is

00:37:43.760 all cause mortality. Are they at an increased risk of death from all causes? I think anybody would

00:37:49.260 understand the answer to that question is obviously yes. The question is how much? And in this analysis,

00:37:53.660 if you compare a smoker to a non-smoker and ask the question, what is the probability of that smoker

00:37:59.540 dying in the coming 12 months from any and all causes? The answer is it's 41% greater than the

00:38:06.720 non-smoker. Kind of makes sense. What if you take two people, one with coronary artery disease,

00:38:11.880 known CAD and the other without? Well, that's about a 29% difference in all cause mortality. 29%

00:38:19.080 greater risk, I should say, if I'm going to be more accurate. What about somebody with type 2

00:38:23.180 diabetes? Well, again, it's a 40% greater risk of all cause mortality in the coming year. High blood

00:38:30.700 pressure, 21%. End stage renal disease. So somebody who's on dialysis awaiting kidney transplant, a whopping

00:38:38.740 178% increase in all cause mortality. So now what we do is we do the same mortality analysis on that

00:38:47.640 massive cohort of people for whom we have VO2 max data. So these are the data that we showed earlier

00:38:53.180 where we looked at people in those quartiles. And so what I do every time I run a patient through their

00:39:00.700 VO2 max the first time is I figure out where they are and say somebody shows up in the below average

00:39:06.580 camp. So that means they're in the 25th to 50th percentile for their age. I say, look,

00:39:12.120 if you just go from below average to above average, right? If I were just to compare you from

00:39:18.400 your level at the 25th to 50th percentile to someone who's in the 50th to 75th percentile,

00:39:24.880 the hazard ratio is 1.41. In other words, you are 41% more likely to die in the coming year than

00:39:33.020 somebody who is that much fitter than you. And by the way, it's not, it's not lost on anybody that

00:39:38.180 that's the exact same hazard ratio of a smoker to a non-smoker. That's how big the difference is.

00:39:43.600 And if you want to go from below average to high, so now you're going from say the second quartile

00:39:49.600 to the third quartile, it's a 100% difference in risk. It's a doubling of the risk of death

00:39:58.020 for that coming decade. I won't go through the rest of these numbers here, but they're all

00:40:02.060 staggering. And by the way, even just going high to elite, 29% difference in relative risk.

00:40:09.520 When I talk about how VO2 max is the single most important biomarker we have for lifespan,

00:40:15.700 these are the data from which I make that claim. There are obviously other data that are identical

00:40:19.980 to this on different cohorts, but the point is there aren't other biomarkers that will give you

00:40:26.500 hazard ratios of this magnitude. Now people often ask, why is that the case? And I think the answer

00:40:33.020 is that VO2 max is probably a remarkable integrator of work. So it is not a biomarker that changes

00:40:41.380 quickly and easily to the magnitudes required to do this. You're not going to take your VO2 max from

00:40:48.600 low to elite in a year. You can do it. I would argue you absolutely can do it, but it's not going

00:40:55.280 to happen in a year. And therefore when it happens, it's going to reflect an astronomical volume of

00:41:02.660 work that has been done. And the benefits of that work are what are being captured in the VO2 max

00:41:08.200 number. That's kind of the lifespan side. I'm going to pull up the other graph here, which is more so

00:41:14.160 on the health span side. And I think this was also in your book, but when you kind of combine

00:41:19.840 all three of these VO2 max figures, the first one we looked at with just the bracket and the

00:41:25.260 breakdown, how it compares to different diseases. And then this one kind of paints a really good

00:41:30.800 holistic picture. And so do you want to walk listeners, viewers through this as well?

00:41:36.020 Yeah, this is another figure that we show our patients all the time. Actually, we're

00:41:39.360 probably building another one of this because there's a couple issues I have with this figure,

00:41:42.660 namely it stops at the age of 75. So I want to see this data extended to another two decades. And I

00:41:48.160 realize that it's harder and harder to get those data, but I think we can estimate them.

00:41:51.420 What this figure shows is really the other bookend of why we want a high VO2 max. So the figure above

00:41:59.600 and the discussion I just had a moment ago makes it abundantly clear that if you want to live a long

00:42:04.180 life, you better have a high VO2 max. This figure says, if you want to live a good life, you better

00:42:11.060 have a high VO2 max. Because this gives you a very clear all-in-one view of what actually happens

00:42:20.380 as your VO2 max declines. You lose capacity. So the graph has a lot of information on here,

00:42:27.640 but it can basically be distilled down into the following. You have three curves for the purpose

00:42:32.280 of illustration. You have people in the top 5%, people right at the middle of the pack, and people

00:42:36.900 in the bottom 5%. So those are the green, black, and red curves respectively. By the way, for anybody

00:42:42.140 paying attention, these data are pulled from a different data source than the previous data. I

00:42:47.300 don't think this is as rigorous a data set, and therefore the numbers don't line up completely. So

00:42:52.340 the 50th percentile here is not the 50th percentile elsewhere, but for the purpose of illustration,

00:42:56.120 not important. The x-axis is time, of course. So as age marches along, you are watching a reduction

00:43:04.040 in VO2 max, which is the y-axis, for all curves. So again, observation number one is, doesn't matter

00:43:09.380 how fit you are, your VO2 max is going down, down, down. Again, as I said, the problem with this graph,

00:43:15.820 at least one of the problems is, stops at the age of 75. And unfortunately, that deprives a patient

00:43:23.000 from seeing that the curve doesn't continue along the trajectory of what came before it. It actually

00:43:28.840 gets steeper. And so what you realize pretty quickly is that depending on where you want to

00:43:37.120 be, and that's demonstrated by the activities on the right, you're going to need to be pretty high

00:43:43.480 to avoid the fall. So what it's showing you is, hey, if you want to be able to run 10 miles an hour

00:43:48.140 on flat ground, you need a VO2 max in the mid to high 50s. If you want to be able to run six miles an

00:43:54.360 hour, which is a 10 minute mile up a very steep hill, you need to have a VO2 max of 50. And as you

00:44:00.040 walk down this list, you see that the VO2 max requirement goes down as the aspiration goes down.

00:44:08.840 The point that isn't really clear on this curve is at what point does the VO2 max become sort of

00:44:15.560 rate limiting for activities of daily living? And that's in the high teens approximately. So once the

00:44:23.120 VO2 max is into the high teens, we would say that you are now going to be limited in what you can do

00:44:29.380 from an activity of daily living standpoint. Having studied these types of data for a very long time,

00:44:35.420 I know that for myself personally, and by the way, this tends to be true for most of our patients

00:44:39.740 when we put them through the centenarian decathlon exercise, most people, at least based on what they're

00:44:45.240 telling you they want to be able to do in the last decade of their life, are going to require a VO2 max

00:44:49.420 of about 30. So high twenties to 30 in the final decade of their life. And I mean, Nick, when you

00:44:56.380 look at that, what's your takeaway? If I'm telling you, you need a VO2 max of 30, if you're 90.

00:45:02.760 Yeah, you better be in the 95th percentile and above along the way.

00:45:07.640 You have to be higher, right? Because the people on this graph who have a VO2 max of 30 at age 75

00:45:15.840 are going to be lower than that at the age of 90. So yeah, you have to be way above the top of the

00:45:23.920 green curve at the outset. So again, like I know people hear me say, and you've alluded to this,

00:45:29.480 that, oh, Peter, he's just being kind of extreme, blah, blah, blah, blah, blah. No, no, no, I'm not

00:45:32.760 being extreme. The data are right in front of us here. If you want to be able to be completely

00:45:38.360 unencumbered in the last decade of your life, you need to have a very high level of fitness when you're

00:45:44.200 in midlife. And if you don't, that's okay. You have time to do it, but don't wait too long.

00:45:49.200 Yeah, it kind of is one of those things where it's like, we often joke, does everyone need to

00:45:53.520 measure their lactate two times every workout? Probably not. That might be you on like the

00:45:59.720 heavy data side, but looking at VO2 max, if you want to be able to do those things,

00:46:05.540 that's not like you're measuring lactate every day. That's just a black and white fact kind of

00:46:11.480 written in stone. Yep. You should talk about how you can train for VO2 max, but yeah,

00:46:16.180 you don't need the devices to do this, even though I like using devices.

00:46:20.240 Well, and that's actually where we're going next, which is when do you start when someone is starting

00:46:25.480 to train or getting back into it? You mentioned you'll start them in the zone two a few days a week.

00:46:31.120 Obviously zone two, two days a week, 30 minutes is a lot different than a VO2 max exercise, which

00:46:36.900 can take a lot more. So how do you have your patients in that age bracket 15 plus? When do

00:46:43.460 you have them start training for VO2 max? How do you have them start training? How do you think about

00:46:48.000 that? So a couple of things, one, the wider the base, the higher the peak. So I want to build a

00:46:54.120 reasonable aerobic base before I start pushing VO2 max. And by the way, you do experience increases in

00:47:01.440 VO2 max just from base building aerobic activity. So if you take a person who's completely deconditioned

00:47:09.220 and you put them into just a zone two program and you slowly add duration and frequency to that,

00:47:15.960 and then you retest their VO2 max, it'll be higher, even if they have never done a single interval.

00:47:21.040 But ultimately to really start to boost VO2 max, you are going to need to add more intense movement.

00:47:27.880 I think that the easiest way to do that and the way we typically do it with our patients in a really

00:47:32.740 detrained individual or untrained individual is just to add a little bit of interval training to

00:47:39.680 the zone two workout. So for example, if a person is doing their zone two on a treadmill,

00:47:46.120 and let's say you've got them walking three miles an hour, and after a few months, they can handle

00:47:51.980 three miles an hour at 4% or 5% incline, you say, great, I want you to finish the workout doing

00:48:00.720 five one minute, quote unquote, bursts where you increase the slope from 5% to 10%. And you're just

00:48:10.140 going to do it for a minute. It's going to really tire them out. You do a minute on and take a minute

00:48:13.620 off, a minute on, take a minute off. So you start to get them used to increasing the intensity.

00:48:19.700 This also becomes a chance to assess, is this going to be something that they can do safely,

00:48:24.660 or are they going to completely deteriorate in form? I'll give you an example of something I used

00:48:28.940 to do. So I used to do really, really, what I think is looking back, I mean, I'm lucky I never got

00:48:33.900 injured, but I used to do some really stupid things for VO2 max training that I think put me at too

00:48:40.160 greater risk for injury. So I used to do deadlift Tabatas. So, you know, I would put 225 pounds on a

00:48:47.420 bar and see how many reps I could do in 20 seconds, take 10 seconds off and repeat that

00:48:52.080 eight times. Now, did that do a lot for my VO2 max? Oh, you can bet it did. But when I think about

00:48:58.660 the risk I was putting myself under from a movement perspective, being under that much fatigue in the

00:49:05.440 seventh and eighth round of that, where you're trying to push harder and harder, I just don't

00:49:09.900 think that makes any sense. I mean, that doesn't make sense in someone like me, who has a lot of

00:49:14.620 training background. So what do I want to do? I want to make sure that they're doing these

00:49:18.420 intervals, which we'll talk about in a second, in an activity where the form isn't going to

00:49:23.080 deteriorate to the point of injury. Now, let's talk about the gold standard for how to train VO2 max.

00:49:29.120 And this is something we've discussed at length in at least two or three other podcasts that we'll link

00:49:33.580 to. The sweet spot for that energy system is three to eight minutes of work. What defines that?

00:49:43.240 What defines that is you do as much work as you can at a steady state in that period of time. So at

00:49:50.000 the low end of that is three minutes. So meaning how hard can you push for three minutes such that

00:49:56.260 it's roughly the same level of work output. So watts, if you're on a bike, for example, but by the end of

00:50:03.000 three minutes, you're truly spent. And then at the upper end of that, it would be up to eight minutes

00:50:07.940 long, which obviously means it's going to be far less wattage, but the same physiologic response,

00:50:13.240 which is by the end of it, you are truly gassed. I've talked about this again. I personally just

00:50:18.620 tend to gravitate to four minutes, four to five minutes is where I like to do the work, but I think

00:50:24.060 it's great to mix it up. And I'll use four minutes as an example, just so folks understand what this

00:50:30.680 should feel like. When I'm doing a four minute interval, I barely notice the first minute. So

00:50:36.560 if at the end of the first minute of a four minute interval, you're dying, you went out way too hard.

00:50:41.140 It's okay. Try it the next time. At two minutes, I'm still feeling pretty darn good. And believe it

00:50:47.520 or not, sometimes I'm wondering if I shouldn't be pushing a little bit harder. At three minutes,

00:50:51.940 I'm truly wearing it. And that last minute is brutal. And that's again, assuming I'm largely

00:50:57.280 holding power constant for the four minutes. So that's a general rule. The way I describe it is

00:51:02.760 three quarters of the way into the interval. So six minutes, if it's an eight minute interval,

00:51:07.800 three minutes, if it's a four minute interval, three quarters of the way into the interval,

00:51:10.660 you should be at the 50% level of your pain. So once a person is ready to graduate into a dedicated

00:51:17.420 VO2 max session, that's what I want to do. And I want to see them doing that once a week. Again,

00:51:23.280 if you're training to be an elite level cyclist, you're going to have to do it more than that.

00:51:27.280 But if you're training to just minimize risk and maximize gain, I want to see people start to push

00:51:33.840 those. And maybe the first time they do it, they can only do four rounds of that. But eventually

00:51:38.600 you'll get up to five, six, seven, eight rounds of that. Again, if we're talking about four minutes

00:51:43.780 and when you put in a warmup and a cool down, and obviously I should say you're doing that at a

00:51:48.260 one-to-one work to recovery ratio. I should have mentioned that earlier. So

00:51:51.240 if it's four minutes of work, it's four minutes of very, very passive recovery,

00:51:56.360 not a hardcore active recovery. It's a true rest and recovery. We're talking about 60 to 75 minute

00:52:02.020 workouts here.

00:52:03.340 Yeah. And so I think from what I'm hearing you say is correct. It's one of those, as it relates to

00:52:08.380 VO2 max, even though it's so important and we just looked at all the numbers of why it's so important,

00:52:13.620 it's also one of those in an older population who maybe is deconditioned. You're not pushing them to

00:52:20.260 start VO2 max training right away. Like it's important to get the base. And it's also important

00:52:24.980 to take, even when they start VO2 max training, take it slow. And it's more important to build that

00:52:30.680 over time than it is to just try to rush into it and either not enjoy it or worst case, get hurt.

00:52:37.560 That's right. And the older and less conditioned you are, the less I want you to hurt during those

00:52:45.460 VO2 max intervals. I bring it back to me because I can speak from my own experience with much more

00:52:50.300 clarity. The level of pain I am in today when I do my VO2 max sets is nothing compared to what it

00:52:58.520 was 10 years ago, Nick. 10 years ago, it was truly pushing to the point of vomiting. I do not push that

00:53:05.900 hard anymore. I still push hard, probably harder than most people would expect, but it's not that

00:53:12.020 level. And in 10 years, when I'm in my early sixties, it will be even less of a push than it is

00:53:17.320 today. So the name of the game is play the game and stay in the game forever. And so we are really

00:53:24.840 looking to minimize injury here and we're looking to minimize burnout. And the first few times a person

00:53:31.080 even experiments and dabbles with these four minute intervals. I actually want them to come

00:53:36.000 away thinking that wasn't too bad. Great. Try a little bit harder the next time, but we're not here

00:53:42.380 to sort of wipe you out after the first session or even the first couple of rounds. Anything else you

00:53:49.120 want to say on the cardio side before we move to the strength side? We could talk about how to go

00:53:55.760 about doing it. The good news is for VO2 max, I think you have many more options for zone two,

00:54:01.300 believe it or not, you're kind of limited because of the steady state nature of it. So again, for me,

00:54:06.380 zone two, if I'm not traveling is always on my bike, which is on a stationary bike. So on a trainer

00:54:12.260 and that's it full stop. If I'm traveling, I will usually do it on an inclined treadmill. So I go to

00:54:20.460 what I consider a normal brisk walking speed, which is 3.4 to 3.5 miles per hour. And then I just take

00:54:29.140 the incline up. So I might warm up at 10 degrees or 10% grade, but usually I wind up at about 15%

00:54:35.480 grade. So three and a half miles an hour, 15% grade. That's my zone two. So outside of that, you can do it

00:54:42.120 on a rowing machine if you're a really good rower. But for most people, they're not efficient enough on a

00:54:47.200 rowing machine. So that you typically end up blowing up and through their zone two ceiling.

00:54:52.660 I can do it on a Stairmaster, but you know, I just have to be sort of careful about it. By the way,

00:54:57.280 when you're using Stairmasters and treadmills and all these things, remember, you probably don't want

00:55:00.660 to have your hands on the device because there's too much variability in how much of the stress you're

00:55:07.300 taking away. Does that make sense? Like if you're in a treadmill and you're holding onto it, there's so

00:55:11.080 much variability in how much of the load you're alleviating that I prefer to just go hands

00:55:16.880 off the machine and settle in at a steady state that's going to be consistent. When it comes to

00:55:23.000 VO2 max, you have way more optionality. That's where I ride my bike outside, but you could be doing

00:55:30.580 almost anything provided that there's a constant enough space for you to do it for at least three

00:55:36.060 minutes. Swimming, great way to do VO2 max training because you don't have the impact, all those other

00:55:41.760 things. So you could do it on a treadmill if you wanted to, and you could run, or you could again,

00:55:45.900 just walk at a steeper incline if your zones permit it. So I guess that's the only other point I would

00:55:49.780 make about this. And if someone is older, let's say 65 plus, so they're in the older side of what

00:55:57.420 we're talking about, and they haven't done zone two before, and they say, hey, do you have a preference

00:56:02.100 on, is it better to start on a treadmill versus a bike? Have you noticed anything as it relates to

00:56:10.400 those two words? We talked early on about the importance of even just walking, getting like

00:56:14.980 5,000 steps, 7,000 steps. So would you want to see people or encourage them to start on a treadmill,

00:56:21.320 or do you think a bike is just as safe, just as effective?

00:56:25.160 Yeah. I mean, look, I think all things equal, if this is the only exercise a person is going to be

00:56:31.060 doing, I might lean a little bit towards the treadmill if they were truly agnostic, just because

00:56:36.840 at the end of the day, walking is a more valuable skill than cycling. Cycling has no application

00:56:41.660 beyond cycling, whereas walking is a very important part of who we are. It's our superpower to be

00:56:47.280 bipedal. So the more time you can spend doing it, the better you are. Again, for someone like me,

00:56:52.920 it's kind of moot because I walk a lot anyway, I'm rucking, I'm forcing that system to work elsewhere.

00:56:58.060 So, you know, I might as well do something I enjoy the most, which is probably riding a bike.

00:57:01.420 Moving on now from the cardio side to the strength side, we already kind of looked at how muscle mass

00:57:08.920 can drop as we age. What do we know about the possibility to gain muscle mass as we age?

00:57:16.440 You know, it's really interesting. It's not that dissimilar from what we've talked about on the

00:57:21.460 cardio front. So research is very consistent here in demonstrating that resistance training

00:57:27.640 can increase muscle strength and muscle hypertrophy at any age. Again, you tend to get into very small

00:57:36.100 studies here, but when you look at large pooled analyses, you can see that even if you limit your

00:57:43.160 analysis to people over the age of 80, which are people who are clearly in that area of being on the

00:57:49.560 downhill for strength and hypertrophy, training can offset losses and in a deconditioned individual can

00:57:56.760 actually make gains. Just as I hopefully made a case for why you can't overstate the importance of

00:58:02.900 cardio training, both at low and high intensity, I don't think you can overstate the importance of

00:58:08.600 strength training. I just don't think there's anybody out there who shouldn't be lifting weights.

00:58:13.500 I can't think of a case. I mean, unless you're decidedly saying, I don't want to live the longest,

00:58:19.300 healthiest life I can. If that's the case, then by all means, don't lift weights. But if you're in the

00:58:23.140 camp that says, I want to maximize how well I can live and maybe even how long I can live, what should

00:58:27.640 I do? You have to be lifting weights regardless of age, regardless of sex, regardless of injury.

00:58:32.900 You have to work around all of those things. So again, there's a very similar study to the one I

00:58:39.620 cited earlier. Again, I don't want to go too study heavy, but this is just so illustrative of the

00:58:44.720 point. There was a study that looked at people in their late seventies and early eighties and people

00:58:48.760 in their twenties and at the outset measured three rep max for leg extension and then put them on a

00:58:55.480 six week resistance training program. And the people in their late seventies and early eighties had a

00:59:02.640 78% increase in their strength, which is almost identical to the 83, 84% increase that was found in

00:59:13.100 the younger individuals. Again, it's important to understand that yes, these people were significantly

00:59:20.040 different in the absolute strength that they had. The average leg extension in the people who were in

00:59:26.500 their late seventies and early eighties was only 22 kilograms versus 178 kilograms for the young

00:59:32.080 participants. But nevertheless, this is an important point that is everybody has the capacity to improve

00:59:40.940 and therefore everybody needs to be doing this. I think the other thing that we've talked about in

00:59:46.000 previous podcasts, most notably, I think we've talked about this with Andy Galpin on a couple of

00:59:49.680 occasions is the importance of type two fibers. One of the things that Andy said that has always stuck

00:59:55.560 with me, and I think it's just such a great way to think about this. He almost described it as a

01:00:00.360 hallmark of aging is the atrophy of the type two muscle fibers. So again, you have type one fibers,

01:00:07.340 you have type two fibers, the type two fibers are the glycolytic fibers. They are the much more powerful

01:00:13.220 fibers. They have more contractile force. They're the ones that are responsible for power, not just

01:00:19.720 muscle size and not even just strength and clearly not muscular endurance. And these are the things that

01:00:24.700 basically peak when we're in our twenties. And so every day I'm sort of thinking about what am I

01:00:29.780 doing to preserve them and minimize their loss? And again, a study we'll link to demonstrates that type

01:00:37.400 two muscle fiber cross-sectional area was increased by 27% in men aged 60 to 73 with 13 weeks of resistance

01:00:47.100 training. Now, again, you have to train relatively heavy for your level of strength. You have to push

01:00:55.120 to make those results happen. But again, this can be done very safely as we'll talk about.

01:01:01.720 Yeah. And I think now's the time to kind of look at that a little bit, which is you have a patient

01:01:06.240 who's older, they come to you and they have not been strength training. Maybe they even do a DEXA and

01:01:11.780 they see their metrics are really low as it relates to muscle mass. How do you start to incorporate that

01:01:17.820 strength and resistance training to that individual? I mean, I think there's a real parallel here

01:01:23.000 with what we talked about on the endurance side. So I always start from the same vantage point, which

01:01:28.540 is if you're new to strength training, I want to make sure that in two to three months, you're looking

01:01:35.360 back at the last two to three months thinking, A, I enjoyed that. It wasn't as bad as I thought it was.

01:01:42.600 Because remember, if someone hasn't lifted weights before, there's a reason, right? Like there's

01:01:46.780 something about it that they are either intimidated by, afraid of, or didn't think it was valuable enough.

01:01:51.540 I mean, there's a reason for it. So A, I want to undo that reason. Secondly, I want them to feel

01:01:57.880 something is different. I want them to feel like, well, you know, I remember when I started this,

01:02:04.060 I could only do this many pushups and now I can do that many pushups. Or when I was doing leg

01:02:08.400 extensions or leg presses, I had the pin on this weight and now it's like 50% higher. That's the

01:02:15.560 first principle. Second principle is, again, similarly, we are going to start with volume more than we are

01:02:21.060 going to start with load. Muscular resistance matters more to me than strength at this point.

01:02:25.620 So I'm not going to lead in with, let's go after those type two fibers. It's going to be,

01:02:30.720 let's work on the type one fibers. And I don't care if you need to do 15 to 20 reps on every exercise,

01:02:36.460 so be it. I'm not even really at this point going to be concerned with all the nuances of RPE.

01:02:43.260 We've talked about this on many podcasts, including not just the podcast with Andy,

01:02:47.180 but with Lane Norton, the data are that the number of reps you do for hypertrophy and strength,

01:02:53.480 especially for hypertrophy, don't really matter provided you get to within one or two reps of

01:02:58.000 failure. We're not even really going to push that out of the gate. We might prescribe, hey,

01:03:03.160 pick a weight that you fail at about 12 to 15 reps, but again, less concerned as to whether that's an

01:03:10.660 RPE 2 or an RPE 4. The other thing to keep in mind is in parallel to this, you've got to be

01:03:16.160 working on some of the stability stuff, which is not necessarily weight-based. So this is where

01:03:21.000 you're working on intra-abdominal pressure exercises, really making sure that they can

01:03:25.740 kind of pressurize the cylinder as we stay, breathing exercises. So a lot of the stuff we

01:03:30.400 borrow from DNS and PRI, we want to make sure that they can move their ribs correctly. And obviously,

01:03:37.460 you want to make sure that they have the ability to even recruit muscles correctly. And a lot of those

01:03:45.120 things are kind of hard, but I'll never forget an example Beth Lewis had me do one of the early

01:03:49.600 times when I met her, which was laying on a floor. So picture me laying on my back, my knees are up,

01:03:55.420 but my feet are flat on the ground. So I'm in a very relaxed position. And it was an exercise around

01:04:01.540 being able to sequentially recruit hamstrings one leg at a time and put the foot down into the ground

01:04:08.840 and pull it back, if that makes sense. So again, that's a pure hamstring isolation exercise.

01:04:13.280 And yet, despite having very strong hamstrings, I really struggled to do that exercise while

01:04:17.720 keeping my pelvic floor stable. So again, those are the types of things where you're not going to

01:04:22.280 get injured, but you're going to have to learn to start recruiting and controlling a muscle. And

01:04:28.140 again, once you do that, you're much safer lifting. How do you think about resistance training for

01:04:34.840 people who are in the even older category, which is let's say 65 plus. I know at the outset,

01:04:40.360 you kind of mentioned that at a certain point, the muscle mass you're losing and the things you

01:04:45.420 have to be aware of is even higher. So how do you talk to a patient about this? Who is

01:04:50.940 even in that older category? I think you just have to do everything a lot slower. So for example,

01:04:56.640 somebody at this age, you'll do TRX, but you want to be much more stable in the positions you're doing.

01:05:02.180 I would almost without exception, only have somebody at this age, if they've never lifted before,

01:05:07.680 only using machines to start. I wouldn't really want them mucking around too much with dumbbells

01:05:15.020 outside of maybe doing carries. I wouldn't want them picking up dumbbells to do lunges or things

01:05:19.400 like that. I would sort of save that for phase two of what they're doing. And truthfully, even though

01:05:25.060 DNS, dynamic neuromuscular stabilization, which people know I'm a big fan of, when people think

01:05:30.120 about it, you sort of think of these baby positions. Well, the reality of it is those positions

01:05:34.580 are very important for people of any age. And so teaching an older person, especially a person

01:05:41.460 who's new to physical activity, some of those positions is very valuable because A, it's doing

01:05:47.840 all the stuff I talked about a second ago, but they're also getting comfortable with being on

01:05:51.440 the floor and moving on the floor. Again, this is something that you and I will take for granted,

01:05:56.920 Nick, for some time, but people 20 years old or 30 years older than us can't take it for granted

01:06:02.880 that being on the floor, moving on the floor and getting up on the floor unassisted is something

01:06:07.780 that they should be able to do easily.

01:06:09.760 You kind of hinted at it there. So let's say someone is kind of in this older bracket,

01:06:14.100 even 50 plus, and they're like, okay, I'm going to start resistance training. They obviously don't

01:06:18.880 have a home gym. Most people in that category aren't going to have that. And so if they do walk

01:06:24.060 into kind of their local gym fitness center, you would encourage them to start on the machines

01:06:30.120 at first and lower weights just to slowly work that up before grabbing free weights,

01:06:35.780 grabbing dumbbells, anything like that. At this level, it's difficult for me to provide

01:06:40.060 very thorough analysis because everybody is different. And clearly what you might say makes

01:06:45.820 sense. If this person also happens to have a trainer who's really good with them, yeah,

01:06:51.420 you're going to say, look, you're going to push things a little bit quicker. But if we're really

01:06:54.920 starting at, Hey, this is a person who's going to be doing a lot of this stuff alone in a gym

01:07:01.340 where there's a ton of intimidating stuff going around, I would say, yeah, let's stick with the

01:07:06.740 machines. And I wouldn't be trying to do dumbbell presses or kettlebell exercise or anything like

01:07:14.040 that. No, I think you really want to build your strength and stability with body weight and with

01:07:18.820 machines before you progress. Again, if you have the luxury of having a trainer and that trainer is

01:07:24.020 very good, I think they'll be able to progress you more quickly to those other things.

01:07:29.300 So then Peter, you kind of hinted at it there, but a lot of people who are in the older category,

01:07:35.080 they may be concerned about resistance training due to potential injury. So when you have your

01:07:41.560 patients who are older, start to resistance training, start to build muscle, are you worried

01:07:47.520 about injuries? Kind of how do you speak to them about how they should think about that aspect,

01:07:52.860 especially starting out or if they've never started before?

01:07:58.140 I think anybody who's worked with people, be it athletes or people who are really deconditioned,

01:08:03.580 you always have to think about this, right? Because you're always balancing, providing enough

01:08:09.200 training stimulus to get the benefit. And remember, training is a hormetic activity. It has to create a

01:08:17.200 stimulus, whether that be on the aerobic system, whether that be for type one fiber, the type two

01:08:22.960 fiber, like there has to be a stimulus that comes from pushing outside of a comfort zone. So we have

01:08:30.500 to have that training stimulus, but we know that if we do too much, we're going to get injured. And I hope

01:08:36.140 that by now I've made the case for why injury must be avoided at all costs, because injury means

01:08:42.560 time to decondition. And the older we get, the more problematic that gets. Again, I think about the

01:08:49.180 back injury I sustained when I was 27 years old that basically left me unable to walk for three months

01:08:55.020 and unable to do much of anything for nine months. Well, today, if you look at me, there's really no

01:08:59.740 lasting effect of that. But imagine that had happened to me when I was 70. That's it. My life is over. I

01:09:05.760 never get back to where I was. So it's probably safe to say that the most common reason for injury

01:09:13.220 when you're starting out is progressing along the intensity axis too soon. So remember, we talked

01:09:19.720 about how you push frequency, you can push duration, you could push intensity. I think you want to err on

01:09:26.240 the side of my heuristic is move the frequency, then the duration, lastly, the intensity. So that's

01:09:34.600 clearly true on the cardio training side, but I think it's also true on the strength training side.

01:09:39.000 Obviously, another very important part of injury is just a lack of neuromuscular control. So that

01:09:45.820 accounts for many things from why people fall more frequently as they age to how people get injured.

01:09:52.720 If we're just limiting it to talking about strength training, why are individuals getting hurt when they

01:09:57.000 lifting weights? Well, a lot of it is maybe they're moving a weight that they can't control. We've talked a

01:10:02.500 lot about the importance of being able to control the eccentric phase of a movement. And I think

01:10:08.300 we've all seen someone in the gym who's just throwing weights around and getting away with it,

01:10:13.160 but you're going to stop getting away with that the older you get. So we want to really make sure that

01:10:17.780 people have the coordination. They're doing the types of drills like agility ladders, hand-eye

01:10:24.780 coordination exercises, ball tosses, such that they're generating neuromuscular control in addition

01:10:31.400 to strength. Probably the other big area where we see injuries is due to a lack of movement

01:10:35.860 variability. So people say, well, do I need to squat and deadlift and bench press? And I think

01:10:41.660 the short answer is no. I think a lot of those things can be done with, for example, squats and

01:10:47.640 deadlifts. You can accomplish many of those goals using single leg variants that are far less weight.

01:10:54.820 And even something like a bench press with a bar, I would much rather substitute in,

01:10:59.980 once you're ready for that, floor presses and single arm floor presses. You'll be laying on the

01:11:04.700 floor with knees up, feet flat on the ground, one arm straight up, the other arm doing the presses.

01:11:10.380 And again, what's nice about that is on a floor press, your range of motion is nowhere near what

01:11:14.380 it is on a bench because you're obviously not going to be able to bring the elbow below your back,

01:11:19.980 which you could on a bench. So you lose a bit of range. It's clearly not quote unquote as good a

01:11:24.600 pec exercise, but there's also a very good margin of safety there. Think about how much harder it is

01:11:30.200 to hurt yourself doing a floor press than a regular traditional bench press. These are just some slight

01:11:35.260 examples of ways that you can think about minimizing injury. By the way, just as an example, like when I

01:11:40.920 was coming back from shoulder surgery, I mean, it was probably a year of just doing floor presses

01:11:45.860 before I proceeded to go back onto a bench. Yeah. It kind of reminded me, I can't remember who it

01:11:51.740 was, but someone once told us they used to do Tabata deadlifts and that could be potential good

01:11:58.040 example of a good way to get injured. Correct? I mean, anybody's stupid enough to do that, Nick. I

01:12:03.660 mean, gosh, I just, I don't even know what I would say. If they're doing Tabata deadlifts, you have to

01:12:09.060 question everything they say, right? Like how can they be trusted on anything? I think you would probably

01:12:13.500 have to say they're, you shouldn't listen to a word they say. Well, if I can remember who that is,

01:12:19.120 I'll make sure to tune them out going forward. If you can remember, let us know.

01:12:23.540 On that front, fall risks. You've talked about it before. You mentioned it earlier. Do you just

01:12:29.380 want to speak about fall risks? We also have a few graphs here that, again, we wouldn't have pulled if

01:12:34.000 they didn't tell such a story, but I think it'd be really important here to talk about fall risks

01:12:39.120 because I think this is important, not only for people in this age category, but also even anyone

01:12:44.560 who's still listening that's even younger to see what this can look like. And it's also to give them

01:12:50.020 that motivation to even train at a younger age, kind of what you hinted at earlier. It's like saving

01:12:56.280 for retirement at a much early age. So what do you want to tell people about falls?

01:13:01.160 I just don't think we can say enough about it. I think back to all of the failures of our

01:13:05.880 traditional medical training and there's so many, right?

01:13:09.120 In four years and $250,000 of education at Stanford, how many hours of lecture did I have

01:13:16.500 on exercise? Zero. When was this discussion about falling presented to us as medical students?

01:13:23.880 Never. So in the United States, over 14 million or 25% of people over the age of 65 will fall each year.

01:13:34.180 Now, to be clear, that's people who report it. So we believe that that number is significantly higher.

01:13:40.560 This risk goes up quite non-linearly. So by the time we're talking about octogenarians and

01:13:45.640 non-agenarians, the annual incidence of falling is at least 50%. And you'll recall that I said that

01:13:53.940 the risk of death from that fall, depending on the series you look at, will be somewhere between 15%

01:14:00.100 and 30% of those falls, if they result in a broken hip, will result in fatality within

01:14:07.000 the 12 months that ensue. Pull up this graph. This is a graph we had showed in a newsletter

01:14:12.640 a couple of years ago. Every once in a while, you don't really need any statistics to understand this.

01:14:17.060 You just need to look at the graph. So this is the normalized death rate per 100,000 people over the

01:14:25.860 last basically 15 years. These are data from the CDC. And you can see that just from 2007 to 2016,

01:14:34.140 we've seen a 30% increase in fall deaths. To put it in perspective, the projection is that by 2030,

01:14:43.360 we're going to expect to see seven fall deaths every hour in the US. Again, it's very difficult to wrap

01:14:51.620 our minds around this, I think. And I think all of us as physicians, certainly myself in this

01:14:57.940 category, unless you're a physician who specifically has a geriatric practice, maybe where you would see

01:15:03.840 more of this, I just don't think we can wrap our minds around this problem and the magnitude of this

01:15:09.700 problem. Again, if you look at the data in 2018, we're talking about 36 million falls reported to 8

01:15:18.340 million injuries. That looks like it's going to very quickly become 52 million falls with 12 million

01:15:27.380 injuries in about five years for people over the age of 65. So I think that it's safe to say that falls pose,

01:15:36.500 not by magnitude, but certainly by severity, as significant a threat to an aging individual as the typical

01:15:44.340 horseman that we've spoken about so often. What do we know about the reasons for falls? What makes

01:15:52.260 a fall worse than the others? Because as you mentioned, these are only reported falls. So

01:15:57.700 there's probably a lot of times where if someone falls and they get up and they're just a little

01:16:01.780 banged up, they're not going to report it to anybody. And so if we want to double click on falling

01:16:06.340 in particular, what do we know about more detail on that, that make it more dangerous than others?

01:16:11.700 Yeah. So I think there's two ways to kind of think about this. There's what is it that increases our

01:16:18.500 susceptibility to fall? Why is that going up as we age? And then there's another issue,

01:16:24.420 which is not only does your probability of fall going up, but the severity of the fall

01:16:28.980 is also going up as you age. So those two things are compounding. And that's why if you look at the

01:16:35.580 data and actually do think I included this figure in outlive, I have a figure that shows the death

01:16:43.420 rate of falls by decade. And if you're trying to explain to somebody what exponential growth looks

01:16:49.480 like, you just show them that graph. That's exponential growth. And that's why two things

01:16:55.820 are compounding non-linearly and you put them on top of each other. So let's talk about it. Like,

01:17:01.580 why is this happening? Well, I think if you're asking like, why are there more falls? It's going

01:17:06.740 to be lower limb weakness. And we should double click on specifically like the role of the toe

01:17:11.780 there. We had a recent podcast with Courtney Conley that discussed that. Difficulty with walking and

01:17:17.620 balance. Remember I said vestibular changes kick in around the age of 65. So all of us become less

01:17:24.140 visually capable and we have less just innate vestibular capacity, visual difficulties, foot

01:17:31.260 pain, poorly fitting footwear as we age. And then of course there's medications that people take. So

01:17:37.740 the older we get, the greater we see the incidence of hypertension. Hypertension does need to be treated.

01:17:42.700 It's an enormous risk for stroke and heart attack, but sometimes we over-treat it and people become

01:17:48.200 orthostatic. And when they stand up, they get lightheaded and fall. I don't know if you know anybody

01:17:52.740 that that's happened to Nick, but that can also be kind of a devastating consequence of just being

01:17:58.700 alive. You also talk about things that I don't think are necessarily age related. All of those

01:18:04.360 things are age related, but obviously just having uneven steps around clutter, all of those things

01:18:10.140 play a role. So the more of these factors you check off, the more likely you are to fall.

01:18:14.840 Now to the question of why is it more catastrophic? An amazing statistic is that the leading

01:18:22.460 cause of traumatic brain injury in people over the age of 65 is falling. 95% of hip fractures are

01:18:29.440 driven by falls. Clearly frailty is the leading cause of this. So frailty means poor muscle mass,

01:18:37.860 poor reactivity, and low bone density. Those are probably the things that are driving the severity of

01:18:45.840 the fall, which are so much higher in a person who's older than a person who's younger.

01:18:50.800 You recall, I alluded back to the podcast with Andy Galpin, where we talked about the atrophy of

01:18:56.200 the type two muscle fiber. Well, I think Andy used that as the great example of another reason why

01:19:02.500 falls go up as people age is that if you or I step off a curb, we weren't expecting to be there. Or,

01:19:13.440 you know, when you're stepping from one level to another and the level is different than you expected,

01:19:17.220 that immediately destabilizes you. Well, the ability to react to that very quickly and get

01:19:24.600 a firm footing, that is a very power-driven movement. That's not really about how strong

01:19:30.240 you are. It's actually about how explosive and powerful you are. That is a type two muscle fiber

01:19:35.360 phenomenon. And as you watch the atrophy of those two fibers, you have far less reactive speed in your

01:19:42.720 feet. And therefore, you're more likely to fall in response to that. Again, the more we can train

01:19:51.080 these systems, the better we are going to be able to resist falling. You mentioned there Courtney's

01:19:57.340 episode, which if anyone hasn't listened to her watch will be really good to go back to. But can we

01:20:02.360 double click on the role that the foot plays in fall risks? And even in particular, one thing she

01:20:08.080 talked about, which was toe strength. Yeah. Again, great episode. Absolutely worth going back to

01:20:13.640 if you haven't listened to it. And also we'll talk about the videos that Courtney and I put together,

01:20:19.540 but foot health matters. And I think one of the things I took away from the discussion with Courtney

01:20:24.640 was that toe strength was the biggest predictor of falling in people over 65. In that podcast,

01:20:33.160 Courtney ran me through a bunch of tests to determine toe strength. One of those tests,

01:20:40.180 my two favorite, right? So one of those tests was a little card that you put under your toes

01:20:45.680 and it's a dynamometer. So it measures the force that you can push each toe down as the card is trying

01:20:54.940 to be pulled out. And so the rule of thumb, if I recall, was your great toe should be able to push

01:21:02.980 down with at least 10% of your body weight. And if it can't, it's too weak. Toes two through five

01:21:10.120 collectively should be able to push down about 7% of your body weight. Another great test was the

01:21:18.580 kind of lean forward test. So this was when you're standing up straight, we have this little laser

01:21:24.520 device. It sounds more complicated than it is. I've obviously already gone out and bought said laser on

01:21:28.820 Amazon link to all that, but you shoot it against a wall and you get a distance and then you lean

01:21:34.760 forward and without catching yourself, just letting your toes basically do the work to see how far they

01:21:42.160 support you. And you should be able to, I believe, be able to move at least five inches or maybe it's

01:21:46.860 four and a half inches there. So those are some great ways to test. And again, it's just added so much

01:21:53.220 more to how I think about the importance of this stuff. Because I have to be honest with you,

01:21:58.640 I've always thought of foot as an important thing. Not always, but you know, in the past five years,

01:22:04.600 the importance of toe strength and feet has been relevant to me for other reasons, but I never

01:22:09.540 appreciated what a role it played in falling. So I'll leave it at that. But just to say, we'll link

01:22:15.340 here to a whole bunch of exercises that go to explain how to strengthen your toes. Next thing you

01:22:23.220 want to talk about here is really calf strength. And again, in the videos, Courtney goes through

01:22:28.860 the benchmark tests for both gastroc and soleus test. I would say the following, virtually nobody

01:22:36.680 I've ever seen has been able to pass these tests out of the gate. These are very difficult tests.

01:22:42.900 And that tells us that most of us are heading into older age with underdeveloped strength in our lower

01:22:51.600 leg. And so again, it's actually changed my training and I have added much more soleus and gastroc

01:23:00.720 training. And frankly, it's been at a much heavier weight than I've trained in the past because of

01:23:06.860 my understanding of how those fibers work. The other thing here is around ankle mobility. So another set

01:23:12.940 of tests that Courtney put me through were around dorsiflexion and tibial rotation. And again,

01:23:18.760 I was surprised that I did not pass these with flying colors. And I think I passed on one side,

01:23:25.820 but not the other. We showed the side that I failed on if my memory serves me correctly.

01:23:30.560 I'll also always remember something that someone told me many years ago, which was if you can't walk

01:23:37.420 down a flight of normal height stairs, so call it a seven or eight inch step, whatever normal is,

01:23:42.680 and keep your toes perfectly pointed forward, you don't have enough dorsiflexion. So if you think

01:23:49.580 about it, a lot of people when they're walking downstairs have to turn their toes somewhat out

01:23:54.220 to accommodate the tibial or the shin angle with the foot. And so I would encourage everybody the

01:24:00.720 next time they're walking downstairs to actually see if they can walk with feet perfectly parallel and

01:24:07.260 pointing forward. And if that's difficult on your lower shin and upper foot, you probably don't have

01:24:15.080 enough dorsiflexion. And so again, we'll link here to a whole bunch of exercises that you can use to

01:24:22.060 train that. And there are a handful of devices here that I use, and I really like these devices.

01:24:27.320 Don't have any affiliation with all of them. So not promoting something that I'm a part of,

01:24:31.400 but definitely something that, that I'm a big fan of. The last few questions we wanted to hit are

01:24:37.100 just kind of on a few different variables that relate to exercise. The first is bone mineral

01:24:42.460 density. And you kind of talked about it with falls and frailty, and we had a whole AMA that people can

01:24:48.780 look at on bone mineral density. But what do we know about resistance training for bone mineral

01:24:54.500 density in older adults? Because I do know this is something that as people get older, they're much more

01:24:59.960 worried about and looking at even compared to people in their twenties, thirties. And also,

01:25:05.560 I think this allows you to talk about, which I think is one of your favorite news stories

01:25:10.140 on this subject. So do you want to speak to that? Yeah. BMD or bone mineral density,

01:25:16.300 which is one of the kind of four pieces of data you get from a DEXA scan is typically reported as both

01:25:22.180 a Z score and a T score. Now it's really important if you are getting a DEXA scan, because you want this

01:25:27.100 information, you need to make sure that it's reported segmentally. So a lot of places that

01:25:33.300 do a DEXA scan don't give you the hip and lumbar spine readings. They'll just give you total body

01:25:41.300 T score and Z score. And unfortunately, that is not sufficient to understand your risk. So you need

01:25:48.420 a T score for the lumbar spine, and you need a T score for at least one, if not both of the hips.

01:25:54.720 We'd like to see it for both hips, but some places we'll just do one because the concordance

01:25:59.320 between hips is pretty high. I'll take a moment just to explain what a T score is. A T score is

01:26:04.140 the difference between your bone mineral density and the mean level for a 30 year old of your sex

01:26:11.640 divided by the standard deviation. If the T score is below minus one, that is defined as osteopenia.

01:26:20.800 If the T score is below minus 2.5, that is defined as osteoporosis. So that's sort of one thing to

01:26:28.840 understand. Another thing to understand is how bones work from a density standpoint. A lot of

01:26:36.580 this is already covered in that AMA that we did, and we should obviously link to that for long

01:26:41.260 listening. But I'm just kind of giving the TLDR here. We basically are in a bone building, net bone

01:26:48.360 building phase until our early 20s. We sort of hit bone peak, and then it's mostly a decline from

01:26:56.320 that point on. For women, the decline becomes quite precipitous once they hit menopause. If they are not

01:27:02.820 placed on estrogen therapy, you might ask why. Well, it has to do with the fact that estrogen is

01:27:08.200 potentially the single most important hormone when it comes to regulating bone health. And the reason

01:27:14.960 for it is that bones respond to load. So that gets to your question, Nick, which is why does

01:27:22.640 strength training matter so much? It's because it is a load. The bones need a compressive force

01:27:29.120 on them to grow, and the compressive force comes typically when the muscles around them are contracting.

01:27:37.460 By the way, the one thing that I recall from that podcast that stood out as even a greater impact on

01:27:43.540 bone strength was wrestling and jiu-jitsu. Take that for what it's worth. I know that both of those are

01:27:49.220 near and dear to your heart. But what happens is when the bone is placed under load, think of it as a

01:27:56.020 strain gauge that measures the deflection of the bone. And that strain gauge has to communicate

01:28:02.300 through a chemical signal to the osteoblasts and osteoclasts, which are the bone building and bone

01:28:09.020 decaying cells, respectively. And that chemical signal, so the mechanical signal is transduced

01:28:15.200 into a chemical signal, that's done via estrogen. And so that's why estrogen is so important, because

01:28:19.860 it's the chemical messenger that says, hey, I'm under load, I'm being deformed, please give me more bone

01:28:26.580 building material here. So what else can I say about that? Well, look, unfortunately, this is another one of

01:28:33.580 those things that declines precipitously with age, and it's nonlinear, meaning the rate of decline

01:28:40.300 goes up by decade. It's not a constant rate of decline. You referred to a study that was done by

01:28:47.340 Belinda Beck at, I believe, Griffith University in Australia. We'll link to that, but it was called the

01:28:52.080 Lift More Trial. It was published in 2015. I've linked many times before to a great YouTube video where

01:28:58.280 she kind of talks about the high level of this. This is a study that recruited healthy post-menopausal

01:29:04.200 women with low bone mass. So these were women that all had at least osteopenia, T-scores below minus

01:29:11.040 one. And the intervention group was given eight months of just twice weekly, 30 minutes at a time,

01:29:19.180 so 60 minutes total, supervised strength training, where they were doing five sets of five reps at more

01:29:27.320 than 85% of their one rep max. The reason this study always caught my attention is these were

01:29:33.120 women who didn't have a background in strength training, and yet they were doing five by fives.

01:29:39.600 And so we want to also kind of dismiss the idea that you can't take somebody who's new and get them

01:29:46.360 strong. Five by fives are real set. Those are big workouts, and these are being pushed to 85%,

01:29:52.140 beyond 85% of their one RM. So that was the intervention. The control group was just given low

01:29:57.300 intensity exercise. And after eight months, the BMD of the lumbar spine in the treatment group

01:30:04.860 had gone up by almost 3% at the same time that the controls had lost over 1% of the BMD in their

01:30:13.800 lumbar spine. And basically the same thing was true in the femoral neck. You saw an increase in the women

01:30:20.100 who had been training versus a significant. It was almost a 2% decrease in the control group.

01:30:25.520 So again, to me, it's just one of my favorite studies because of the population that it's using

01:30:30.760 and the simplicity of the intervention. So I just can't say enough about the importance of this.

01:30:36.380 I didn't realize it either, but how awesome of a name for a study is Lift More, M-O-R.

01:30:41.920 Like it's an A plus name.

01:30:44.140 Gotta do it.

01:30:45.160 Yeah, I just gotta do it. That should be a license plate for you. I feel like every now and then you're

01:30:49.520 looking for license plates, Lift More is an A plus one. Although people might be expecting

01:30:54.380 someone insanely jacked bodybuilder.

01:30:57.800 That's true.

01:30:58.380 Like Arnold style to walk out of that.

01:31:00.300 Yeah. I would not do justice to that license plate.

01:31:03.100 Yeah, that's probably true. Just need to do more Tabata deadlifts to get that muscle size up.

01:31:09.000 Okay. What about protein? Another subject that you've talked heavily about tons of places. We can link to

01:31:14.940 all of them, but how does protein relate to muscle building, especially in people 15 plus? And how do

01:31:21.540 you talk to your patients about it? Oh boy, they're sick of it. I'm sure. Because we talk about it a

01:31:27.240 lot. Protein by itself stimulates muscle protein synthesis. Ingested protein by itself stimulates

01:31:36.800 muscle protein synthesis. So in English, what that means is simply eating protein, even without a

01:31:43.960 training stimulus, promotes the building of muscle. Of course, that effect is dwarfed by the effect of

01:31:51.540 a training stimulus plus protein. Look, I think at the high level, this is relatively straightforward.

01:31:58.800 You probably want at least 1.6 grams of protein per kilogram of body weight. And as you get older,

01:32:07.300 you should start to move that number higher and higher because of what's called anabolic resistance.

01:32:11.980 So as we get older, the muscles become less sensitive to the effects of the amino acids.

01:32:21.460 By the way, I won't get into it here because we covered it in great depth on the podcast recently

01:32:26.460 with Luke Von Loon, but it was actually the first time I had a really good explanation,

01:32:31.060 at least speculation, as to why anabolic resistance is taking place. So I've never actually really known

01:32:36.680 why. I mean, it turns out that maybe that's because nobody knows, but Luke offered a list of

01:32:41.960 several very interesting and plausible physiologic reasons for why the aging individual is less and

01:32:49.840 less sensitive to amino acids. So again, we've done so much on protein. I don't think I need to say more

01:32:56.140 here. We'll link to all of those references with both Luke and Don Lehman and Lane Norton as well.

01:33:02.720 But the long and short of it is all of the stuff we're talking about in this podcast needs to be

01:33:07.900 supported nutritionally and nothing is more important than that of protein intake. We can

01:33:14.480 talk about how to divide it all up. All of that's covered in those podcasts, but the short of it is

01:33:18.580 you really want to be at a minimum of 20 grams per serving, but it's more nuanced than that,

01:33:24.300 of course, because the type of protein determines the speed with which you're going to be able to

01:33:29.200 incorporate it. General rule is protein in food is going to give you a longer, more forgiving window

01:33:36.580 in which to assimilate it. We can link to even a recent newsletter we wrote that addressed a study

01:33:42.800 looking at some of the conventional beliefs that were challenged by a study that actually Luke was

01:33:48.940 an author on looking at the difference between whey and casein protein in terms of muscle protein

01:33:54.720 synthesis over time. All right. So Peter, I think that kind of wraps at least everything we were

01:34:01.280 hoping to get out. And as we said in the beginning, we've covered some of this stuff in greater detail

01:34:05.720 and other places we'll link to. We didn't want to bog it down with too many scientific studies

01:34:10.200 and we hope to just kind of give people a little bit of insight, how to think about starting to

01:34:15.320 exercise as an older age and one, why it's important, how to do it, how to start building it up.

01:34:20.160 And so I think as we wrap any last bit of insight or any last bit of advice you would give to people

01:34:28.180 who are in that category, the 50 plus, the 65 plus who are saying, okay, you convinced me I'm going to

01:34:35.080 start doing this. Yeah. I just kind of go back to some of the stuff we've already talked about,

01:34:39.820 which is if you're in that camp, if I'm talking to you and I've hopefully convinced you of this,

01:34:45.600 I don't want you to get hurt. I want you to have fun. I want you to look back at this in 90 days

01:34:50.460 and say, I'm really glad I made this change. And that means do something as much as you can

01:34:57.380 try to do something every day. And if it means going out for a 15 minute walk after dinner,

01:35:04.000 great. If three months from now you've managed to get to a point where you have a portfolio approach

01:35:11.520 to how you're exercising. So you're doing a little bit of stuff that is actually resistance training,

01:35:18.400 hopefully even progressing beyond body weight. And you're even starting to challenge the different

01:35:22.840 energy systems from a cardio perspective, walking at a modest pace versus a little bit of really

01:35:28.020 brisk walking or uphill walking and you're not injured and you're enjoying it. We've won the game.

01:35:33.100 Yeah. I think that's all really solid. And hopefully, again, hopefully people enjoy this

01:35:39.340 no matter what age you are, but I think that's it, Peter. So anything else you want to say before we

01:35:44.620 part ways? Try to avoid Tabata deadlifts. Just so you know, I didn't miss it. I did

01:35:51.320 appreciate the callback to you face planning in Brazil from low blood pressure. So we'll include those

01:36:00.140 links to the photos in the show notes, but I didn't want to interrupt you because you were

01:36:05.200 going down a good path, but I did pick that up just so you know. All right. Awesome. Peter,

01:36:09.960 we'll see you next time. Until next time. Thank you for listening to this week's episode of the drive.

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The Peter Attia Drive - June 24, 2024

#307 ‒ Exercise for aging people： where to begin, and how to minimize risk while maximizing potential ｜ Peter Attia, M.D.

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