The Peter Attia Drive - #378 ‒ Women's health and performance： how training, nutrition, and hormones interact across life stages

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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00:00:53.200 of a subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Abby Smith-Ryan.

00:01:07.360 Abby is the Associate Chair for Research in the Department of Exercise and Sports Science,

00:01:12.640 the Director of the Applied Physiology Lab, and the Co-Director of the Human Performance Center at

00:01:17.960 the University of North Carolina at Chapel Hill. She's authored more than 180 peer-reviewed papers,

00:01:23.520 books, chapters, and has led NIH and industry-funded trials on exercise and nutrition interventions.

00:01:29.600 Her research focuses on body composition, metabolism, and cardiovascular health, but with a special

00:01:34.800 attention to women's health through the perimenopausal and postmenopausal transition,

00:01:39.960 as well as overweight and obese populations. She is also a dedicated mentor, educator, and advocate for

00:01:45.740 empowering women with evidence-based approaches to health and performance. In this episode, we discuss

00:01:51.080 how early exercise and play shape bone health, muscle development, and cardiorespiratory fitness

00:01:56.780 in young girls, the impact of puberty and menstruation on athletic performance, motivation, and recovery,

00:02:02.920 how to tailor training and nutrition throughout the menstrual cycle, including strategies for fueling

00:02:08.340 hydration and managing inflammation, the science behind supplements such as creatine, omega-3s,

00:02:14.060 and magnesium in supporting women's health and performance, the transition into perimenopause

00:02:19.500 and menopause and how hormonal changes influence metabolism, muscle preservation, and fat distribution,

00:02:25.720 practical exercise, programming for busy women, balancing resistance training and aerobic training

00:02:30.500 for those with limited time, nutrition and training during pregnancy and postpartum,

00:02:36.220 including common mistakes and how to safely rebuild strength, and the evolving role of hormone therapy

00:02:41.720 and how women can better advocate for their health through evidence-based and lifestyle-driven

00:02:46.120 approaches. So without further delay, please enjoy my very informative discussion with Abby Smith-Ryan.

00:02:57.160 Hey, Abby, thank you so much for coming out to Austin.

00:03:00.040 Really appreciate the invite.

00:03:01.740 Tell me a little bit about your background in terms of what got you interested in this space.

00:03:07.120 You look pretty fit. I assume you were an athlete growing up.

00:03:10.000 Yeah, I'll take that as a compliment. I was a collegiate distance runner, but I have always

00:03:14.660 had a love of strength training, which is a little bit impeding for endurance goals. I really fell in

00:03:20.940 love with science, the ability to ask a question and answer it. And so I started early with research

00:03:26.180 and then fumbled my way in that space, really understanding the more you know, the more you don't

00:03:31.820 know. And here I am.

00:03:34.680 As my friend Bob Kaplan used to say, the further you get from shore, the deeper the water gets.

00:03:38.580 Okay. So you're a distance runner. So in college, that's what? 5K, 10K?

00:03:44.180 Yeah. 3K, 5K, 1500, 800 if my coach was mad. I'm not that fast.

00:03:50.160 Yeah. My daughter runs track. I feel like the 800 is the worst, most painful event in the lot.

00:03:57.880 I would add the 1500. You have to do two more laps at a similar pace. So it leverages that too.

00:04:03.360 Yeah. But there is something about that approximately two minute all out effort that is

00:04:08.800 really brutal. So, all right, there's a lot I want to talk about. I'm trying to think of the

00:04:14.980 best way to help orient it, but clearly there are certain things that just seem obvious and true

00:04:20.600 across the board. For example, we know that exercise is a remarkable tool to delay the onset of chronic

00:04:27.720 disease. We also know that it's a remarkable tool to improve health span or quality of life.

00:04:34.200 But particularly, I want to just focus with you and your expertise around what we can understand

00:04:39.720 in terms of exercise across the life cycle of a woman. And I want to almost start basically at

00:04:45.500 the beginning. So I'm pretty sure there are no teenage girls listening to this podcast. I would be

00:04:51.140 comfortable saying there are exactly zero of them, but there are probably parents of those. And a

00:04:57.420 previous guest made a point that I thought was amazing and has never left me, which is osteoporosis

00:05:04.200 is a childhood disease. What she meant by that, of course, was that particularly for women, they are

00:05:10.960 reaching their genetic ceiling at about the age of 19 in terms of bone density. And then from 19 until

00:05:16.800 the end of life, they're sort of hanging on to what they've got. And then they've got all of these

00:05:20.640 things that get in the way, such as menopause. Let's just start with that. So if you're even not

00:05:25.400 a teenager, you're a 10-year-old girl, how do you think about the role of exercise across several

00:05:32.000 dimensions, but not the least of which being bone health, but muscle health and reaching their

00:05:36.740 cardiorespiratory potential? It's a big question. I would sum it up of exercise is the best medicine

00:05:43.440 starting young. I would consider it more play and then transitioning into lots of different types

00:05:48.740 of exercise. But really, there's lots of literature to suggest this. The earlier you start and the

00:05:54.620 better base that you have, the easier it is over time to maintain that fitness. So when we think about

00:06:01.040 young girls, the biggest conversation and even some of the research we do is the addition of

00:06:07.160 menstruation often is a turning point when women and girls leave sport based on a number of things

00:06:13.340 of how their body changes, how their performance differs. And so part of what my lab looks at is

00:06:20.320 understanding how that menstrual cycle might impact performance, recovery, bloating, mental health.

00:06:27.340 And so part of why I'm here is the ability to have that conversation. When I was growing up,

00:06:32.800 no one talked about it. Were you a runner growing up as well? Yeah, I played all sports. I loved

00:06:38.460 every sport you could imagine. It was my ability to live life and I'm very thankful for that. I grew up

00:06:45.480 in a space where it was exercise more and eat less. And when you add running, it's this ability to really

00:06:53.700 see how your fitness changes. Same thing with resistance training. You can see how strong you

00:06:59.520 get. It's a very empowering tool. But I think we don't talk about it enough with young girls of what

00:07:05.340 is menstruation. Why is it healthy? As when you go into sports, a lot of times it's like, oh, it's a

00:07:11.320 badge of honor when you don't have your menstrual cycle or there's a lack of knowledge of it is very

00:07:16.820 much related to nutrition. Let's talk first about pre-menstrual cycle. Are there any do's and don'ts

00:07:25.320 that you think of for young girls who are playing sports in terms of what they can be doing to augment

00:07:32.040 their training? So for example, if you're talking about a young girl who plays field hockey or

00:07:36.360 volleyball or basketball, do you have any thoughts on what they should or should not be doing in the

00:07:41.940 weight room, for example? I don't work a lot with young kids and I actually have two little boys,

00:07:46.740 but I think I would tell you the same thing of, and there's a lot of really interesting data that

00:07:51.880 we haven't done, but not specializing. Being in lots of different sports to accelerate lots of

00:07:58.560 different types of muscles and movement, and I'll speak to my personal experience of my favorite lift

00:08:04.220 when I was about 11 or 12 was the Romanian deadlift. Resistance training is the best prevention of injury

00:08:10.920 and oftentimes coaches don't include that. There's a lot of time on the soccer field or the softball

00:08:16.360 field, and so total body exercises, whether we start with resistance bands or lightweights or

00:08:22.460 plyometrics or med balls, those are all really great things. So let's talk now about this transition

00:08:29.920 as a girl enters her reproductive years. It seems that intense exercise can delay that. The two

00:08:36.860 athletes I tend to hear this most about are gymnasts and runners. Does that also happen with swimmers?

00:08:42.180 I mean, they seem to have some of the highest volume as well, so I would guess that's the case.

00:08:45.700 Yeah, it depends on, I think, the events, but yeah, absolutely. Cyclists.

00:08:49.420 Is there a downside to that? I mean, there is. We've done a little bit of work more capturing once

00:08:56.400 the female is in college, so kind of the aftermath of that, and there is data that it very much

00:09:01.920 negatively impacts bone. Because of the delay of estrogen onset.

00:09:05.740 Absolutely. I mean, there's a number of things oftentimes related to caloric restriction or

00:09:11.780 indirectly overexercise. I am a big believer that it's not always intentional. The other thing we see

00:09:17.720 often with things like track and field and gymnastics is every athlete we scan, they have

00:09:25.200 not full-on scoliosis, but a spinal curve, which really demonstrates the point you mentioned that

00:09:31.420 osteoporosis is a childhood disease of setting bone. And what we do with those young girls has a

00:09:37.920 lifelong impact, whether that's a straight spine or a curved spine.

00:09:42.040 Say more about that. I wasn't really aware that the scoliosis component could be partially acquired.

00:09:47.180 Yeah. Now, I've been at UNC for about 15 years, but when we first started doing DEXA scans,

00:09:52.520 we do a lot of whole body for body composition. Every high jumper and every gymnast has a very

00:09:59.260 distinct curve. Some of them are aware. Obviously, it's a very thick scoliosis, they know, but many

00:10:05.340 of them were unaware. And it's really important then to say, okay, well, how do we stabilize this as

00:10:11.460 you age? You've already got that. You can't necessarily change that at 18, 19, 20, but you

00:10:16.900 can very much work on the musculoskeletal system. And I would guess pole vaulters as well, right?

00:10:20.980 Anybody who's got an asymmetric. Exactly.

00:10:23.820 Interesting. Do we see something different in male equivalent of those sports?

00:10:28.820 We do not have a male gymnastics team. Don't see it as much. Love to get your thoughts. What do you

00:10:36.420 think? To be honest, I've never thought about it until you brought it up. I don't know. You could

00:10:42.340 make an argument that if it were less prevalent in males, that maybe males have more musculature

00:10:47.340 around the spine and therefore they're more able to offset what's happening. That might be an idea,

00:10:53.040 but I actually don't know. Yeah. Or even age of onset of puberty,

00:10:55.960 that could impact it as well. All right. So as girls get into high school

00:11:01.300 and college and their training, let's talk a little bit about this idea of reaching your

00:11:06.500 potential early. Let's start with something like VO2 max. So we talk a lot about it in adults and how

00:11:13.320 important it is and how much you're trying to maintain it. But what do we know about the ceiling

00:11:18.440 that a person has when they're that young? We don't deal with people so young, but I remember being

00:11:24.340 that young and having basically an unlimited capacity to train. And I'm pretty grateful I

00:11:30.300 took advantage of it, but I know that that's not necessarily something everyone's going to do.

00:11:34.940 Yeah. Maybe I'll reframe it. I don't know. And I don't do this work with young people,

00:11:39.560 but there really isn't a ceiling per se. Meaning when you're young, I think the best part is,

00:11:46.160 is to see those training adaptations. And I think the body is more responsive. So for example,

00:11:52.500 I always joked of like, I went out for cross country to get in shape for basketball,

00:11:57.340 obviously very different physiological systems. And I did not feel fit when I then transitioned

00:12:02.400 to basketball because it's a different energy system. But that fitness then by the time the

00:12:07.500 end of basketball, I was more fit. And so that adaptability is there when you're young and setting

00:12:13.440 the stage. Is it a ceiling effect that you can never add? I always view it as exercise is one of

00:12:19.760 those things you can do regardless how old you are. And you can always see improvements if that's

00:12:25.020 the goal. So I wouldn't say a ceiling, but I think definitely on the skeleton and definitely

00:12:29.740 on our habits of understanding that you are in control and you can see these really cool

00:12:36.860 physiological adaptations by changing your training.

00:12:41.200 So let's talk a little bit about nutrition as well. What do you think are the most important things

00:12:47.640 for a young woman to be thinking about? And I guess we can talk about this under different

00:12:52.960 circumstances. We can talk about this under eucaloric conditions where we're just trying to

00:12:57.640 maybe do recomposition versus weight loss versus weight gain. Take it however you would like to talk

00:13:03.640 about it. That's a big question. I think if we talk about young women, my conversation would be all

00:13:09.520 about nutrition as fuel. It's really getting adequate nutrition. And that is really where I landed

00:13:16.380 with some of our nutrient timing work of often when you're young or let's say midlife and busy,

00:13:22.940 you want to prioritize getting enough calories. But sometimes you can offset that or take advantage

00:13:28.720 of your training by what you eat before, during, and after. Not that that it's necessarily any better.

00:13:34.960 And so when I think about a young female athlete and this idea that there's increased GI distress,

00:13:40.740 it's hard to exercise when your stomach is full, but really teaching them it's about providing nutrients

00:13:46.820 so that they can perform better, recover better, that education about what it is versus necessarily

00:13:53.240 what foods to eat and not to eat. I think about this again, just through the lens of my own selfish

00:13:58.420 interest around my daughter. So when she's running cross country, I'm always concerned she's not eating

00:14:03.480 enough because practice is first thing in the morning. Understandably, nobody's really hungry

00:14:09.080 in the morning. She's not really eating. She sort of has a bagel and takes a bite out of it.

00:14:13.740 Then they run and then they're in class and then they're not really eating. And then I just worry

00:14:19.840 that they're sort of not getting enough calories. So what are the strategies you think about for

00:14:24.600 young athletes to hit their caloric requirements when training and school are impediments?

00:14:30.900 One of the things is to think about what types of food. So in that scenario, especially into puberty

00:14:36.580 is higher quality fat foods, essential fats, and often it's less food and still gets that caloric

00:14:42.260 density. What are some things you recommend? Higher fat milk, higher fat yogurt, your nuts,

00:14:48.260 your seeds, being really intentional about not necessarily changing the foods you're eating, but just

00:14:53.260 small swaps instead of a skim milk, a whole milk and things that you can pack with you. Those would be

00:14:59.920 the key first things. The other things would be, there's, you know, a lot of people that talk about

00:15:04.400 intuitive eating, eating when you're hungry, but when you're exercising, you're often blunting that

00:15:10.320 response or most girls and women deal with GI distress. So I say that of planning more of that

00:15:17.720 consumption.

00:15:18.400 Why is that? Are you saying that the carbohydrate density or concentration, they tend to have more

00:15:24.140 dumping issues or things like that?

00:15:25.760 It's not just dumping. It's just the whole GI tract. I think some of it is stress-induced. Honestly,

00:15:32.080 it's a really good question. I'm not a gut researcher. Some data suggests that it aligns

00:15:36.380 with the menstrual cycle. There's a lot of GI distress right before menstruation, and it's not

00:15:41.080 just cramping. So there's a number of elements that go into that. It's not just carbohydrate-driven,

00:15:45.780 which is an important component because I do think now the conversation with young female

00:15:51.500 athletes is to not eat as many carbohydrates, be very protein-centric, when in reality,

00:15:58.280 carbohydrates are so important for any active individual, but especially our young females.

00:16:05.180 What strategies do you recommend for any woman of any age who's training and trying to manage her

00:16:11.780 cycle? So whether she's 18 or 38, how do you think about training around the cycle?

00:16:17.160 We've done a lot of work in this space. And I'll tell you this based on our data and others is

00:16:22.780 we can train at any given time in our cycle. But what we do see is it's very clear that women

00:16:29.060 and girls feel worse during different phases of the cycle. And I think that's a really important point,

00:16:35.700 particularly in the luteal phase, right before menstruation, often women feel more fatigued.

00:16:41.340 They have more bloating. It can impact recovery and soreness. And I say that a woman can still compete

00:16:47.940 and they will, but often it's this ability to say, like for me, like maybe I didn't meet my max.

00:16:55.320 My performance is not as good. Then it's a little bit of, oh, you're fine. That's a physiological response.

00:17:02.380 I've always wondered when you watch the Olympics or something where you've got this one shot

00:17:06.960 in four years. And it's easy to sort of look at people like Michael Phelps, who have been so

00:17:12.440 successful over so many Olympics or Simone Biles, but that's not the norm. The norm, which of course,

00:17:18.320 there's nothing about the Olympics that's the norm, but the norm might be you get one shot at this in

00:17:22.780 your life. And it's always struck me as the greatest injustice for women, for female athletes,

00:17:30.680 if their event falls at the time of the wrong time in their cycle, that has to be impeding performance,

00:17:37.500 right? I mean, I would argue, no, it is a question that I've thought about too, of like, how great

00:17:42.040 would it be if we could ask our Olympians, whether they're on their menstrual cycle or they're not,

00:17:46.620 or having their period. But what all of the data shows is that a woman is going to compete regardless.

00:17:53.600 I do think it's more about the recovery. So if we take an event where they, often the Olympics is not

00:17:59.500 just a single event, it's repeated. And so really bringing science into help with recovery and

00:18:05.640 inflammation and protein breakdown, where we might do it differently in the luteal phase versus the

00:18:11.220 follicular phase. So really using more tools to help with the recovery, not necessarily that peak

00:18:16.320 performance, that seems to still be there. Let's go through the entire phase. So day zero or day one,

00:18:23.200 when the period starts, in some sense, I would guess that from that point to the next week,

00:18:29.500 from a hormone perspective, the hormones are very low. Tell me what's happening from a performance

00:18:35.300 perspective. We'll do it in quarters. Let's do this. So this will call that the first quarter of

00:18:39.620 the cycle, which is when her period's actually happening, probably the first four or five days

00:18:44.080 of that. FSH, LH, estradiol, they're all pretty low. So walk through the strategies. And we don't have

00:18:49.880 to do this through the lens of the Olympics, but let's do it through the lens of you are training

00:18:54.620 really, really hard. You want to maximize your performance and recovery throughout the entirety

00:18:59.560 of your cycle. So what are you doing this week? Let me just qualify. I think it's really important

00:19:03.560 that we're going to talk about this traditional cycle, but it's very clear that every cycle is so,

00:19:09.560 so very different. I say that we in the lab have used some really cool at-home monitoring tools.

00:19:15.420 Technology has changed. I think that can be really powerful to say, okay, well, maybe you only bleed

00:19:21.280 for three days or your hormones are not textbook. But if we talk about low hormone phase, that

00:19:28.320 follicular zero to five days approximately, typically we have greater carbohydrate oxidation.

00:19:34.360 We feel better. We perform better. Like I would say, and based on the literature, that's when

00:19:39.200 I wouldn't say you want to do anything less, but it would be less thought provoking. You just do what

00:19:44.860 you need to do and eat fuel. You will burn more carbohydrate. There's a lot of nuance.

00:19:51.100 Meaning it depends on if you have a long-term event, but I would say in general, follicular

00:19:55.860 phase, things are pretty steady. I would say with the loss of menstrual fluid, there's some

00:20:01.300 things to consider, obviously hydration. I mean, we always think about iron. Would there

00:20:06.780 be a transient loss? Potentially. I think with iron, though, you're not going to necessarily

00:20:11.800 just change that through menstrual fluid loss.

00:20:15.160 What's the relationship between the volume of blood loss during the cycle and the intensity

00:20:20.500 of exercise? Are those inversely correlated or is it more dependent on the woman's individual

00:20:25.160 genetics or physiology?

00:20:26.940 I have a colleague, Claire Bades out of Australia, that's looking at fluid loss and the ability

00:20:31.460 to capture that. But it's so variable. I'm not so sure that we know because some women

00:20:36.100 lose a lot of fluid and others don't. So I'm not so sure we know.

00:20:40.000 Okay. You're dealing with the physiologic loss. You're losing oxygen carrying capacity.

00:20:44.560 So for endurance sports, that's going to be noticeable. So you're saying in that first

00:20:48.620 week, approximately, you're going to see an increase in carbohydrate oxidation. Does that

00:20:54.520 drive an increased appetite of carbohydrates?

00:20:57.320 Typically not. And this is a general nutrition component of, I think I will go back to what we

00:21:03.720 started with. Regardless of the phase of the cycle, we need to eat enough and really focus

00:21:08.860 on that. When we think about that early phase of the cycle, maybe have a little bit more

00:21:13.020 carbohydrate. But I wouldn't say it's necessarily directly related to appetite. Typically, we see

00:21:18.000 the majority of the changes to nutrient timing and nutrition in the luteal phase, which we

00:21:23.400 haven't got to. I would just say eat regularly and then obviously match it based on your intensity

00:21:29.820 and volume of your exercise.

00:21:32.420 Okay. So now let's move into late follicular phase. So we're now kind of day 7 to 14. So now

00:21:38.840 we're really seeing FSH is going up, estradiol is really going up, and she's moving towards

00:21:45.140 ovulation. So first of all, is a woman, I know that some women can sense that they're

00:21:50.060 ovulating, but what is a woman feeling on average during this period?

00:21:54.100 I always say this is the most important time because it's when a woman feels their best,

00:21:58.040 they're also the most fertile. And so often this is when we see, if we were to measure peak

00:22:04.380 performance, maybe it feels a little bit easier. Women feel their best, which I think,

00:22:09.440 although it may not change outcomes of performance, they might feel it has a direct translation to

00:22:15.540 volume, quality of exercise, potentially sleep, kind of optimizing recovery.

00:22:22.720 Okay. Anything beyond that in terms of behaviors or changes you would make in training if you were

00:22:29.080 coaching someone during that period of time? I mean, in coaching, you often can't say,

00:22:34.660 oh, it's ovulation, we're going to do things differently, especially if you have a whole team

00:22:38.800 or an individual. But I would say that is a really good spot to understand peak performance.

00:22:45.220 And so what we've done, and part of my interest in this field is understanding how certain aspects

00:22:50.880 change so that we can do more research in females. So for instance, I often wouldn't test in

00:22:58.040 ovulation. If I am trying to understand how a female's body changes, or if I'm tracking changes,

00:23:04.400 I would capture them in the follicular phase, or I would capture them in the luteal phase.

00:23:10.300 Part of it is ovulation sometimes lasts a couple days, or a woman might have menses and bleed,

00:23:16.880 but not actually ovulate. And so there's a lot more variability, but that's where that technology

00:23:21.860 comes in, where we can begin to narrow it down. All right. So right after she ovulates,

00:23:26.720 you're now into this early luteal phase, estrogen is actually coming down before it makes its second

00:23:32.540 rise, and progesterone is slowly rising. For most women, my recollection is this is not yet the period

00:23:39.620 where they're experiencing the progesterone crash, and therefore this is also not a particularly

00:23:44.380 difficult week.

00:23:45.820 Right. Some women have, like, do we know when you're done ovulating versus that early luteal,

00:23:51.100 unless you're really paying attention, you might not.

00:23:53.020 Okay. So we could almost treat this week like the week before.

00:23:56.320 Yeah.

00:23:56.900 All right. So now it's this final week, this last week of the luteal phase, where

00:24:01.020 perhaps the most dramatic things are happening. It's the progesterone crash and estrogen,

00:24:07.220 but I think it's really the progesterone that's driving more of the emotional changes that are

00:24:10.740 being perceived. What is the effect of that physiologically? Because the emotional effects

00:24:14.160 alone could be sufficient. The last time I looked into this, it was not clear why some women

00:24:19.400 were more susceptible to this than others. There are hypotheses out there. Some women have a greater

00:24:23.840 density of progesterone receptors in the CNS that may render them more susceptible to that depletion,

00:24:29.720 but I don't think we understand this yet, unless there's something that's come up in the past few

00:24:33.680 years that I'm not aware of.

00:24:34.660 I mean, I haven't looked as much at the brain aspects. You're right. It's very individual. That's

00:24:39.800 where we see changes in anxiety, depression, but we also see things physiological, changes in

00:24:44.980 thermoregulation, fluid water retention. Those things will change, greater inflammation. I'll go back

00:24:52.220 to what you said that week prior to that rise in progesterone. Oftentimes that's a strategy that you

00:24:59.340 can prepare for that crash, whether that's prioritizing your sleep or targeting inflammation,

00:25:05.720 if it's severe.

00:25:07.900 What strategies would you recommend there?

00:25:09.900 Actually, we had a conversation before you got here. Let's say we have a female that does

00:25:15.100 experience a lot of changes in anxiety, depression, and or fluid retention or painful periods.

00:25:22.240 Really going into that luteal phase where progesterone peaks, there's some interesting

00:25:27.580 approaches where increasing omega-3 could be helpful to start down-regulating inflammation.

00:25:33.020 So slightly higher doses, two to three grams, potentially some zinc and magnesium to help with

00:25:39.600 the vasodilation, sleep. Research says sometimes that luteal phase sleep goes down or the follicular,

00:25:47.360 but for those individuals that are having more sleep disturbances, we can start to tackle that.

00:25:52.360 Obviously, increasing fruits and vegetables, helping inflammation.

00:25:55.460 The other thing is in that progesterone rise, there's some data that suggests that there's

00:26:01.820 an increase in protein turnover, protein breakdown, and this edema. So for instance,

00:26:08.500 I really want to focus on supplements, but we looked at something like creatine,

00:26:14.100 which really pulls water into the cell. And we evaluated what happens in the follicular versus

00:26:20.000 the luteal phase. And creatine was able to take that extracellular fluid and bring it into the

00:26:26.260 cell. So help with fluid in the right places. And so indirectly, that also supported performance.

00:26:32.920 There's some strategies that we might change to really optimize that. There's also some interesting

00:26:38.400 data that suggests caffeine might be more helpful in the luteal phase to help with those fatigue

00:26:44.320 components. A lot of the things you've talked about seem like great ideas all around. Now,

00:26:50.760 maybe omegas at that level is a bit higher and you would reserve those. You would pulse that in based

00:26:55.000 on that. But obviously, magnesium is critical all around. Our view is that creatine is quite valuable

00:27:00.760 throughout. If a woman didn't want to have to manage it by cycle, would it just be safe to say,

00:27:06.100 look, if you enjoy caffeine, by all means, take it. You might be getting more benefit in the

00:27:10.120 luteal phase. Creatine might benefit you more by reducing actual bloating and pulling the water

00:27:15.960 into the cell. I actually never knew that. I knew that creatine did it. I never made the connection

00:27:19.820 that it would be of a benefit during the luteal phase. That's pretty interesting. By the way,

00:27:24.280 how are you guys dosing creatine in women? I think I know your views on this, but in reality,

00:27:29.560 in a lab-based setting. So we have a pretty cool study right now in the first with creatine and

00:27:34.400 perimenopause. Because we have a lab restriction, we often will load first just to accelerate that

00:27:41.060 creatine saturation and then follow it up with five grams a day. I'm a big believer that five grams,

00:27:46.940 but even now the data in our midlife women or the brain health is up to 10 grams. Yeah, we've changed

00:27:52.800 our thinking on this. And by the way, I completely hear you unloading because if you just go steady

00:27:57.060 state, it takes weeks to get there. It takes way too long. Yeah, so totally get that. But yeah,

00:28:00.940 it's actually funny. I had Rhonda Patrick on the podcast recently. We were talking about that. And

00:28:04.260 I came out of that podcast thinking, you know what? I think we should move our maintenance dose from

00:28:08.200 five to 10. And so we've kind of just done that. That's great. Yeah. We typically will do five grams

00:28:13.920 following that loading. And that's what we're doing now. And your load is how long? It's usually five

00:28:18.380 days. Five days or 20? So 20 grams at five days split in four or five gram doses. Yeah. Okay. But for the

00:28:25.240 average person who's not trying to enter a study, just go to 10 a day and we feel pretty good about it.

00:28:29.600 So again, really interesting point. And I'd love to hear what women are experiencing if this is

00:28:35.300 reducing some of the edema that they're getting during that luteal phase. Talk a little bit more

00:28:41.540 about the protein issue. So are you saying that potentially during early luteal phase,

00:28:48.220 muscle protein synthesis is not as efficient? This is a debatable topic right now. And I'll just say

00:28:54.840 first in the luteal phase, we also tend to see an increased metabolic rate.

00:28:59.640 And what do you think that's driven by? Is that temperature? Is that...

00:29:02.380 I mean, maybe temperature, maybe the luteal lining or the uteral lining. I'm not exactly sure. There's

00:29:08.860 a number of metabolic processes. Maybe it's the progesterone.

00:29:11.400 How much is it, by the way?

00:29:12.600 It's usually like a couple hundred calories.

00:29:14.580 A couple hundred calories a day of...

00:29:16.060 Energy expenditure. And I think that's relevant because in reality, what's 200 to 300 calories,

00:29:21.040 but it's often when women and girls feel their worst.

00:29:25.400 And they might not appreciate it on the scale because if anything, they're retaining more water.

00:29:29.440 The scale might suggest you're gaining weight, but in reality, you're losing stored energy.

00:29:33.960 Right. And if I'm gaining weight on the scale, I have extracellular fluid, I don't feel very good.

00:29:40.580 I'm not going to eat more. Often I eat less. And this is also when we see those increased cravings.

00:29:45.760 So it is this perfect storm for often under consumption of food.

00:29:49.840 Some of it is just eat enough. And that's really, we've looked at different nutrients across the

00:29:55.480 menstrual cycle, but it comes back to getting enough. So if we talk about the protein component,

00:30:00.920 we have a paper in review right now looking at protein synthesis across the menstrual cycle

00:30:05.640 in young women. Like if you're getting adequate amounts of protein, it's not something I'm super

00:30:11.220 concerned about.

00:30:12.200 And you're defining adequate above 1.6?

00:30:14.520 Yeah, about 1.6. And I think you can also get away with nutrient timing around the workouts.

00:30:21.260 If you're optimizing amino acids around training, you won't see those negative side effects.

00:30:26.180 Got it. But 1.6, again, is not always easy to get. I just came back from a long travel stint. I was

00:30:33.340 gone for about a week and I was all over the place. I don't think there was a single day I got near,

00:30:38.660 I'm targeting two grams per kilo. Not one day that I hit it. The reason I always target two to even

00:30:44.160 slightly more is that if I fall short, I can be at 1.6. But I promise you there were half those days

00:30:49.140 I didn't hit 1.6.

00:30:50.740 I think one, it's really valuable that you say that. And I think people need to hear that.

00:30:55.100 I recommend the same thing. I go about one gram per pound is my goal. And there's many days I don't

00:31:01.040 get that, but it's still that consistency and optimizing timing. I'm not going for five hours

00:31:07.780 without getting protein. So I have amino acids in the bloodstream, which can help maintain.

00:31:12.420 Yeah. I was so frustrated with myself because I normally travel with protein snacks,

00:31:17.460 got my David bars and my venison sticks or whatever. And I just, for whatever reason,

00:31:22.220 I was in such a rush when I packed, I didn't take any of that stuff. And I was in Asia and you're

00:31:27.900 eating these tiny quantities of amazing fish all the time, but like.

00:31:32.540 Could you tell a difference? Could your body feel a difference?

00:31:35.100 Yeah. I mean, I think part of the difference is my training volume was also so much lower.

00:31:39.200 Lower, yeah.

00:31:39.900 So you could perhaps argue that, yes, even though I was probably getting only 1.2 grams per kilo of

00:31:47.320 protein per day, I did actually lift every day that I was supposed to lift, but I don't think the

00:31:52.920 lifts were nearly as intense as they, you know, the hotel gym's not the same as my gym.

00:31:56.480 My cardio workouts, I was kind of phoning them in. So again, look, I feel fortunate it's just a week,

00:32:02.340 but there's a person who's traveling constantly. This is a bigger deal and they've got to pay more

00:32:07.180 attention to it.

00:32:08.200 It's important to know that even when we know the right answers, it's hard to follow it.

00:32:13.300 One of the benefits of exercising consistently is that a week here and there is not going to

00:32:17.580 have these severe negative side effects.

00:32:19.640 If a woman is getting 1.6 to 2 grams per kilo, we don't have to worry about it. But if a woman,

00:32:27.800 for example, she's a vegetarian, so she's going to have a real hard time hitting that,

00:32:31.860 you're going to maybe make a note that says, look, right after your ovulation, this is actually a

00:32:36.760 time to pay even more attention to protein intake because of this reduced MPS.

00:32:40.960 Absolutely. Especially with an aging muscle. So a young female muscle and male muscle is resilient,

00:32:48.880 but absolutely if we're into our 40s, 50s, based on some of the science around anabolic resistance.

00:32:56.020 And obviously the hormones change differently in that timeframe, but yes, in that luteal phase,

00:33:02.080 it could help with soreness, recovery, a number of components, injury prevention.

00:33:06.980 Now let's not talk about a team athlete. Let's just talk about an individual.

00:33:11.460 We're long done with college. We're not on a team anymore. We as the individual are in charge

00:33:15.500 of our own training. So a woman who's listening to this, who is herself active, whether it's my wife,

00:33:22.320 she's training for marathons or whether it's a woman who's just training to stay in shape,

00:33:26.840 what guidance are you giving around, if anything, how you would change intensity and volume

00:33:33.620 throughout the cycle? If we're talking about, let's just say someone in their 40s, I mean,

00:33:39.460 I would say we're just trying to exercise and that intensity and volume would be periodized based

00:33:44.740 on something else. Got it. So in other words, you're going to change intensity and volume based

00:33:49.060 on longer mesocycles that are around peaking and tapering for whatever the events are, but we're not

00:33:55.800 going to do a monthly up and down based on the cycle, which means you are accepting the fact

00:34:01.640 that you will sometimes train not feeling as good as you do during other times in the cycle.

00:34:07.380 Right. I have two thoughts on that. Should we, or does your periodized four-week program,

00:34:12.240 could we align it with our period and our menstrual cycle? That might be something that we need to look

00:34:16.700 into. You're just shifting your four-week mesocycle, but yes, a hundred percent. We are going to train

00:34:23.120 whenever and do those long-term effects, but then also giving ourselves some grace of like,

00:34:27.480 oh, if you didn't hit your goals or your minute per mile or whatever it may be to take a step back

00:34:33.460 and say, oh, where do my hormones play a role? Or I also maybe needed a little bit longer recovery.

00:34:40.320 And there's some interesting data too with work to rest ratio. We might just need to,

00:34:44.780 I think, empower women to say, first of all, when is your menstrual cycle or what does that look like?

00:34:50.540 How long, which helps us understand when it changes, how long are you bleeding? And are you more tired

00:34:57.000 based on those hormonal things or is it something else?

00:35:00.720 So this might be a relief to some women to hear that because it makes them maybe accept the fact

00:35:07.180 that, hey, I don't need to like over-science this thing. It is what it is. And I can't imagine what it

00:35:13.960 would be like as a guy where my hormones are pretty much always the same. And yet if these very powerful

00:35:20.380 androgens are moving up and down throughout a cycle, the lack of predictability and how you're going

00:35:25.160 to perform can be pretty frustrating, but it seems like grace with yourself is a high virtue.

00:35:31.740 Yeah. I'd say that's one of the reasons I came as a scientist. I have a lot of data and evidence,

00:35:37.160 but how I do it in real life. I mean, some days I'm lucky I'm training at five in the morning

00:35:42.460 all day. Like we're lucky just to get it in. And so consistency matters. And I would say empowering

00:35:48.660 women, we were not taught about our bleeding patterns, our changes in hormones, what's normal,

00:35:54.740 even down to the changes in brain and mental health. And so I kick that back and say, if there's a way

00:36:01.620 that we can measure that and a woman can track that, it's really empowering versus, wow, I just feel

00:36:07.880 terrible or what am I doing? It allows us to tease out when there is something we need to change,

00:36:13.440 whether it's our nutrition, our meds or whatever it may be. But first and foremost, asking, okay,

00:36:18.800 well, where do my hormones play a role? And how does that change as I do get older?

00:36:23.800 Now, if a woman is on an oral contraceptive without the placebo week, so if a woman is just

00:36:29.020 taking the hormone throughout the cycle, obviously completely suppressing ovulation and therefore

00:36:33.680 completely suppressing a menstrual cycle, is there a performance advantage to that? In other words,

00:36:39.240 if you were trying to make that Olympics, would that potentially be the strategy?

00:36:43.440 It's more indirect, I would say, based on the literature and even working with female athletes

00:36:48.280 is that that consistency, potentially over time, there's less variability. So there is more

00:36:53.680 consistency with the training. And indirectly, a lot of times women are taking a hormonal contraception

00:36:58.780 to help with symptoms of their cycle, whether that be mood or cramps. And so a lot of times females

00:37:05.960 feel better. And then just in general, not having to bleed. Some women I know skip the placebo week so

00:37:12.900 that they don't have to deal with that. And that in itself is a nice thing not have to worry about.

00:37:17.200 All right. So let's talk about now as women enter the perimenopausal stage of life, which

00:37:23.420 obviously for some women can be relatively short and brief and for others can sort of drag on for a

00:37:28.520 while. But if we identify it based on some sort of irregularity, a slowly upward drifting FSH,

00:37:35.200 what are the ways you would advise a woman to start thinking about how she exercises and eats during

00:37:42.080 that phase of her life, which again, could last for years?

00:37:45.500 This is where a lot of the data has led me. Luckily, as I roll into it, it's not how I planned

00:37:51.320 it, but I am happy to have more data.

00:37:53.700 You're becoming an expert into the period of life you're going into at some point.

00:37:56.620 Not really intentionally. I would say that it's very much symptom driven. And so often we don't

00:38:03.320 know when our FSH is rising or we're not getting our measures. So first and foremost, getting blood

00:38:07.600 work done is really valuable into our even starting in our 30s so that we know individually when that

00:38:12.700 changes. We have leveraged at home hormone urine analyses where you measure daily urine, which really

00:38:20.160 starts to say, okay, well, maybe my hormones are changing.

00:38:24.320 And what are you measuring in the urine?

00:38:25.460 There's a couple of different devices that we've used, and this is just in the science perspective.

00:38:30.840 Most of them are measuring some form of estrogen, some form of progesterone, FSH, LH,

00:38:38.500 all in like a pee stick, a urine stick.

00:38:40.700 And how accurate are they relative to blood?

00:38:43.980 They're not. I always say they're not telling us the exact same thing,

00:38:47.660 but we're trying to work on some of that validation.

00:38:50.220 So you can correlate what you're seeing in the urine?

00:38:51.940 Absolutely. Yeah. But more importantly,

00:38:53.780 we're now able to see that daily variation. And so like if I have a spike or one of our

00:38:59.820 participants does, or it's a drop and I feel terrible or I feel better, you can start to

00:39:04.580 identify that. Or if there's no peak at all, it's impacting sleep or hot flashes. It really allows

00:39:12.400 us to have those tools to say, okay, no, this is what's happening versus that single point in time

00:39:16.740 we're getting our blood work done. And the estrogen that's being measured,

00:39:20.280 is it just estradiol or is it estriol or estrone and everything?

00:39:24.580 Yeah. I mean, usually it's one marker. It depends on the device.

00:39:28.140 The thing I would advise women who are listening is to be really consistent. We think that day five

00:39:33.420 FSH in the blood is probably your best test because again, you really consistently know what

00:39:39.400 it should be. So when you're fertile day five, so if day one is the day your period starts,

00:39:44.240 if you have an FSH level on day five, it really should be low. And that's the thing that we're

00:39:49.400 watching to climb as she's entering perimenopause. So once that number is even hitting 10, we sort of

00:39:56.060 know that she's now entering that zone. And obviously if you look at a woman in menopause,

00:40:01.240 that number is going to very quickly rise to 25, 30, 50, et cetera.

00:40:05.120 Can I ask you a follow-up?

00:40:06.680 Yeah.

00:40:07.060 What do you do if they have an IUD and do you ever use like AMH numbers?

00:40:11.720 Yeah. We do look at AMH. It can be somewhat helpful, but yes, it's definitely harder if

00:40:17.580 there's an IUD that's completely preventing that.

00:40:20.020 I ask because it really is, there's so much variability happening. And as a researcher,

00:40:25.420 we want to capture that real-time translation, but also the variability is there. And so to get

00:40:31.580 some quality research, my motivation for being here too, is that clinical connection. How do we

00:40:36.240 take clinical practice and form research and vice versa? So that's good. I'll have to look at our

00:40:40.640 day five numbers.

00:40:41.520 And of course, some women with an IUD will still break through and have a period,

00:40:45.000 but it might only be three times a year. And so you just try to capture those moments.

00:40:48.720 That's great.

00:40:49.220 Yeah. Okay. So going back to...

00:40:51.620 I didn't actually answer your question.

00:40:54.760 We have looked a lot at this space and I'll tell you, it wasn't as a scientist,

00:40:59.280 as the data leads us. And so we did an initial study as a follow-up to some of the SWAN studies

00:41:04.300 using very sophisticated measurements of metabolism, body composition of what happens

00:41:09.520 pre-menopause, perimenopause, and post-menopause. Repeatedly, we're seeing in perimenopause,

00:41:15.760 there are some pretty, I want to say significant, but changes to metabolism, changes to muscle size,

00:41:23.020 muscle quality, and bone, even metabolic flexibility that tend to be a bit more stable

00:41:29.380 into post-menopause. And so I will get to your question, but I say that of it really now we are

00:41:35.880 really diving into that perimenopause window because it seems that's where the time we really

00:41:41.640 need to take advantage of lifestyle behavior changes to have this lifelong impact, improve

00:41:47.720 health span. It's coming in our late 30s to our 40s to our 50s with our exercise and nutrition.

00:41:55.060 So what is a specific change you might make for a woman? So maybe let's take the first example,

00:42:00.760 which is a woman who's actually not exercising that much because she's got three kids under six

00:42:07.900 and she has her hands full. Going to the gym every day is not on the list when you're trying to manage

00:42:14.020 that. But as she's becoming perimenopausal, how do you make the case to her that exercise

00:42:20.740 should be prioritized for her health beyond the usual things that you would hear? Like,

00:42:26.280 of course, exercise is good for you, but how do you make the case if you can,

00:42:29.800 that actually, despite how busy you are, this is a great time to start this or re-engage in this habit?

00:42:36.180 I mean, I would follow it up of not just say re-engage or start this habit. You're

00:42:41.180 never too late old to start and it will literally impact your health forever. And I would say based

00:42:48.560 on the data, it doesn't have to be 150 minutes a week of exercise. It's really consistency. So

00:42:55.540 there's data. I would love to get your opinion on this, but intensity is more important than volume

00:43:01.900 and consistency is more important than volume. And so really telling her that I know I struggle with

00:43:08.260 mom guilt. And often these women are worried about taking care of everyone else with this desire to

00:43:13.840 care for them. It's amazing how little dad guilt occurs. I mean, I was going to ask you, surely

00:43:18.580 there's dad guilt. No, it's not the same. I think the truth of the matter is I'm way less selfish than

00:43:24.460 I used to be. But the truth of the matter is my wife is infinitely more selfless. We're wired that way,

00:43:30.480 aren't we? Yeah. And I feel bad sometimes. It depends. Like, look, if my wife is in the middle of

00:43:35.520 training for a marathon and only one of us can do our workout, it will be her. But ordinarily,

00:43:41.780 she'll always be the one to say, look, if we only have time for one of us to do something today,

00:43:46.020 she'll take it. She'll take the hit and let me do it. I mean, you throw in the kids. I have two

00:43:50.460 little boys and they say, don't go. Like, why are you going to run? It's bringing them into it too.

00:43:55.820 I think women, the other reason I'm passionate about it is that we have the ability to not only change

00:44:00.740 our health span, but also generations behind us of, hey, this is really important so that I can,

00:44:07.340 I always joke with my kids of like, do you see any other mom killing you on the flag football or

00:44:11.640 the baseball of like, it allows me to be out there and to keep up with them as well. So I tie it back

00:44:18.420 into health and longevity and quality of life. If you want to live healthier longer, you need to put

00:44:24.420 the time in now and it will ultimately help you be a better mom, wife, et cetera.

00:44:29.300 Grandmother.

00:44:30.000 Exactly. Yeah.

00:44:31.520 I want to touch on your point about volume and intensity. We've been looking at this a lot and

00:44:38.500 I'll tell you what our reading is of the literature is actually that with unlimited time, volume matters

00:44:46.340 the most. As volume goes down, intensity becomes more important. In other words, if a person

00:44:54.000 only has 150 minutes a week to exercise, you have to prioritize intensity because you're

00:45:03.280 not really getting enough volume to maximize conditioning. If a person is willing to train

00:45:10.260 12 hours per week, which is obviously a lot, then you have the luxury of relying on the volume for

00:45:18.200 the benefits and the ratio of high intensity to low intensity is going to be a lot shorter.

00:45:24.000 And so this is a slightly more nuanced view that I think often gets communicated. And it's the

00:45:29.580 difference between the professional runner or the professional cyclist who's out there 25 hours a

00:45:35.220 week training. And yes, 80% of their volume is going to be really, really low intensity,

00:45:40.860 but that's none of us. And so, yeah, we do have to prioritize high intensity training.

00:45:46.860 And I was giving a talk recently and someone said, if I only had, and they gave some incredibly low

00:45:52.560 number of minutes to train a week, what would it look like? And the truth of the matter is,

00:45:57.580 if you're trying to maximize the training effect, it's going to mostly have to be pretty high

00:46:01.820 intensity. But of course you run the risk when it's just high intensity that A, you're missing some

00:46:06.460 of the other benefits, but you're not building a strong base. Yeah. I mean, I think it would go back

00:46:10.360 to what the outcome we're looking at. I definitely hear you. And I'm an exercise physiologist. I love

00:46:15.880 volume. I will tell you when I first started in this space several years ago, I was an endurance

00:46:21.340 runner. I thought we had to train until you like couldn't walk and really started looking at high

00:46:26.960 intensity training. And when we go back to that sedentary woman, you mentioned with three kids,

00:46:33.060 if we want improvements in VO2 max, that volume does come into play, but we can get those changes

00:46:39.460 more quickly with that high intensity, which is sometimes what we need. Now I don't feel as

00:46:43.620 terrible when I go work out when I'm just starting. And so the other thing is there's some fascinating

00:46:48.920 data on exercise snacks, that higher intensity, short periods of time. And then are you familiar

00:46:54.360 with Scott Trappi's work that shows he's measured and tracked some pretty elite endurance athletes over

00:47:00.180 time? Just doing volume doesn't help maintain the integrity of the muscle size and quality. It does.

00:47:06.100 It's very good at capillarization and blood flow. You're talking just endurance training?

00:47:10.840 Yeah. We haven't talked about resistance training, but where volume is maybe not the only way. So I

00:47:16.560 would just tweak that a little bit of intensity is going to matter no matter who you are. But yes,

00:47:21.500 depending on our performance goals, sometimes you do need more volume.

00:47:24.940 So let's talk a little bit about how you might structure that because I think this is the more

00:47:29.360 realistic scenario. I think it's a luxury for the person who's got 18 hours a week to train where

00:47:35.060 we can talk about how much zone two, how much zone one, zone three, and zone five. But now let's talk

00:47:41.280 about the mom who says, okay, I'm going to carve out three hours a week in total for training. That's

00:47:49.320 going to be my resistance training. That's going to be my endurance training. First of all, how much of

00:47:54.260 that three hours are you going to want to put in the weight room versus on the treadmill?

00:47:59.220 Yeah. I mean, it would come back to goals, but if it was just a general, let's say midlife woman,

00:48:03.920 I would absolutely prioritize a few days a week of whole body progressive resistance training.

00:48:09.140 We're doing a study right now and have done where we try and get it into two days. We do a little bit

00:48:13.740 higher intensity progressive and then two to three days where you're doing aerobic exercise. And

00:48:20.540 hopefully two of those might be high intensity. It really does come back to the goals. Are they

00:48:24.700 trying to lose fat, gain muscle, just move? But in reality, you need a blend of some resistance

00:48:31.640 training consistently and some exercise that elevates your heart rate versus just low to moderate

00:48:38.220 intensity.

00:48:38.740 In that example, would you say, okay, we're going to do two 45 minute whole body resistance

00:48:43.860 days?

00:48:45.280 I don't even have time for that. Let's say 30 minutes. We've done a protocol and this is not

00:48:49.660 the only way, but just for time efficiency where it's 30 minutes, it's six to eight reps.

00:48:55.500 So 60 to 80% one RM, 30 seconds in between each exercise, two minutes in between it's 30 minutes.

00:49:03.020 We're done.

00:49:04.000 Okay. That takes an hour a week. And then of the two hours that you're going to be left

00:49:08.400 for say running on a treadmill or being on an exercise bike, how do you structure those? It

00:49:14.640 sounds like you're saying two thirds of that time might be high intensity. A third of it might be

00:49:19.580 low intensity.

00:49:20.900 Yeah. I mean, I would say at a minimum one day a week of high intensity interval style training,

00:49:26.320 if you can get two in, it's going to be a bigger bang for your buck as you're starting.

00:49:30.340 And I do think there's a lot of value of just movement. So maybe on that day where you have a

00:49:35.000 little bit more time, whether you're walking or doing more of that low intensity, riding a bike,

00:49:39.320 I mean, the freedom to just get some blood flow and get that heart rate up.

00:49:43.160 And how do you structure the high intensity days?

00:49:45.440 I mean, there are so many different ways. The protocol that's been very effective for us

00:49:50.500 in very fit individuals down to cancer individuals is 10 sets of one minute on one minute off with that

00:49:57.840 one minute being anywhere from 90% to 110% of max.

00:50:04.760 How do you explain 110% of max?

00:50:07.040 What I would do is say pick an intensity that you couldn't go for a minute in 20. You pick an intensity

00:50:12.300 that one minute is really hard and you need to take a break. We've done it where you measure VO2 max

00:50:17.900 and very calculated, but we've also done it where we just said, hey, go do something for a minute

00:50:22.840 that's really hard and you need to take a break. And then that next minute you go again.

00:50:28.380 Okay. So in other words, yeah, again, most people are not going to have VO2 max measured,

00:50:31.600 but you would say anywhere from 90 to 110% of VO2 max.

00:50:35.300 Or of max heart rate we've used as well.

00:50:38.340 Yeah. My issue with heart rate training when it comes to anything that's that short is the heart

00:50:43.820 never gets to max heart rate until the very end. So I find that the lay person, when they're training,

00:50:51.460 let's say at the beginning of the interval, their heart rate has come down. Now it won't

00:50:54.800 come down that much, but let's say it comes down to a hundred beats per minute. And let's say their

00:50:58.760 max is 180. When they're 30 seconds in, it's only 140. They might look at that and back off a little

00:51:05.300 bit. They might be a bit confused. So they might try to speed up more than they should. So I've always

00:51:09.340 felt like you have to be able to teach people how to RPE their way through those efforts.

00:51:14.060 Of course, the nice thing is on a bike or on a treadmill, if you're doing it on some sort of

00:51:19.180 ergometer, the power or the speed are locked in and that forces you into the effort.

00:51:25.300 A hundred percent. I also think the goal of the interval style training, if you're doing it,

00:51:30.120 you know, in a lab is that you'll still see benefits, even if you're not necessarily

00:51:34.700 hitting that 90%. It might just take a little bit longer. And we've done this where we did

00:51:39.880 some at home in a family med clinic and just said, here's some guidance so that they don't feel like

00:51:45.540 they just have to do it on a bike or a treadmill. They begin to feel what a high intensity feels like

00:51:51.340 also because RPE and heart rate does vary day by day.

00:51:56.060 And you suggested one-on-one-off for 10 rounds?

00:51:59.660 Up to 10. Sometimes we start with six, but yes, it just feels you can do anything for a minute.

00:52:06.080 Now there's a lot of good science of doing 30 seconds and we've looked at different protocols,

00:52:10.200 two minutes, but that one minute on, one minute off is something you could do on your own.

00:52:14.860 And it tends to be very feasible. And when you tell that woman, we go back to have,

00:52:20.020 it really takes 10 minutes of work, 20 minutes total. And I love doing that sometimes when I

00:52:25.560 say I won't have any time to exercise or I got to get my kids to baseball. Maybe it's only six

00:52:29.740 intervals today. You get it in, get it out. And you have a, not only an effect there, but that

00:52:34.440 lasting effect for the day after.

00:52:37.260 So if you're going back to the case of our hypothetical woman here,

00:52:41.340 if she's got two hours that she's willing to put into cardio, cause you've taken one hour on

00:52:46.960 resistance training, would you do two of those since with warmup and cool down your, let's just

00:52:52.060 say each of those is half an hour. So now you're at two of those is another hour for the remaining

00:52:57.000 hour. Would you prescribe one or two low intensity days?

00:53:01.280 Yeah. It all comes down to do you have a whole hour by itself? Now, as I've aged, like I need

00:53:07.580 exercise every day, otherwise I'm unwell. So that 30 minutes, it's a bit more manageable to do

00:53:14.020 and depending on intensity. So yes, I would split it up so that more days than not, we're doing some

00:53:20.480 sort of exercise. The other thing I'll add is prioritizing that high intensity training a couple

00:53:27.080 days versus an added low intensity days. It does increase lean mass as well, which can be helpful

00:53:32.500 for that midlife. So let's talk a little bit about some of the goals that women might be coming into

00:53:38.420 this with. So let's start with, do you ever differentiate between weight loss and body

00:53:43.700 composition? I mean, they're basically the same thing, aren't they?

00:53:46.460 It's one of the things I'm passionate about because most women say, I want to weigh less

00:53:51.060 or we were taught like, oh, I don't want to know my body fat when in reality, like we should know

00:53:56.720 and you want to measure so that a lot of times the weight doesn't change or goes up. And so it is all

00:54:04.040 about body composition, but a lot of women don't understand that.

00:54:07.540 How would you counsel a woman that came to you and said, I want to lose weight, which would be the

00:54:10.760 common statement for anyone. This is not, this is men, this is women. Everybody says, I want to lose

00:54:14.680 weight. What they really mean is I want to lose fat.

00:54:17.100 Yes. So we would do some sort of measurement and we do a pretty comprehensive, whether it be a DEXA

00:54:23.420 scan or a multi-frequency bioelectrical impedance or an at-home scale, they're all different, but most

00:54:30.560 of them do a pretty good job with tracking changes. And what I would do is based on that number, calculate

00:54:35.740 ideal weight. And from that, it tells us, okay, here's our percent fat and our muscle, but here's my goal

00:54:41.900 percent fat and muscle based on my health goals or my weight goals. A lot of times people think,

00:54:48.220 oh, I want to weigh what I did in high school, but in reality, they'd have to lose muscle for that.

00:54:53.220 And so giving them more of a target percent fat with that to inform our weight goal.

00:54:58.540 And how do you make a determination of what the ideal body fat percent is?

00:55:03.140 I mean, depending on the device, a lot of times you can use NHANES. Really around the 50th percentile,

00:55:09.480 we see a lot of cardiometabolic changes. So using a lower percentage, there's normative data that I

00:55:15.340 would use based on the individual. But to what percentile do you bank? Down to the 50th percentile?

00:55:21.120 Oh, no, no. Usually we want it down to like the 25th percentile and lower. Yeah. 50th is what you want

00:55:27.000 to stay away from. Yeah. Got it. If a woman came in and she was five foot six, probably the average

00:55:33.620 height and 150 pounds, which tells us nothing yet. But now you do a DEXA scan and she is 30% body fat.

00:55:42.940 My guess is that's probably about the 50th percentile of NHANES.

00:55:46.480 How old is she?

00:55:47.520 40.

00:55:48.220 Yeah. I would say that it's a little bit lower, probably 30th percentile.

00:55:51.160 Okay. So if she said, look, I want to lose 20 pounds, I want to go from 100, what did I say?

00:55:57.660 150.

00:55:58.320 Yeah. I want to be 130 pounds. So how would you then advise her?

00:56:01.600 So we would measure her body composition, see what her bone weighs, what her lean soft tissue

00:56:06.800 or muscle and her fat, also where she stores her fat. And then we would understand how much

00:56:12.280 food she's consuming.

00:56:14.200 And a typical 40-year-old woman, let's say she's a mother of two,

00:56:19.000 what would be the typical pattern of fat storage on her?

00:56:22.520 So most often, this is tricky because it's changed. I mean, most women store it in their

00:56:28.340 hips, but as we age, we store more in our abdominal region. And so it's not always visceral fat,

00:56:36.600 but that is a lot of the conversation and why we measure it. A lot of women then begin to store

00:56:42.020 more in their visceral region, kind of on their organs versus their hips, which comes with an

00:56:47.380 increase in cardiometabolic disease.

00:56:49.540 So in the case of this woman, let's assume that her visceral fat is actually quite low.

00:56:53.380 And let's assume that she's also metabolically quite healthy, even though you haven't necessarily

00:56:57.100 measured that, but let's just say she's had some other blood tests and she's metabolically healthy.

00:57:01.080 And that this is just mostly subcutaneous fat, whether it be on her hips or on her abdomen,

00:57:05.400 but it's not inside.

00:57:06.540 That's great.

00:57:07.100 But let's be honest, we all want to look better. She sort of says, look, I want to be 20 pounds

00:57:11.960 lighter. And by the way, if she wants to exercise, it's great to carry 20 less pounds around on the

00:57:17.000 Right. Well, I would usually say that 20 pounds is probably too much. Based on historical

00:57:23.140 measurement, we're probably looking at more of a 10 pound if she's 150, 5'6". 140 pounds based on

00:57:30.440 that skeleton is probably more reasonable. And then it would include some follow-up measurement.

00:57:36.060 So we're doing a project right now where many women are not necessarily losing weight, but they're

00:57:42.080 replacing fat with muscle. Again, that comes back to some nutritional strategies.

00:57:47.000 And so I guess the question is, how do we get her to lose weight? There's a blend of

00:57:52.740 hypocaloric intake. So we need a slight calorie deficit. So understand what she's eating.

00:57:57.500 A conversation that we're not having in this midlife is it's not just taking out food. It's

00:58:04.680 adding in foods like fiber that help with satiety, enough protein and complex carbohydrates. So it's

00:58:11.680 balancing that with her workout and having some of a calorie deficit.

00:58:15.960 Now, a lot of women or anyone for that matter, but we're talking about this hypothetical case,

00:58:21.020 a lot of women in this situation of being 150 could easily get to 130 with a GLP-1 agonist.

00:58:27.580 And so let's just say a woman says, look, I'm going to take this GLP-1 agonist because I'm going to

00:58:31.060 weigh 130 pounds. What are the strategies you're going to employ to figure out a way to say, look,

00:58:37.780 I want of the 20 pounds that you're going to net lose, I'd like to make sure that no more than five

00:58:44.480 of them are muscle and therefore 15 of them are fat, which by the way, would be an enormous

00:58:50.760 improvement in body composition, right? She would go from being 35% body fat to 20% body fat or 22%

00:58:57.780 body fat or something like that. So what kind of strategies would you employ there, both in terms of

00:59:04.460 nutrition and in terms of her training? In those cases in general, in that life space, we know that

00:59:12.200 our muscle quality is also changing. It just emphasizes the need for resistance training. And

00:59:19.240 there's a lot of different ways to do that, but I would absolutely prioritize resistance training to

00:59:25.040 help to maintain that lean mass and improve the muscle quality. And then protein has to be a

00:59:31.620 conversation, particularly thinking about maintaining amino acids over the day. So consistently

00:59:38.280 feeding, usually the goal is around 30 grams of protein evenly spaced throughout the day. We've also

00:59:44.720 done some work with essential amino acids around exercise, which really helps optimize that maintenance

00:59:50.340 of lean mass. And what would you target per day? So if she's at 150, would you target 150 grams of protein a

00:59:57.140 day? Yeah. I mean, usually you use the goal weight to identify, but yes, I would say 130 to 150 grams of

01:00:05.060 protein. It has a higher thermic effect. That's a pretty aggressive fat loss, weight loss. So yes,

01:00:12.300 if we could get to 150, that would be a good goal. Yeah. And the reason I bring this up is I think that

01:00:18.540 we just have to accept that many people are going to use these drugs. They're becoming more and more

01:00:25.300 tolerable. Manjaro or trizepatide is significantly easier to tolerate than semaglutide. And what I just

01:00:32.840 want to make sure is that all the people that are out there wasting away have the insight into,

01:00:39.480 hey, it doesn't have to be this way. I can still take this drug. I can still lose weight,

01:00:44.100 but I also have to do something kind of deliberate to make sure I don't have a negative impact on my

01:00:50.280 skeletal muscle. Which I think is such an important point that, I mean, most men and women,

01:00:55.640 most women really want to weigh less, but the loss of muscle can have a dramatic impact on our health

01:01:01.900 long-term. And we're just starting some of this work with these GLP-1s of what is the right amount,

01:01:07.520 or can we alter the dose or help us feel better if we add things like resistance training and higher

01:01:12.860 levels of protein? And there is good science on the protein side of things. Because they impact

01:01:18.840 appetite, it's still focusing on the nutrients. And that really ties into some of our work with

01:01:25.280 nutrient timing of if you are then on a GLP-1 and going to exercise, you absolutely want to think

01:01:32.220 about having amino acids before and or after to really maximize the effect of the workout.

01:01:39.340 Yeah. I was talking with someone yesterday actually about her experience on both

01:01:45.580 semaglutide and terzepatide. And it was just very interesting because she said that nobody had

01:01:53.220 talked to her about, and I think this is most people's experience, nobody explained to her that

01:01:57.700 when you're on one of these drugs, you don't just go about your day eating less. You actually have to

01:02:03.380 create a new diet that of course is lower in calories, but has to be much higher in quality

01:02:08.980 to compensate for the reduction in total energy. In other words, exactly what you're saying.

01:02:13.520 But it was interesting that she didn't know that until she figured it out herself. And it of course

01:02:19.120 makes me wonder how many people are not being counseled correctly to be able to use this drug.

01:02:24.060 It's a great drug. It's an amazing tool, but it comes with a responsibility for lack of a better word,

01:02:29.560 which is you're going to have to make these direct and very deliberate changes in the energy

01:02:35.740 composition. And then obviously around the training. Most people are also not measuring

01:02:40.620 body composition. And so you really don't know what type of weight you're losing. And we see this

01:02:45.600 accelerated loss of muscle and bone. What's your theory on why the bone densities are going down?

01:02:51.780 Well, that was my second point is depending on who's taking these drugs, if we're looking at a

01:02:56.200 younger population. We're seeing with and without these drugs, but under consuming calories, there's

01:03:01.900 this relative energy deficiency syndrome that is happening in parallel with perimenopause.

01:03:07.840 So if we're under fueling, some of the same symptoms and side effects of perimenopause are really coming

01:03:14.140 from just under fueling, which is I think going to only go up with these GLP ones. If you're eating less,

01:03:19.780 it does impact hormones and you have the fatigue and the drop of progesterone and estrogen,

01:03:25.420 but it's not necessarily driven by your ovaries. It's driven by the lack of caloric consumption.

01:03:32.540 So let's assume in this case of this hypothetical woman, she's showing up and she's not really got

01:03:38.200 much of a huge exercise routine. So now you're kind of introducing her for the first time. And let's

01:03:42.720 assume she's also in the, look, I've got three hours a week I'm willing to put into this. How are you

01:03:47.520 going to divide her three hours per week where now her goal is recomposition?

01:03:52.920 I don't think I would change much. I mean, I would definitely-

01:03:55.760 Only two 30-minute strength training sessions or would you flip it?

01:04:00.020 If you're doing high intensity resistance training, like optimally you might do one additional. It does

01:04:05.480 depend on the soreness and what we're doing. I think the other thing that we need to consider is the

01:04:10.100 lack of energy. So if she's under eating, we might not have the ability to do as high of volume and

01:04:15.640 intensity on those two resistance training days. The other thing we want to consider though is those

01:04:20.880 cardiovascular changes. And that's why I like HIIT is that it can stimulate an increase in muscle at

01:04:28.000 the same time and still improve those kind of vascular changes we would see. So maybe one day,

01:04:33.700 maybe I would flop it.

01:04:34.920 Meaning give a third day of resistance training?

01:04:37.360 I mean, if we had it or encourage her to-

01:04:39.740 Yeah, she's giving you the time. She's saying, look, I'm going to give you three hours. You tell me

01:04:43.040 how to do it. Honestly, I would maybe do the three resistance training and take one of those 30

01:04:49.700 minutes, low intensity cardiovascular days to add the resistance training.

01:04:55.360 All right. So she's going to do one low intensity cardio day, two high intensity cardio days,

01:05:00.240 three strength days. All of those are 30 minutes a pop.

01:05:04.120 Yeah. I would say if she's unfit, that might be a lot for her. Probably change one of those

01:05:10.800 hit days for a low intensity day. Okay. So two low intensity, one hit,

01:05:14.380 three days in the gym. And those three days in the gym are all whole body? Or at that point,

01:05:18.780 do you start to go body type once a week?

01:05:22.620 I still like body type, our major muscle groups twice a week. So a push pull. I really think it

01:05:29.080 depends on the individual. Is she tolerating it well? Is she feeling good? Or is she run down? If she

01:05:34.380 doesn't have energy, then I would split it up.

01:05:36.280 Would you suggest a timeframe over which that degree of body recomposition is going to be more

01:05:44.180 sustainable and therefore less dramatic in the getting there phase?

01:05:49.020 Yeah. And I think it's a really important point, especially when we think about a lot of our lab

01:05:52.980 based work. We're looking for accelerated time or accelerated changes in a short period of time.

01:05:58.800 So yeah, for more sustainable, I think the body part over a specific. So if we're looking at 24 weeks

01:06:04.900 is often what we're looking at would be more of a concentrated push pull, whether it be leg day,

01:06:10.540 upper body, leg, upper body.

01:06:13.020 And you would say 24 weeks, if she came to you and said, look, how long would you like this to take?

01:06:18.900 Would you want this to take up to 24 weeks? Would you want to make this a one-year project? Again,

01:06:23.740 part of this comes down to how you would even dose the trisepatide. Our view in this is we want the

01:06:29.460 patient to be on the lowest dose possible and take as long as necessary to get there. So I would say

01:06:35.100 I want this to take a year and you're on 2.5 milligrams, maybe five milligrams, but we want it

01:06:40.940 to be long and slow so that the adaptation is gradual.

01:06:44.800 We are in the process of looking at some of this now of actually including a lean mass indicator

01:06:50.260 before titrating the dose up of saying, let's see how your body is responding before we change

01:06:56.580 the dose. I feel like we're talking about a couple of different things here. So yes,

01:07:00.040 we would want that to be long-term, but on the flip side, most people want to see some effects

01:07:05.740 pretty quickly. So it's a balance of what are we, what type of weight are we losing and are we

01:07:10.360 tracking that and making sure muscle is an important component of that?

01:07:14.580 Okay. Now you've done a lot of tracking in yourself, right? How many years have you been at

01:07:19.420 this yourself, your sort of self-quantification?

01:07:21.740 Hmm. I gosh, at least more than 20 years. We measured it in college all the way through grad

01:07:27.160 school. And now I do mine every like six to nine months.

01:07:30.860 Okay. So what have been your observations in yourself based on this and how generalizable

01:07:35.500 do you think they might be?

01:07:36.840 I mean, I think initially it's really important to understand low. So just for instance,

01:07:42.460 when I was a distance runner, I had nine stress fractures and it was every time my body fat

01:07:47.200 got below about 15%, which is really not ridiculously lean. So that injury indicator.

01:07:54.100 You're how tall?

01:07:55.200 I'm about five, six.

01:07:56.620 And when you were at 15% body fat, that was what weight?

01:07:59.920 One 20.

01:08:01.260 Okay.

01:08:01.580 One 15.

01:08:02.340 So that looks pretty normal. Like you're a lean looking person, but you're not a bean pole.

01:08:06.560 No, but it was my set point.

01:08:08.840 Yep.

01:08:09.040 And so it's really important to use these numbers of not like, Hey, how do I compare to someone else?

01:08:14.840 But Oh, about this is too much for my body.

01:08:18.640 At that point, you were amenorrheic, I'm assuming.

01:08:21.040 Honestly, like no one talked about it, but yes, for most of my competitive career, probably.

01:08:26.020 Is that a sign to a young girl that she's either not eating enough or she's exercising too much

01:08:31.940 or to a woman of any age?

01:08:33.420 Menses is a really good indicator of overall health and wellbeing. The hard part is we should catch it

01:08:40.360 way before someone loses their menstrual cycle. And there is some competition level that it might

01:08:46.820 fluctuate, but you don't want to go the entire year without having your period.

01:08:51.580 Okay. At 15% body fat, you were clearly below the threshold at which your body was now catabolic

01:08:57.880 and you're having 15 stress fractures?

01:09:00.680 Nine.

01:09:01.400 Yeah. That's pretty incredible. When did you put that behind you? Graduate school?

01:09:06.260 Yeah. I thought there was a lot of conversation about it being bone. Oh, bone density must be low.

01:09:12.600 But when we actually measure bone, my bone is very high. So it very much was a fueling nutrient

01:09:19.040 timing. But I went on to grad school to really dive into that, not just that component, but

01:09:23.560 understanding the nutrition components of it. And during grad school, I had some great mentors that

01:09:29.320 brought in nutrition. And I did not believe in dietary supplements as a collegiate athlete.

01:09:34.920 And really all my early work in grad school was around creatine and beta alanine and really

01:09:40.480 understanding some of those impacts. And I think part of the fun part about being in this field is

01:09:45.900 you are your own self-experiment and even how you measure composition. So is it DEXA? Is it

01:09:52.540 BODPOD? Is it bioelectrical impedance? And knowing that those numbers are all very different.

01:09:56.900 So I also very quickly learned that I didn't need to train for hours a day. That's where

01:10:02.920 that bridge of intensity and volume come in, especially in grad school. And then even into

01:10:09.700 my time as a professor, I always like to face my fears, which is why I'm here today with

01:10:15.660 you, Peter. I did a physique show early in my career. How do you change the body in a way

01:10:20.980 that maybe is not normal or in a way that pushes the envelope and really dials in science and then

01:10:27.900 have since changed or measured before and after two kids? And my translation is science really matters.

01:10:34.840 I just want to go back. When you were in college and you were running, were you guys spending time

01:10:38.840 in the weight room?

01:10:39.620 We were, and I loved it.

01:10:41.040 So you were lifting and running. I was going to ask, because I'm struck by the point you made

01:10:46.420 about how your BMD on the DEXA was normal, but you were still having these stress fractures.

01:10:52.100 And I was kind of wondering if there was something that was missing because of the type of activity

01:10:57.580 you were doing. But in the weight room, you're getting the appropriate deformation.

01:11:02.140 Yeah. I mean, we've looked at this too with some of our other athletes. It really seems to be a

01:11:06.500 muscle quality issue. I mean, this was more of a protein breakdown catabolic component.

01:11:11.700 And these were all tibial or where were these from?

01:11:13.540 It was all my left leg and left foot. So some of it was inside leg on a track. I was a D2

01:11:20.600 athlete. So we competed in cross country, indoor track, outdoor track. So some of it was just

01:11:26.380 repetitive strain.

01:11:27.560 Exactly. And there was twice it happened during a race. I finished and I couldn't walk.

01:11:32.260 I say that in a way of, I love to push hard and work hard. And sometimes that's too much.

01:11:39.080 It comes back to the training intensity, volume, specificity, and nutrition. You can't do one

01:11:44.800 without the other.

01:11:46.000 Do you remember how much protein you were consuming back then?

01:11:49.240 I don't. But what I do remember is that, and this was an early sign of underconsumption,

01:11:54.920 is that I had the worst GI distress. I remember having a colonoscopy. And in reality, I couldn't

01:12:01.420 have a big meal before I went and did a thousand repeats on the track. I also went for extended

01:12:07.140 periods of time without eating. So it wasn't necessarily total amount. It was just several

01:12:13.160 hours in between that also played a role.

01:12:16.600 Meaning you weren't getting enough protein around your training.

01:12:19.200 I think it's protein and carbohydrates. We train twice a day, every day, morning, go to class,

01:12:25.320 train in the afternoon, go to some sort of meeting. And so just gaps of long periods of time without

01:12:30.820 fuel versus more frequent consumption.

01:12:34.120 Got it. When you got to graduate school, did you continue to run?

01:12:39.660 Yeah. And I thought you had to train all the time. I still train and love exercise,

01:12:45.020 but I learned that you didn't have to train as much. And I really started to learn the

01:12:51.140 keys of nutrient timing and optimizing nutrition and the impact of some dietary supplements.

01:12:57.020 Besides creatine, what are your other staple supplements now? You mentioned some

01:13:00.600 amino acids. Whey protein amino acids are going to get you the same, but sometimes I don't want a

01:13:06.700 milky substance and the amino acids are absorbed a little bit faster. Omega-3, like now is maybe a

01:13:13.520 little bit different than then, but omega-3, vitamin D, magnesium, creatine, multivitamin. Those are the

01:13:23.360 key ones. I do like a probiotic, which is debatable, but multi-strain based on my GI system.

01:13:31.460 How did your body comp then change over pregnancies? And have you, so if you go back to prior to your

01:13:39.060 first pregnancy, what was your body composition and how did that change at your second? And then

01:13:46.080 obviously following that, I mean, this is probably something most women are very interested in, which is

01:13:49.860 what should I expect is going to happen? Do I have a new set point after pregnancy?

01:13:54.380 I don't really need to talk about my personal numbers, but I think this is really important

01:13:58.200 where science plays a role of where now and even through pregnancy, I think through with both my

01:14:05.300 children, it was maybe about an 8% increase in body fat. And depending on measurement, sometimes you

01:14:11.620 can't really tell the lean mass components, but I definitely didn't lose muscle and I gained some fat.

01:14:18.180 And then as a follow-up, usually I would measure about three months postpartum and it took about

01:14:24.140 six months to get back to normal. I think it's important to say, you don't have to exercise crazy.

01:14:31.300 It's finding time when to train. I've been the same percent body fat and changed muscle depending on my

01:14:38.780 training for the last 15, 20 years. After I learned a little bit in grad school, how to optimize,

01:14:44.800 a lot of my students always say, it's not fair you have science on your side, but we all can have

01:14:49.360 that. Meaning consistency, some high intensity and appropriate nutrition. You don't necessarily

01:14:55.800 have to have a new set point. And if you have that consistency, it can really help.

01:15:01.020 So your youngest child is how old today?

01:15:03.440 Eight.

01:15:03.980 Okay. So you're eight years post your second pregnancy. And is your body composition today

01:15:09.660 approximately the same as it was prior to the birth of your first child? Interesting. Not just your

01:15:15.560 weight, but your actual body composition.

01:15:17.280 Yeah. And I would say the biggest change I like to periodize, like I, you know, sometimes I'm leaner

01:15:22.220 or sometimes I'm not like as part of my training, but it's not very different. And I also like to play

01:15:27.520 around, especially now when the message is, oh, as a midlife woman, you can't gain mass or you're losing

01:15:34.000 muscle mass. It doesn't have to be true. And I have gained lean muscle, or if I'm training for

01:15:40.200 something that's more aerobic, I've maybe lost a little muscle. Or I mean, you can appreciate this

01:15:46.060 with your traveling of sometimes your diet is more locked in and sometimes it's not, but it's all

01:15:51.480 about prioritizing that. And one thing I often tell women is the times that I want to be leaner

01:15:57.620 is I'm actually eating more. I'm prioritizing whole foods, eating consistently throughout the day

01:16:03.120 versus the times when I'm not paying as much attention is where I might gain some fat mass.

01:16:09.540 Yeah. Explain that. That seems a little counterintuitive. When you say you're eating

01:16:12.820 more during the periods in which you're leaner, you mean more volume of food, but lower caloric

01:16:17.820 density, or what do you mean? And more frequency. And I'd love to talk through some of the fasting

01:16:23.900 literature, but in reality, as a woman, this is not just me personally, this is based on science as

01:16:29.860 well of many women might wake up, not eat breakfast, might have something at 11 and then continue on

01:16:37.040 or grab a snack. And those foods are typically not necessarily nutrient dense. Whereas if you

01:16:44.020 shoot for about 30 grams of protein and some fiber, some vegetables kind of evenly throughout the day,

01:16:49.080 it stimulates metabolism. You're getting more macro and micronutrients.

01:16:54.040 Yeah. So in other words, the mistake that you think people are making is time restriction.

01:16:59.860 I think there's a time and place for time restriction. What we've seen right now when

01:17:04.820 we're looking at this is many women chronically time restricting, it can lower metabolism.

01:17:10.580 And then there's the aftermath on our hunger hormones. When they start eating, they can't stop

01:17:15.740 or it does impact protein synthesis and metabolic rate and muscle loss. So especially in this midlife

01:17:23.500 window, I think we need to pay a little bit more attention to food consumption.

01:17:28.460 Yeah. By the way, going back to what you said about within six months of your pregnancy,

01:17:33.500 you had returned to your pre-pregnancy body composition. Were you breastfeeding during that

01:17:40.240 period of time?

01:17:40.800 I was breastfeeding and I will tell you, I do not do pregnant research, but I did take this approach

01:17:48.080 during pregnancy. I believe birth is one of the most athletic events you'll do and you should

01:17:53.340 train for it. I exercised consistently and I slowly increased my calories in a way that was almost like

01:18:01.640 a refeed period so that I had a bit of a caloric surplus. And then postpartum, obviously it's hard to

01:18:09.740 nurse and feed yourself and all the things, but I was able to go back to normal calorie balance.

01:18:15.240 And so yes, nursing does help, but I also was exercising consistently. And so there's a bit of

01:18:20.420 calorie play you can do to help with those metabolic changes.

01:18:25.400 What was your exercise in the third trimester? What were you prioritizing?

01:18:29.740 With my first trial, I could do some running, but it was resistance training. I squatted,

01:18:35.040 I did lots of lats, like really thinking about what are the muscles that are going to help you

01:18:39.940 deliver. Those are the ones that I worked up until the day I delivered. I wasn't doing as much

01:18:45.420 necessarily high intensity work, but changes optimizing blood flow and muscle fatigue to help

01:18:51.720 with birth.

01:18:52.640 How long after delivery were you back to exercising?

01:18:56.400 I had two natural deliveries. So I definitely started walking within a couple of days. And then

01:19:01.900 I was doing resistance training within a couple of weeks, but lightweight. I mean, that's the benefit

01:19:06.680 of being active. If I could go back, I would run within a few weeks. Nothing crazy.

01:19:13.760 When you were pregnant, how much did you need to sort of fight cravings? Did you fight cravings?

01:19:20.160 Did you give into cravings? Did you have the typical cravings that women often talk about

01:19:25.480 during pregnancy?

01:19:26.900 Yeah. Oddly, I didn't want to eat animal proteins, which was really hard. And I didn't

01:19:31.380 want a protein shake. None of that sounded good. And so I definitely had to prioritize plant-based

01:19:37.680 proteins. That's just what tasted better. And then interestingly, like I craved donuts. I'm not

01:19:43.460 a person that eats a lot of refined carbohydrates, but I ate those. I included those and I didn't track

01:19:49.400 my macros necessarily, but I was intentional about eating consistently to fuel so that I was a bit

01:19:56.560 on a caloric surplus.

01:19:59.060 And then once you had your children, what changed in your nutrition? Did you very quickly get back to

01:20:05.200 your baseline eating or was there a period in which you still had cravings?

01:20:10.140 I mean, I think GI distress. So often there was probably some lactose intolerance immediately post.

01:20:17.300 I do remember eating a lot of liquid foods because you're carrying a child. So I was

01:20:22.520 prioritizing. Then I kind of integrated protein shakes back and omega-3 and creatine to help

01:20:27.860 maintain when you're not sitting down to eat full meals.

01:20:30.180 So what do you think are the biggest mistakes women are making in the pregnancy and the post-pregnancy

01:20:35.640 phase with respect to training and nutrition?

01:20:39.260 For nutrition, I think it's, we either go one way or the other. We use it as an excuse to eat

01:20:43.640 whatever we want or the opposite of not paying attention. It should be a key priority. And I always

01:20:50.820 still think about the development of the baby, of the neural development. There's a lot of nutrition

01:20:55.620 that can play a role there. And even down to the gut health. So like fruits and vegetables,

01:21:00.540 variety. So really prioritizing nutrition. First resistance and aerobic exercise is,

01:21:06.620 it is an athletic event to deliver a baby. We should exercise. If you've never exercised,

01:21:11.960 you should include something. And if you've always exercised, then you can continue that.

01:21:17.320 I think there's better guidance now than there was eight to 10 years ago. And then into postpartum,

01:21:22.960 it goes back to not the mom guilt, but now how do I incorporate this, especially with nursing and

01:21:29.920 hydration?

01:21:31.240 And sleep deprivation.

01:21:32.400 Exactly. I do think there's something special that happens. Like somehow a mom can go with no

01:21:37.220 sleep and still do all the things. But think about exercise and blood flow. It has a big impact on that.

01:21:42.880 So let's now talk about this, again, going back to kind of this perimenopausal state and even

01:21:48.120 into menopause now. So women disproportionately suffer from sarcopenia relative to men. Presumably

01:21:55.800 there's two things that are feeding into that. Genetically, women have less muscle mass to begin

01:22:00.160 with. And then secondly, it seems that women are less likely to engage in resistance training than

01:22:05.140 men. Do we have data on what the differences are?

01:22:07.720 I love that you're asking compared to men. And you started this conversation of,

01:22:12.260 and what I think is important is let's just look at women too. It's not just the comparator.

01:22:16.360 And there's some really good data, a paper by Bill Kramer, he just wrote and said about

01:22:21.020 one in five women participate in resistance training. So about 19% and it's only one day

01:22:26.220 a week.

01:22:27.320 That's women of all ages.

01:22:28.880 All ages.

01:22:29.040 That's all comers.

01:22:29.700 Yep. I also think we're at this really unique time because we have, so Title IX was about 1972.

01:22:36.800 So now we have this group of women that are aging that do have more experience with exercise

01:22:42.360 and they're aging differently than we knew before. And so when we think about women in

01:22:48.980 this timeframe, whether we compare them against men or not, there are key things that happen

01:22:53.580 with our changes in hormones, even that impacts sarcopenia. Things like oxidative stress and

01:22:59.200 inflammation and change in basal dilation, all of that can impact nutrient delivery and blood

01:23:05.940 flow and cardiometabolic health. So what are the most important things that a woman should do

01:23:13.500 different in menopause compared to premenopause with respect to training? Or is the answer,

01:23:19.960 whatever you were doing before, assuming you were doing the right thing is all you need to continue.

01:23:24.400 In other words, do you need to make adjustments between that phase of life?

01:23:27.500 I would say yes. Everyone throws out menopause. And we actually have some good data on people

01:23:34.600 post-menopause in our 60s and our 70s. What we're really missing is what's happening in our

01:23:40.280 40s and 50s. And our data and some other labs show that muscle quality very much changes. And so we

01:23:48.340 actually did a two-year longitudinal study and brought women back after kind of initial measurements.

01:23:53.680 And in that initial measurement, we gave them pretty comprehensive information about their

01:23:58.580 body composition, their strength, their nutrition. And what we saw was then two years later,

01:24:04.700 individuals that followed some of those recommendations, there were less changes.

01:24:09.320 It didn't align with a lot of our SWAN data, the study of women's health across the lifespan.

01:24:15.320 They were able to maintain some muscle size, but we saw significant changes in muscle quality.

01:24:20.120 And the way I describe that is very much like a ribeye versus a filet.

01:24:26.460 Did you guys do muscle biopsies?

01:24:28.140 We did muscle quality from ultrasound and PQCT. And that PQCT is very related to MRI. We have some

01:24:35.940 of that data now that we've looked at with MRI. And it's the same theme. And there's also a group

01:24:41.860 out of Australia, Severine Lamone. They just did this long longitudinal study looking at

01:24:47.800 perimenopause and a postmenopause. And the data continues to show that muscle quality

01:24:53.140 changes most in perimenopause.

01:24:55.980 Is the muscle fat, is the marbling occurring between cells or within cells?

01:25:02.200 I don't know if we know. Depends on measurement. I'm not sure I can answer that.

01:25:06.780 Got it. So no one's doing a biopsy because that's obviously how we would figure it out or

01:25:10.780 are people doing a biopsy?

01:25:12.000 Yeah, there's a preprint that just came out from Lamone's group that they did biopsies. I would

01:25:17.360 say the downside, so they had pre, peri, and post. But I think there was only about five

01:25:22.460 perimenopause. I'd have to go look and see exactly where the marbling was coming from.

01:25:27.400 There is a really good data on neuromuscular changes and the ability and muscle fiber type.

01:25:33.980 My question back to you be, what's your thought process on why it would matter?

01:25:37.580 Sure. Intracellular fat accumulation would contribute to insulin resistance.

01:25:42.900 Yes.

01:25:43.620 That would be viewed as more pathologic. Athletes often have a lot of fat between cells,

01:25:51.100 but the challenge of static evaluation is you don't know if that's a static pool of fat,

01:25:56.600 which would be a bad sign, or if it's in flux. Is this fat being consumed? Because obviously,

01:26:02.960 fatty acids are very desirable to muscles, especially a very metabolically flexible muscle,

01:26:08.540 which can oxidize fat across a wider range of energy output.

01:26:13.020 So we're measuring that with different ways, not with biopsy, but both with indirect calorimetry

01:26:18.100 through metabolic flexibility. And then we just finished a project looking at microdialysis.

01:26:23.660 This was within the fat. It can also be done within the muscle, but trying to understand fat

01:26:29.340 oxidation, not only during exercise, but before and after exercise to get at that of what is the

01:26:36.000 oxidative capacity? How is the muscle? Is it metabolically flexible?

01:26:40.700 And you're measuring this in what subset of women?

01:26:42.960 This is in perimenopause.

01:26:44.540 Okay. And so what are you finding? Are you looking at maximum fat oxidation with indirect calorimetry?

01:26:49.540 We're doing that as well as metabolic flexibility. So some of our early work demonstrated that

01:26:55.960 it was in perimenopause at moderate intensity that women were become, they were less flexible.

01:27:02.580 How are you quantifying or measuring or defining the metabolic flexibility? What are you,

01:27:07.320 and I assume you're measuring their IC across varying intensities?

01:27:11.280 Yeah. So using a blend of our RER, RQ, so oxidative metabolism from carbohydrates and fat.

01:27:19.100 And then because of that early data, we've then added our fat metabolism through microdialysis

01:27:26.260 to understand fatty acids interstitially before and after exercise.

01:27:32.820 So what are you finding in terms of, are these longitudinal studies as well,

01:27:37.640 or are you only looking at women in perimenopause, but you don't have their data from prior to that?

01:27:42.800 Both. So we have one that was longitudinal. And then we have one that's more of our acute,

01:27:48.280 which has informed our current project looking now, trying to understand how resistance training

01:27:53.320 might modulate that and or nutrition. So we definitely need more longitudinal work. We have

01:27:59.360 some. So what do you see during, at least to the perimenopausal snapshot in terms of metabolic

01:28:05.700 flexibility? I think the most important takeaway is that exercise does make us more metabolically

01:28:12.860 flexible. Even resistance training alone, or does it have to have some cardio?

01:28:16.820 I mean, this is a biased view, but we've really dialed in and looked at more of our

01:28:22.160 high-intensity interval training just because it accelerates lipid fat oxidation. And so obviously

01:28:28.780 during exercise, we're using mostly carbohydrate, but post-exercise high-intensity work blunts any of

01:28:36.940 our hormonal impact, meaning exercise will stimulate metabolic flexibility regardless of hormones and age.

01:28:46.200 What we're even trying to dial in now of how about fasting versus protein intake versus carbohydrate

01:28:53.320 intake, which some of our early work right now that we've just analyzed is that it does seem that

01:29:00.040 protein optimizes blood flow and does not blunt insulin response post-exercise. So it does seem to

01:29:08.100 help with our metabolic flexibility post-high-intensity work. We have not looked at resistance training.

01:29:13.200 Tell me, are you defining metabolic flexibility on a continuum or are you using kind of an

01:29:19.440 on-off switch where there has to be a threshold?

01:29:22.700 Often we're measuring it through not a graded exercise test, but an increased exercise intensity

01:29:28.100 using indirect calorimetry. So we're looking at that switch from fat to carbohydrate utilization.

01:29:34.140 And you're defining that as your RER at 0.85? Are you asking the question, at what intensity

01:29:38.820 do they switch their RQ from below to above 0.85? Not just 0.85. There's some of Asker

01:29:46.060 Eukendrup's work we're using to use a mathematical model to understand the continuum, not just like

01:29:53.060 an on-off. Okay. So help me understand, what is the unit of measure for that? Is it going to be

01:29:59.420 a transition from a certain number of grams per minute in total, or is it just a percentage of

01:30:06.760 fat versus carbohydrate? Yeah. I mean, there's a couple of different outcomes. Sometimes the

01:30:11.440 percentage is the easiest to look at. The ability that, yeah, the fat versus carbohydrate.

01:30:16.980 So what you're measuring pre and post in these women is how much does their percent of fat

01:30:22.340 consumption go up for a given workload? Well, yeah. Then we can split it based on their intensity.

01:30:29.920 So heart rate driven, measured heart rate of low, moderate, and high intensity, and that fat to

01:30:36.920 carbohydrate oxidation percentage. And then does that vary between pre, peri, and post? And then

01:30:43.720 study two is looking at specifically metabolic flexibility based on hormonal concentrations,

01:30:51.640 early, late perimenopause.

01:30:52.980 So what do you think is driving the metabolic inflexibility with aging in women?

01:31:01.000 It's probably impacted by a few things. Some of it related to our oxidative stress and our

01:31:08.120 inflammation. We do see changes in insulin sensitivity.

01:31:11.700 I guess what I'm getting at is, do we have the same literature that cover men during the same period

01:31:17.120 of time where whatever effects are just age related would be the same, but effects that are hormone

01:31:26.440 related would obviously not be present in men. And it would be interesting to kind of disentangle those

01:31:31.460 two.

01:31:32.200 A hundred percent. One of the ways we've tried to do that is measure phenological age, because obviously

01:31:37.620 aging is a really important role, but how much is age versus lifestyle versus hormone driven? And I

01:31:45.860 think more importantly, is how do we use lifestyle changes to optimize that or overcome some of those

01:31:53.380 hormonal components? And currently we do not do prescribe or provide menopause hormone therapy,

01:32:00.640 but that's the next layer of then how does artificially adding hormones impact all of that? It's really

01:32:06.340 what we're trying to identify.

01:32:07.960 So you haven't studied that because that was going to be my next question, which is how does

01:32:11.420 hormone replacement therapy impact this change, all things otherwise being equal?

01:32:16.980 The bad thing about research is it has to be somewhat controlled. And so just now, especially

01:32:22.400 based on the number of women taking hormone therapy is now we're including individuals that are on

01:32:28.860 hormone therapy or are not. And some of my colleagues are prescribing that to understand, but that's

01:32:34.980 really where we're at now. And I think it comes back to why we need more research and dollars in this

01:32:41.060 space to dial that in because it would be great if adding hormones would really help overcome that,

01:32:47.200 but you still have to add lifestyle. So what is that combination? And then like you asked,

01:32:52.940 what component is changing? Is it oxidative stress? Is it arterial stiffness? Is it blood flow? What are

01:32:59.500 the things that are really going to optimize that so that we can really help these women as they age?

01:33:04.800 Yeah. And again, what should the portfolio of training look like?

01:33:08.800 To me, I think is maybe the most interesting question because I just can't imagine there

01:33:14.760 is anything that is going to change metabolic flexibility more than training. And because

01:33:20.300 virtually everybody who is going to be exercising is going to be constrained on time, figuring out

01:33:26.480 what is going to give the most bang for the buck matters.

01:33:29.940 Agreed. And I think that's where a really important takeaway, I think, especially now,

01:33:34.360 it's a little confusing. A lot of women are getting a lot of information about what they should and

01:33:38.180 shouldn't do. But you're exactly right. First, we just need to exercise and that's a potent stimulus.

01:33:43.700 But then it's about optimizing. And so when we go back to metabolic flexibility, a lot of the data

01:33:49.240 when we pull in nutrition is around carbohydrate feeding. But when you talk about insulin sensitivity

01:33:55.600 and those changes, which is where my group has focused and tried to look at what happens when

01:34:00.140 you provide amino acids to also elevate protein synthesis and breakdown. And it seems that if we

01:34:07.500 are eating our protein around training versus our carbohydrate or changing from high to lower

01:34:12.280 glycemic index, that can also optimize metabolic flexibility.

01:34:17.180 Yeah. And I guess the question is, that would probably be true at any age, right?

01:34:22.840 Yeah. I just think it matters more with such a big change. And I guess I don't,

01:34:27.740 let's not quantify big, but when there is a significant change in muscle size, quality,

01:34:35.240 cardiometabolic health, arterial stiffness, neuromuscular changes that are happening

01:34:39.640 in our 40s and our 50s, then those little tweaks do make a difference. Regardless, like it's going to

01:34:46.500 matter then, but it gives us a bigger bang for our buck when we have less time.

01:34:50.820 What do you think are the most interesting questions around women's health that we don't

01:34:59.000 yet have a clear answer to that could be answerable if we had the resources to study it and the will to

01:35:06.120 do so?

01:35:07.100 Well, I hope we do. I hope we can really build this out. I think one of them is women ultimately want

01:35:12.480 to lose weight. So how do we combine our GLP-1s with the kind of what I would call minimal effective

01:35:20.260 dose of exercise and nutrition in a way that women can still live their lives and feel good?

01:35:26.200 So many women are not feeling great on those drugs or they're not feeling good off the drugs. And so

01:35:31.140 there's also a very big component of mental health in here. I know exercise can have a really important

01:35:37.540 role in. The other big question that I think is really important is the impact. We've seen a swing

01:35:44.200 and I would be curious of your take that there's much more conversation now around menopause hormone

01:35:49.540 therapy. I think there's a lot of indirect effects on muscle and training volume, but how much, for

01:35:56.580 instance, adding hormones isn't going to increase muscle directly, but indirectly, maybe I have more

01:36:05.240 energy or I can do higher volume. I can recover better. Exactly. But then does that also put me

01:36:11.140 at greater risk for injury? Are tendons still change? Actually, one of the things I think we

01:36:16.900 have in common, my biggest injury fear is an Achilles tendon tear. And so I think about that a lot

01:36:23.160 of like, how do some of these changes in hormones and really helping women feel better with this new

01:36:29.340 wave of very active women, they're women that are training, like how do they combine that has

01:36:34.780 application to the military, etc. But we need to know a lot more as we're changing our pharmaceutical

01:36:40.740 agents with our lifestyle components. Yeah. I mean, on that particular topic, my intuition is that the

01:36:48.500 answer comes down to the type of training and you're less likely to tear your Achilles sitting on the couch

01:36:55.560 if you never get off the couch. You're not going to tear that Achilles. Now, of course, you're going to die

01:37:00.820 a thousand deaths. So if we give a person hormones as a part of a broader strategy around improving

01:37:08.700 their health and as a part of that, that person becomes more active, that's wonderful. But that

01:37:15.080 doesn't prevent them from having an Achilles injury if they don't do the type of training that

01:37:20.000 would reduce the risk for that. And the good news is we have a pretty good sense of how to do that.

01:37:24.120 I don't think we're going to take that risk to zero. I think you and I are still going to be at risk

01:37:27.620 for it. But I think if we're doing the right things, if we really make sure the soleus and the

01:37:32.700 gastroc are getting a strong range of motion, the bouncing exercise, like we're doing all the right

01:37:37.460 stuff, maybe we take that risk down by 80%. And so I think that's where the education and the training

01:37:43.500 specificity become really important. Now, those things are hard to put into clinical trials.

01:37:47.780 It's really hard to do the clinical trial of I'm going to take a thousand people and I'm going to put

01:37:52.180 half of them on a business as usual training program, which is, you know, a pump and burn program.

01:37:57.000 And the other half of you are going to go on a smart program where you're going to do all of that

01:38:01.260 stuff, but you're also going to do all of this tissue and tendon pliability work and da-da-da-da.

01:38:06.120 And then we're going to follow you guys for Achilles tears over the next 15 years. That study will

01:38:10.520 never get done. So on some level, I suspect we have to be able to think through these things in

01:38:15.540 terms of common sense and best practices. I agree with you completely. I really think that this idea of

01:38:20.840 figuring out what a world looks like where a higher and higher percentage of the population

01:38:26.660 is using a class of drug that has for the first time ever really demonstrated long-term

01:38:33.200 safe application of weight loss, but it does come at a cost if you're not careful. And again, I think

01:38:40.600 the knowledge is there. What you're describing, this is not like hidden knowledge. We know what it

01:38:46.060 takes to do this. I would hope that more physicians are equipped to help their patients understand that

01:38:52.120 we should be able to take advantage of this great drug, but it comes with a responsibility of how to

01:38:57.680 incorporate it. And that's unusual because a lot of times with drugs, we don't do that.

01:39:01.620 If you need a drug for your blood pressure, we don't have to give you like a long song and dance

01:39:05.720 about how to take it. Same thing with a cholesterol drug. You take this drug, it lowers your cholesterol,

01:39:10.180 we'll remeasure it. It's going to be fine. But yeah, the GLP-1, it's a different class and it comes with a

01:39:15.660 whole set of, if you take it, great, but you got to do X, Y, and Z. And it's just as much work. That's

01:39:21.820 interesting. What are the other maybe misconceptions about women's training? What do you find yourself at

01:39:30.400 parties having to correct people on? Peter, I don't go to many parties. It comes back to these absolutes

01:39:37.200 that we're hearing. I have to lift heavy weights or I have to do high intensity training or I have to do

01:39:43.180 plyometrics. And I really wish that we could just tell women of exercise and doing something is

01:39:49.740 better than nothing. And then I do think we can leverage a lot of the traditional strength and

01:39:56.060 conditioning research that we have that was founded in male science. We know the female muscle will

01:40:01.540 respond. And so it's taking our program design that we know has worked, but then understanding that

01:40:09.440 there might be some differences as far as recovery and rest or joint pain. Like there's modifications

01:40:15.780 that are needed. I guess I just wish we could empower women to do the things that they like to do

01:40:22.180 and the traditional rules that we have of change it. If we want strength, if we want hypertrophy,

01:40:29.120 we want fat loss, leverage what we have now.

01:40:32.600 Meaning take all of the data we have on how do you optimize around hypertrophy versus strength,

01:40:38.280 which again, to your point, a lot of those studies have been done disproportionately in

01:40:42.100 male subjects. Are you saying that to the first order approximation, the results should be the same

01:40:47.080 in women? When we look at things like strength and hypertrophy, yes, those same methods can apply.

01:40:53.880 We do see differences, I think, in detraining or percentages of loss in strength and muscle

01:40:59.060 of absolutes. But yes. Are women more susceptible or men?

01:41:03.460 This is some early data, meaning I don't know if we absolutely know because it's so individual.

01:41:09.380 And I think that's where we need to dive into. There are women that will gain more strength than

01:41:14.360 men or have more muscle than men. But when we look at the baseline fiber types, because women tend to

01:41:20.580 have, generally speaking, more type one fibers, they might change slightly different. And there's also

01:41:27.000 some new data. I mean, that's not new, but neuromuscular aging and motor unit recruitment could

01:41:32.740 vary between males and females. But it goes back to your question. Strength training works. And a woman

01:41:39.240 is going to gain strength and gain muscle, but not to the same absolute effect as a man.

01:41:46.660 Are women more susceptible to the loss of type 2A fibers when they age?

01:41:51.280 Yeah, that's a debatable topic. Men tend to have more type 2 fibers. So then there's a bigger

01:41:57.380 area to lose or a percentage. But with age, there's denervation that happens where properties

01:42:05.280 look more hybrid or type 1 for males and females. It does seem that it maybe happens a little bit

01:42:11.540 faster for females. But there's a lot, I think, that we're still... How much exercise prevents that?

01:42:17.400 Yeah. Well, I was going to ask. A couple of years ago, I had Andy Galpin on the podcast,

01:42:20.680 and he said something that always struck with me, which is that hypertrophy of the type 2A muscle

01:42:25.480 fiber is, I don't think he said it this way, but it's basically the synquinon of aging. And boy,

01:42:31.260 that always stuck with me. And it really resonates. The first thing you're going to lose,

01:42:36.960 you and I are long past our peak on this, is explosiveness. We've lost power. We're way on the

01:42:42.600 back nine of power. Strength, not so much. Hypertrophy, not so much. So strength, the next

01:42:49.140 thing that starts to go, and basically hypertrophy is the last thing we go. So the thinking, at least

01:42:54.520 what I took away from that, is if we're losing power in our 20s, if basically we peak powers in

01:43:00.180 your 20s and it's all downhill, that's the thing I want to fight to preserve. Now, I'm never going to go

01:43:05.500 and do the same sort of insane workouts I was doing in my teens and 20s, but I'm still going to fight

01:43:12.300 for power. I'm going to do it in a more controlled way. I'm doing more stuff on a Kaiser as opposed to

01:43:18.420 jumping around and doing insane box jumps and things like that. But I'm still jumping. I'm still

01:43:23.780 bouncing. I'm still trying to recruit that fiber whenever I can. And so would you make the case that

01:43:31.760 that's even more true for women, given that they are losing more of them?

01:43:37.740 A hundred percent. And that woman probably, I would say, who cares about power? But really,

01:43:42.500 it's about- But here's why I care about power.

01:43:44.380 No, no, no. I'm saying that I don't think people-

01:43:45.100 Oh, you're saying a woman might say that.

01:43:46.740 I mean, I think many people might say, why do I care about power? But absolutely,

01:43:51.360 because there's so much relationship to health and quality of life and injury prevention.

01:43:55.420 I would give a very tangible example. This to me is the best example of why every person needs to

01:43:59.940 care about power. If you or I were to go and walk down the street right now and we were so

01:44:06.800 lost in discussion that we lost our footing as we stepped off a curb, it wouldn't phase either of

01:44:13.420 us. We would step off that six foot curb and we would immediately be able to readjust our footing

01:44:19.320 and prevent ourselves from falling on our faces. And we would go on carrying on talking about metabolic

01:44:24.220 flexibility. When a 65 or 70 year old person steps off that curb and misplaces their footing,

01:44:31.580 they are very likely to land on their face because they don't have power. And that's the reason I want

01:44:37.560 everybody to care about power is it's the difference between falling when you stumble versus regaining

01:44:44.060 your footing. And it doesn't have to do with if you want to dunk a basketball. That's cool.

01:44:47.400 That's a nice ancillary benefit if you want to dunk or ski or all those other things, but it really

01:44:52.560 comes down to life. Yeah, a hundred percent. And that matters more in midlife. I mean, we want to

01:44:58.300 do what we can right now. The more it matters. Exactly. Well, or what we can do now is have a

01:45:03.160 bigger impact over time. If I do things right now in my forties to maintain power, it will help.

01:45:09.100 Inevitably, we are going to lose that. Like you said, I want to ward that off as soon as I can

01:45:14.220 so that I have that ability to maintain power longer. Yeah. So maybe that is another one of

01:45:20.640 the reasons that we see for potentially women suffering more falls. We haven't talked about

01:45:26.720 some of the brain components, but even the side effects that happen in this midlife of a lot of

01:45:33.040 women experience joint pain. And now you want me to go tell a woman to do plyos and bounce and things

01:45:38.580 like there's some intangibles we need to consider of how do I tell a woman to maintain power

01:45:43.560 based on some of these things that she's experiencing. There's also central fatigue

01:45:50.000 and changes to brain health, whether it be indirectly from sleep. And that's where some

01:45:54.900 of the nuance comes or where I think we need more guidance of we know what training tactics might help

01:46:01.520 maintain power. But how do you do that in different scenarios for a female that are maybe unique to her?

01:46:08.200 Yeah. So again, it always makes me sad when I hear about perimenopausal and menopausal women that are

01:46:14.220 complaining of joint pain when you realize that for many of those cases, hormones would probably fix

01:46:19.080 those issues. And so, yeah, it's hard to ask somebody to train when they're constantly in pain

01:46:24.300 when we have a solution to that and we're not giving it to them. Now, what about the woman who's

01:46:28.580 listening to this who's 65, 70 years old and asking, Abby, is it too late for me? Has the ship sailed?

01:46:35.680 No, I think that's the beautiful part about the human body and about exercise. You literally can

01:46:41.860 do it at any time and you can start. If you can start sooner, that's better. But no, you can gain

01:46:48.080 strength and muscle at any age. Obviously, there's some challenges and you might change your volume and

01:46:53.700 intensity. But no, 100% you can start and we all should be motivated to do so. It's the way we can

01:46:59.560 control our health span. So what would be some specific advice? So now we're talking to a 70-year-old

01:47:05.600 woman who's never exercised deliberately in her life. She's never had a workout routine and she's

01:47:13.660 healthy in the sense that she's not riddled with injury at the moment, but she's already experiencing

01:47:19.660 a dramatic reduction in stamina and strength. Maybe she's struggling to open a jar. She can

01:47:26.200 walk up a flight of stairs, but it's sure she notices it in a way she didn't notice it 10 years

01:47:30.180 earlier. So now she has one thing on her side, which is time. So how would you advise her to go

01:47:35.880 about starting a routine for the rest of her life? And how would she tie trade up?

01:47:41.000 I would highly recommend hiring a personal trainer as an initial step to really teach her.

01:47:46.200 How should she look for one? Because there's such a quality continuum in that spectrum. So what is

01:47:51.360 she looking for in a personal trainer? There's a lot of recommendations. So I think referral is a

01:47:56.240 really important starting point. I would hope that maybe a physical therapist has a good

01:48:01.280 recommendation or someone locally. There are some credentials to look for, but it does depend on

01:48:06.000 where she lives. But let's just say you were her trainer. Okay. Yeah. She brought you in. Okay.

01:48:10.340 Okay. You know, she was lucky enough to find someone of your knowledge. How would you think about

01:48:14.820 creating a program for her? I mean, it's all about adding a slightly higher stimulus than what she's

01:48:20.160 doing now. She has no stimulus at the moment. Right. Yeah. So like, I mean, I think for someone

01:48:24.360 like that, there's consideration. So one thing we haven't talked about is people are motivated by

01:48:29.880 different things. Is she motivated by a group? Is she motivated to do it on her own? Is she motivated

01:48:34.980 to be in a gym? In those scenarios, starting with resistance bands at home is a starting point,

01:48:41.600 or is she excited to go do silver sneakers somewhere? That would be a starting point.

01:48:47.560 Or does she need to be in a gym with, I wouldn't start with a ton of free weights, more of our

01:48:53.600 machine based controlled stimulus. There's so many options.

01:48:59.280 So yeah, let's say she's got a gym nearby. It's got a great range of everything. So, you know,

01:49:05.020 she can do all the machines in the world. There's no machine she doesn't have access to.

01:49:08.120 How would you think about putting a program together? I would do a total body program where

01:49:13.140 we're really focused on, and this is not just specific to females, but glute activation to

01:49:18.400 help with that lower body. Yeah. That will also help with slip strips and falls, a push pull for

01:49:24.240 every muscle group. So a glute activation for her is going to be a leg press?

01:49:27.760 A leg press, but also just some neuromuscular activation, standing up. A lot of times the leg

01:49:33.160 press is not activating the glutes. So some banded work to activate the glutes to get started,

01:49:39.160 maybe a leg press, leg extension. I wouldn't probably start with a lunge for this individual.

01:49:45.600 And then from there, something like definitely hitting the hamstring. So every muscle group in

01:49:50.000 the lower body, I'd do something to get the calves to help with the stability. We haven't talked about

01:49:55.380 the shoulder joint, upper body. There's a lot of benefit in strengthening all aspects of the

01:50:00.380 shoulder joint and the deltoids. So a full body, upper body exercise.

01:50:04.660 Okay. And so how many days a week are you going to have her? And how many minutes a week would you

01:50:08.260 have her doing resistance training? That's a tricky question. I wouldn't start her. We'd want her to

01:50:13.680 come back. So soreness is going to be a consideration. Basic initial, not knowing a lot about her,

01:50:20.920 three days a week of resistance training, most days a week of some sort of movement, aerobic exercise

01:50:27.120 is where I would start. And obviously titrate depending. So kind of an every other day to

01:50:32.580 allow for recovery. How long would you want before you would introduce things that are not tied to a

01:50:38.800 machine? So carries, walking with dumbbells in her hands or kettlebells in her hands. How long

01:50:42.960 until you would want her testing multiple things where she's now testing core stability, grip strength,

01:50:50.100 foot reactivity? What do you want to see before you would engage in that?

01:50:54.060 I don't work with a lot of older adults and we often will start them in training. We'll start

01:50:59.240 them with pretty progressive resistance training in a controlled scenario. So I don't know. What

01:51:03.100 would you say for that? What would you look for? I think I would look for the ability to do these

01:51:08.600 things deloaded safely. And then if you can do something deloaded, then I would add low resistance

01:51:13.000 and kind of progress from there. I like things like that a lot. I mean, I really love carries. I think

01:51:18.440 grip strength is so underrated in a functional sense, like not squeezing a little grip squeezer.

01:51:24.060 I guess I would also maybe if you were talking about machines, I'd also love to see a hip thrust or

01:51:28.880 something like that. I know you love the carry. Would anything prevent you from having this woman

01:51:34.500 start with holding some dumbbells to begin with? Definitely not. I was going to say that. I didn't

01:51:39.040 know. Before you walk. Yeah, yeah, sure. Yeah. Can you just hold it? And I like doing a lot of sub

01:51:43.620 maximal efforts. So I would want to, you know, a light enough weight that she can hold it for a minute,

01:51:49.960 rest for a minute, hold it for a minute, rest for a minute, hold it for a minute, but not

01:51:53.280 never failing on those. Seems to be a common theme. One minute on, one minute off.

01:51:58.160 Yeah. Yeah. For that, for sure. I mean, that's one of my favorite sets actually is just a walking

01:52:03.360 carry hold 20 sets of either 30 on, 30 off or a minute on, a minute off with a little less weight,

01:52:09.240 of course. Yeah. I mean, Belinda Beck, this woman from Australia, with that lift more study,

01:52:15.020 I've always been impressed with that, where they were able to basically teach these women how to

01:52:18.840 do barbell deadlifts and things like that. And they were really throwing some weight around.

01:52:23.680 We've done some work with older adults. This is earlier in my career. And they gained massive

01:52:30.300 amounts of strength in 24 weeks doing things like squat and bench press. I don't know if I

01:52:36.220 necessarily have them do squat. We usually do a leg press, but absolutely. You can start at any age.

01:52:41.160 Anything else you think where there's the most daylight between men and women in training

01:52:46.920 that maybe we want women to be more aware of as they consider their own journey?

01:52:52.440 I think this is not my area of research, but the impact on mental health is a huge,

01:53:00.460 really important area that exercise has a positive impact on anxiety, depression, even brain fog. And I

01:53:08.300 always use the analogy of there's days that I feel like I have about 20 squirrels in my brain.

01:53:13.460 And it's when I go exercise that the squirrels finally tame down. But in reality, a lot of times

01:53:19.420 women think that they are abnormal or it's unique to them. But exercise, both resistance training and

01:53:27.100 aerobic exercise has a huge impact on that mental cognition, focus, anxiety, depression. And I would love

01:53:35.680 to continue to provide better prescription there to have women understand what they're looking for.

01:53:43.100 Do you think there are any trends that are out there today that you think are at best incorrect,

01:53:48.880 at worst, potentially harmful as it pertains to sort of things women are being told about exercise or

01:53:53.780 nutrition as it pertains to conditioning?

01:53:56.620 Yeah, I think it's harmful to say you need to only do this or not do that. Our very black and white

01:54:03.500 pragmatic thinking is harmful. Because in reality, every woman is individual. And that's the best

01:54:10.020 part about research is it's little tools in our toolbox. And that changes as we get an injury,

01:54:15.840 or maybe I have lifted heavy my whole life, but I still want to gain strength. Well, I need to modify

01:54:22.120 and adapt. And so exercise does not have to be overwhelming, neither does nutrition. And I think so

01:54:28.340 much of it now is, oh, you have to do it this way, or this is the only way that'll work now that you're

01:54:33.940 in midlife, or you have to change your training, when in reality, most of us are just trying to

01:54:38.340 get something in and do it consistently. So less rules, and really understanding that exercise is

01:54:44.980 powerful, no matter really how you do it. And then thinking about the injury piece, I think

01:54:49.360 injury and recovery from injury, we're not giving enough conversation to,

01:54:54.760 that can be really impactful, especially with injury rates taking longer as we age.

01:55:00.440 One of the injuries we seem to see more in women than in men, and my wife has a theory about this,

01:55:06.600 is high hamstring injuries. What's her theory?

01:55:09.800 That after pregnancy, when the pelvis sort of moves a little bit, so my wife was a runner before

01:55:15.660 and is a runner after, but she said, look, I've never run the same post-pregnancy. So she actually

01:55:22.420 runs the same times. She ran the Boston Marathon this year, and she ran it 19 years ago, and her

01:55:28.280 time this year was only 45 seconds slower than her time almost 20 years ago. Now she trains a lot

01:55:36.380 smarter today, so I think that's why her running times are still really good. But she says, I don't

01:55:42.600 feel the same. I used to float, and now I don't feel like I float. And she's had a couple of these

01:55:49.120 really high hamstring tendinopathies. And we see this a lot in women, and again, more so than men,

01:55:55.060 but I don't, it could be just a small N. But are there any other injuries that you're seeing that

01:55:59.840 you think women need to be aware of? Yeah, I mean, this is probably because most of my colleagues

01:56:05.320 at UNC are studying knee injury, but it does seem kind of ACL injury in midlife.

01:56:11.580 You're seeing more in women?

01:56:12.460 Yeah. And I think some of that, though, is just goes back to the caliber and the accumulation

01:56:18.940 and competitive nature of women in this lifespan. They all played sports when they were younger,

01:56:24.360 so I don't know if it's necessarily a male-female thing. But I do think an area of interest of mine

01:56:30.020 is looking at muscle tendon stiffness and how that changes with not just age, but hormones.

01:56:36.120 And then how do we change and prevent that? Because a lot of times this is not coming from

01:56:41.260 a contact injury. It's coming from someone slipped because their dog pulled them. And so what's

01:56:48.060 happening, I'm not sure. Is it just because more women are more active and now we're hearing more

01:56:52.340 about it? Interesting. Yeah, I'd be very curious to see. That would be really interesting to understand

01:56:57.500 how much of that is occurring as a result of age, in which case you would expect it to be equal

01:57:03.920 between men and women versus hormones specifically. I do think maybe some differences in inflammation

01:57:11.280 and some of the neuromuscular aging that is seen with those hormonal changes. I would hypothesize

01:57:17.780 that would have an impact, but not necessarily just to a knee joint, but some of those musculoskeletals.

01:57:23.120 You're saying that hormone loss is increasing inflammation as the mechanism?

01:57:27.020 No, not directly, but we tend to see more inflammation in perimenopause when estrogen

01:57:35.180 changes. Measured how? It can be in the blood. But with CRP or what markers? Usually high sensitive

01:57:41.200 CRP would be the kind of the key one. So you're seeing that higher in perimenopausal women and not

01:57:46.680 on hormones? I can't answer that directly. So some of the work is showing that inflammation is changing,

01:57:53.760 whether it's coming from hormones or not, or if hormone therapy changes that. I'm not sure

01:58:00.160 we know. Okay. I'm not aware of that, but I'd look into that. All right. Well, is there anything

01:58:05.180 else you think we're missing in terms of trying to make sure we give women at all stages of their

01:58:13.140 lives training input that they might otherwise be missing or dispelling any things that you think

01:58:19.320 they're hearing? You've got to do this workout or you shouldn't be doing this, as you said,

01:58:23.680 like, what are some of those black and white things that you think are most misleading?

01:58:27.280 Well, I have two thoughts. So right now, I know you've talked a lot about creatine on other

01:58:32.600 podcasts. My lab is one of few doing it in women. And I think creatine is great and there's a lot of

01:58:39.320 benefit, but that doesn't mean it's magic. And I think it's important to realize that it can be

01:58:44.560 helpful with training, but it's not the first thing I go to for midlife women. It's one of those

01:58:50.280 things I think we'll continue to see more literature. So like being informed on that.

01:58:54.220 And then the other thing I, one of my motivating factors is to having more conversation around

01:58:58.680 these things of not just training, but physiologically and mentally around this midlife

01:59:04.000 space. And so as a man who has a daughter and a clinician and a wife, I think there's a lot of

01:59:10.300 conversation or I'd be curious of how you would tell these women, or as I bring this back to the lab

01:59:17.320 of how do we have better conversation and be informed on what's hormone driven and what can

01:59:24.940 we overcome versus what do I need medical help for and how do I advocate for myself? Especially

01:59:31.000 as we pull in science, it's very difficult to do. And so many women are invalidated with their

01:59:37.620 experiences and how do we leverage men in the conversation?

01:59:41.880 Yeah. Well, I mean, I think my points of view on hormones are very well known and I do maintain

01:59:47.820 that it's, again, I have yet to find a better example of how the medical system has screwed up

01:59:52.920 in the last 25 years than on this issue, both in the magnitude of what it is and just the fact that

01:59:59.100 it's 50% of the population have been hurt by this. So I've done this analysis literally in a model

02:00:06.280 and I can't come up with a greater negative impact. So luckily, I think the tide is turning.

02:00:12.600 But unfortunately, A, there's a generation of women now that have sort of fallen outside of

02:00:18.720 the window in which doctors who are even starting to come around on hormones feel comfortable

02:00:22.900 prescribing hormones. Although Rachel Rubin was a guest on this podcast and she made a very compelling

02:00:28.320 argument for the fact that that's a little bit of a BS argument. And that really, if a woman is 60

02:00:33.760 and she's been in menopause for 10 years, that's not disqualifying. And there's no evidence that we

02:00:39.100 can point to that we're driving rates of breast cancer by giving that woman hormones. And so if

02:00:43.960 she's going to benefit from it, then she should be on it. As far as women that are going through this

02:00:47.960 process now, I think, again, the good news is I think there are enough doctors out there who,

02:00:53.540 it's still a very small number in absolute terms, who are simultaneously willing to do this and

02:00:59.440 competent to do it. The competence is a hard piece because there are more tools than ever before.

02:01:05.060 In the olden days, it was MPA and CE and that was it. And of course, today we would never use either

02:01:10.520 of those hormones. So you have to know more. But look, we also, that's why this podcast exists,

02:01:15.440 right? I mean, anybody who wants to understand how to safely and intelligently provide hormones and

02:01:21.180 think through the nuances. When do we want to start with this topical? When do we want to use this

02:01:25.680 variation, that variation? I mean, we've got more content on that than I can point to.

02:01:29.720 So it's out there. And I would just say, look, don't be satisfied with no. If a person says no,

02:01:35.320 then it's time to find another person. And again, fortunately, it looks a lot better today than it

02:01:41.100 did five years ago. Five years ago, it was pretty bleak. And I think in five years, it's going to be

02:01:45.500 even less bleak than it is today. And what do you think about the exercise piece? So, you know,

02:01:50.020 we were talking about GLP-1s with exercise. Often when we're talking about hormones and hormone

02:01:55.360 therapy, we're not talking about lifestyle behaviors of the combination of the two to help

02:02:00.360 relieve symptoms. Do you ever see that coming in play or being an important component?

02:02:06.060 Where I sit, it's not really a concern because we're always talking about all of these things

02:02:11.100 all the time. So I'm probably not the right person to answer that question because I'm not

02:02:16.720 seeing the other side of that, but I can appreciate the fact that anytime you can take a drug,

02:02:22.620 it's easier than making a change. And a lot of times those changes end up being more powerful.

02:02:29.280 The sort of quote unquote lifestyle change ends up being a bigger issue. In both the cases that

02:02:34.340 you've mentioned, a lot of times the drug makes it easier to make the change. And in the case of

02:02:38.840 hormone, I think there's just an independent benefit that also comes from it. That's unmistakable. I mean,

02:02:43.180 I think independent of whether you exercise or not, you're going to benefit from taking hormones.

02:02:48.200 The point is, can you have an accretive benefit if you do both of these things? And I think the

02:02:53.880 answer is almost assuredly yes. Again, we're not going to prove that in a study, but it's really

02:02:58.920 hard to imagine a scenario where by combining both of those things doesn't lead to an even better

02:03:03.260 outcome than doing one by itself. And do you see, is there any like key research in this area that

02:03:09.100 would inform your clinical practice? Or do you see a gap that would be beneficial?

02:03:14.720 With respect to hormones and exercise?

02:03:16.380 Yeah. Or midlife women, like even thinking, obviously hormones are often a part of the

02:03:21.120 conversation, but not always.

02:03:23.020 Well, there's the really interesting questions scientifically that often don't matter that

02:03:29.860 much in the real world. So for example, there are lots of questions I could imagine asking if we

02:03:35.660 were talking about unconstrained or unlimited amounts of time. And that applies to some people.

02:03:40.960 I do know some people who have eight to 10 hours a week to exercise. And I think in those situations,

02:03:46.620 we could have a very different discussion about how to optimize training.

02:03:51.880 I'm obviously pretty interested in how you would optimize it in a resource constraint world. And that

02:03:58.160 would be, you know, are four by fours better than one by ones? I don't know the answer. I suspect

02:04:04.060 that in the real world, the answer comes down to whichever you can do more diligently.

02:04:09.520 And I think the application of this stuff is what matters the most. But I also think that,

02:04:15.780 so this is the unfortunate reality of training, which is if you're not providing enough training

02:04:20.720 stimulus, you're getting a suboptimal result. And so what I really want is for people to understand

02:04:26.800 how potent this tool is, if you can provide the right stimulus. And the shorter your volume of

02:04:32.140 training, the more important the intensity of that is. And therefore, if you're only going to lift

02:04:39.200 twice a week for 30 minutes, you can't phone those in. Like you got to actually do the work. In fact,

02:04:45.320 it's easier for me because I'm in the gym six hours a week. So it's like, I'm making up for it in volume.

02:04:51.440 My volume is more than covering it. I'm going to one or two reps in reserve, but I have so much

02:04:56.860 volume that it's okay. But if you told me, Peter, you get two 30 minute shots, I mean, I'm probably

02:05:02.900 going to go to failure on every set. And that's harder. That is neurologically way more taxing.

02:05:08.460 If you told me I only have these two short cardio workouts per week, I can't phone those in.

02:05:16.200 You're showing up to push. Now, does that matter if you're starting out from a low base? No,

02:05:21.880 because any training stimulus matters. But if it's you or I who have a training history that is,

02:05:27.900 you know, this thick, then no, we actually have to show up and crush those workouts if we're going

02:05:33.400 to get the benefit. But I also think it's maintenance as well. Like what, you don't

02:05:37.520 want to have to go in and crush it every four days as we age. So I think it's also understanding what's

02:05:44.460 the outcome. We're still going to get health benefits. Well, that's kind of why I like having

02:05:46.720 the volume on my side is I don't really have to crush many workouts. I really only do one workout

02:05:52.640 a week these days. That's really hard. I'm totally with you. But how would you tell me? So I'm early

02:05:58.060 forties. Most days there are literally not enough hours in the day to get in training. So what would

02:06:04.700 you say if my goal was maintenance? Well, I mean, again, I think you mentioned your kids. One is eight,

02:06:09.400 one is 10 and you're professional and you're probably working your tail off. And so, yeah, I think

02:06:14.720 maintenance and you're in a very rare position, right? Most people at your age aren't in anywhere

02:06:20.740 near the shape that you're probably in. So yeah, for you, maintenance would be great. And I don't

02:06:24.960 want to minimize that. And I also don't want to minimize the importance of avoiding injuries and

02:06:29.040 things like that. So there has to be enough training stimulus for you to maintain muscle mass

02:06:33.880 and enough training stimulus for you to maintain peak cardiorespiratory fitness. But that still does

02:06:38.440 require some intensity. And you can probably get that with the intervals you described. I wouldn't say

02:06:44.140 that you need to be doing any more than that, for sure. Yeah. No, I mean, I think it came off like,

02:06:48.880 oh, we need to crush every workout. No, no, no, no, no. I didn't say that at all. And I don't think

02:06:52.720 you can. I don't think a 40-year-old can crush every workout. But it depends how we define crushing

02:06:57.400 it. My point is, if you've only got a couple of hours a week to exercise, I don't think most people

02:07:03.940 who have never exercised understand how hard they do need to push. Oh, sure. And the difference is,

02:07:08.860 you and I did workouts in our teens and twenties where we were left vomiting at the end of those

02:07:15.300 workouts. Like that was actually the norm. So compared to that, we're not crushing anything

02:07:19.880 today. But we're still working a lot harder than most people appreciate. And when someone is starting

02:07:26.020 from nothing today, I just want to make sure they understand if you're coming into this with very low

02:07:31.300 volume, once you get over that early adaptation, it is going to have to be quite painful.

02:07:36.780 Yeah. And it's teaching people what that good pain is. We do that a lot. And understanding that

02:07:42.800 it's not always about, sometimes it is maintenance. There's different phases of life where we change our

02:07:48.160 goals. And even more motivation to tell that, you said that 39-year-old, 40-year-old to train now,

02:07:55.160 that can go a long way so that you don't have to train as much over time or that you can do it

02:08:00.440 differently and still see a benefit. Yeah. Look, I think this is such a gift to be able to exercise.

02:08:06.320 Like it is such a remarkable stimulus, basically. And it's one thing that I think will never be

02:08:13.500 displaced by a pill. We might figure out how to displace some myokines here and there,

02:08:17.940 but I think there are far too many benefits that we get from exercise that could ever be displaced.

02:08:24.240 You're preaching to the choir, right? I agree with that.

02:08:26.340 So I think that my hope is that everybody finds their way to it. And if the most you can do is

02:08:32.620 be at six out of 10, great. I'll take six out of 10 on this front all day long.

02:08:37.960 But I guess I'm maybe speaking to a narrow subset of people who do exercise, who understand its

02:08:44.920 importance, but maybe aren't making progress because they've kind of have hit a plateau on

02:08:50.660 training stimulus. And I see this all the time, by the way, I talked to a lot of people and they

02:08:55.020 think they're doing zone two, but they're not, they're doing zone one and they're getting actually

02:08:58.920 no training effect whatsoever. It's, they're basically doing recovery workouts every single

02:09:03.200 day. People just have to understand the nuance around that. There's a line between those things

02:09:07.920 and everyone needs to understand where it is. For sure. And what's the outcome? Is it health?

02:09:12.600 Is it performance? What are our targets? Yeah. All right. Well, thank you again. This was

02:09:17.740 enjoyable. And I really love this topic in general, but I especially think it's important

02:09:22.340 for women to understand the complexity around this, because I think there is a lot of conflicting

02:09:28.120 information, probably some incorrect information. And then luckily I do think today, and maybe you'd

02:09:35.520 see this more than I do, but I do think today women are realizing the importance of resistance

02:09:40.060 training, perhaps in a way that they didn't 20 years ago. Now, when I talk to women and I ask them

02:09:45.520 what they're doing for exercise, even the ones who don't resistance train will usually follow it up

02:09:50.220 with something like, but I know I probably should be. And I don't know if I would have heard that 20

02:09:53.880 years ago. No, I think we're in a really cool space and thanks for giving some science, some light

02:09:59.640 in this space. And I think we can really empower women and not just to do cardio and do resistance

02:10:05.720 training and find a time that they can make space for it. Thank you. Thank you for listening

02:10:11.580 to this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes. If you

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The Peter Attia Drive - January 05, 2026

#378 ‒ Women's health and performance： how training, nutrition, and hormones interact across life stages ｜ Abbie Smith-Ryan, Ph.D.

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