[SPEAKER_00]: Welcome back to the Barbell Medicine podcast.
[SPEAKER_00]: I'm Dr. Jordan Fygenbaum.
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[SPEAKER_00]: All right, that's it for the pitch, onto the show.
[SPEAKER_00]: Party Pats, what's your question collar?
[SPEAKER_00]: What is your favorite cholesterol-reducing medication for the gen pop?
[SPEAKER_00]: Should I try to get the crazy monoclonal antibody that blocks the LDL receptor reuptake protein?
[SPEAKER_00]: Hey, no, so you're talking about a PCSK9 inhibitor, although the study just came out, I believe it was last week for where it showed that a PCSK9 inhibitor.
[SPEAKER_00]: It was good for primary prevention in hard to see, especially means if you've never had a hard attack, it actually prevents people from having a hard attack or it was major adverse cardiac events due to how powerful it and how the large magnitude of cholesterol lowering from that.
[SPEAKER_00]: That said, most people will do fine with a statin.
[SPEAKER_00]: It's very cheap, easy to get.
[SPEAKER_00]: Now if the question is, do you need it depends on your risk?
[SPEAKER_00]: And so, yeah, there's a lot too that we've published a lot on cholesterol lowering.
[SPEAKER_00]: Just briefly, when you think about cholesterol and its risk towards a heart disease, in this case, the risk is proportional to the exposure.
[SPEAKER_00]: Basically, that means the higher your atherogenic load and the longer you've been exposed to it, the more risk you're going to get from cholesterol.
[SPEAKER_00]: And actually, in this case, the lipoproteins that carry the cholesterol,
[SPEAKER_00]: around the body, and specifically we're talking about things like LDL, triglycerides, and anything that has an apoliproprotein B on it.
[SPEAKER_00]: These are that's your atherogenic load.
[SPEAKER_00]: And so the higher the more particles that you have,
[SPEAKER_00]: So the higher the count and the longer you're exposed to that without any sort of mitigation.
[SPEAKER_00]: The worst it is and it seems like the lower it goes the better and we're talking about lowering levels down to, you know, neonate levels.
[SPEAKER_00]: So I don't know what your levels are and this is not medical advice.
[SPEAKER_00]: This is edutainment, but lower is better and people will invariably say, no, look at this study.
[SPEAKER_00]: It's an observational study shows that people with lower cholesterol levels.
[SPEAKER_00]: 10 to there's more mortality there they die sooner and that is because there are medical conditions that actually buy virtue of that medical condition cause low cholesterol like cancers for example we'll tend to cause a lowering of cholesterol levels but when we see people who have genetic mutations that actually keep their cholesterol levels low
[SPEAKER_00]: whether or not you need a medication, that's something you should take up with your physician.
[SPEAKER_00]: I don't think starting with the PCSK9 inhibitor is what I would do.
[SPEAKER_00]: I'd probably favor a stat and plus or minus is that am I if someone needs it or something like that.
[SPEAKER_00]: But yeah, you know, some people would benefit from a PCSK9 inhibitor as well.
[SPEAKER_00]: David Rodriguez, 168.
[SPEAKER_00]: A doc, why are a lot of fitness influencers like, I think that was an auto-correct advocating for very low volume training to failure.
[SPEAKER_00]: Is this trend because high intensity is greater than hypertrophy?
[SPEAKER_00]: I think what this question is getting at is higher intensity, more productive than higher volume training for high-purture feet, and I would just say simply no, that's not really the case.
[SPEAKER_00]: Both factors are related, and so I think about this as almost like a functional threshold.
[SPEAKER_00]: For hypertrophy training, for example, there is no like minimum intensity, meaning that you could theoretically train with like as low as 30% of your one rep max or as heavy as you know 90% 85% of your one rep max.
[SPEAKER_00]: So really anything between like 3 and 23 and 25, 3 and 30 reps, if you're doing blood flow restriction stuff at the high end, the point is you have to get somewhere in your failure, right, and we're talking at least, you know, four or five reps left before you would you would get to task failure.
[SPEAKER_00]: Um, and so at that point, if once you're at that threshold, then the relationship that you see between training and hypertrophy is a dose-dependent relationship between volume.
[SPEAKER_00]: The higher the volume is, generally, the more hypertrophy people get, provided that they can tolerate it.
[SPEAKER_00]: And usually there's like an on-ramp where people are sort of getting used to it or accommodating um, towards the training load and then they start growing.
[SPEAKER_00]: Or at least we can actually pick up.
[SPEAKER_00]: the muscle growth a few weeks, a few weeks in.
[SPEAKER_00]: So like we three week for that's when you can kind of detect it.
[SPEAKER_00]: Some of that's due to the testing issue.
[SPEAKER_00]: Like how do you actually just measure a very small minute amounts of hypertrophy?
[SPEAKER_00]: But yeah, that's kind of what happens.
[SPEAKER_00]: Now, once you get north of, you know, it's definitively high volume.
[SPEAKER_00]: And admittedly there's no consensus on what is low volume, what is moderate volume, what is high volume?
[SPEAKER_00]: We're all just kind of making it up.
[SPEAKER_00]: But when you think about doing more than, let's say, 15 sets per week, 20 sets per week, certainly would qualify.
[SPEAKER_00]: At that point, the volume lever has been kind of pulled, right?
[SPEAKER_00]: It's been pulled.
[SPEAKER_00]: And for hypertrophy, at that point, then intensity is the other lever that you'd want to pull.
[SPEAKER_00]: And so taking more of those sets closer to failure would probably get you more hypertrophy than adding more volume.
[SPEAKER_00]: So that's the thing there, but advising people to do low volume intensity or low volume training to failure to be being superior to higher volume training at that functional threshold that is not consistent with the research.
[SPEAKER_00]: So it's unoption.
[SPEAKER_00]: um, just not like an optimal one and, you know, generally speaking, when I'm thinking about programming, I want people to do as much training as possible, right?
[SPEAKER_00]: And the two biggest bottlenecks are time, and then they're physiological tolerance.
[SPEAKER_00]: So, logistical tolerance, time, mostly, and then physiological tolerance.
[SPEAKER_00]: How much can they recover from?
[SPEAKER_00]: More training, generally speaking, more training
[SPEAKER_00]: generates more fitness adaptations, more health adaptations, and so on and so forth.
[SPEAKER_00]: So I'm doing less than that can work, but there's still your leaving gains on the table.
[SPEAKER_00]: Chris and Zari, what is the ideal way to regulate volume?
[SPEAKER_00]: Adjust based on if I'm seeing progressive overload or not?
[SPEAKER_00]: Oh, yeah, there's a lot to unpack here.
[SPEAKER_00]: So regulating volume insinuates that there's some sort of dynamic adjustment that needs to be made throughout a micro cycle, so like one week of training or a mesocycle, so like a training block.
[SPEAKER_00]: And I don't know that that has to happen.
[SPEAKER_00]: There are ways to do that.
[SPEAKER_00]: So for example, I could prescribe a work up to a set of five reps on the squad at RP-7 and then do three more back offsets, but terminate the set once you get RP-6.
[SPEAKER_00]: And so on a good day, you're going to do more reps, more volume, than on a day where your performance is down.
[SPEAKER_00]: That's one way to regulate volume.
[SPEAKER_00]: I like doing that if somebody's training resources and recovered resources are more dynamic.
[SPEAKER_00]: That said, the total volume doesn't actually change that much and a person who's going to like a powerlifting meat for example, and who presumably has a lot of resources to train, sometimes I worry that we're not getting enough training volume in and so in that case, I would do an alternative prescription.
[SPEAKER_00]: So that's how I would do it like within a microsycle or a mesocycle over the course of a training year or training career, volume is one of the biggest levers that we can pull to sort of manage training load.
[SPEAKER_00]: Because over time you're going to need more training load to match your new level of fitness provided it's going up, but if your fitness level's going down then you'll need less training load.
[SPEAKER_00]: Sometimes that happens.
[SPEAKER_00]: Various things that come up in life.
[SPEAKER_00]: And so, how do you know when you need to increase training load?
[SPEAKER_00]: And I think the main things that you need to focus on is one, am I still making progress or not?
[SPEAKER_00]: If you are making progress, it's really challenging for me to want to recommend a change period, any change.
[SPEAKER_00]: So, carry on.
[SPEAKER_00]: We're assuming that that improvement in progress is real and not an artifact.
[SPEAKER_00]: And so what I mean by that is, you know, day to day, your performance, my performance, everybody on this, you know, Instagram live, their performance oscillates.
[SPEAKER_00]: It ebs and flows.
[SPEAKER_00]: It goes up and down within, you know, some non-zero percentage range.
[SPEAKER_00]: There's a ceiling and a floor.
[SPEAKER_00]: Right, and I think based on the data right now that we have, it's probably somewhere between plus 5% and minus 5% that's your kind of normal range.
[SPEAKER_00]: And so I would expect people over a three week, four week more weeks.
[SPEAKER_00]: period, if the programs working for them, their strengths should trend up above that sort of ceiling.
[SPEAKER_00]: So if anything greater than a 5% gain in strength, I tend to think is real just like anything more than a 5% loss in strength that persists more than one session.
[SPEAKER_00]: I believe that is likely to be real.
[SPEAKER_00]: So we can call that our minimal clinically important difference in strength, because anything less than that, I think is mostly artifact, right?
[SPEAKER_00]: So so many is seen progress.
[SPEAKER_00]: I'm probably not changing the training.
[SPEAKER_00]: If over four weeks, five weeks, six weeks, they're not really seeing progress, then I start wondering, okay, are they overdone or are they overcooked, right?
[SPEAKER_00]: Are we cooked, chat?
[SPEAKER_00]: Or do they, are they not generate enough training stress from their current training load?
[SPEAKER_00]: And so you think about how are they sleeping, how is their motivation, any injuries, things of that nature, are they feel fatigue, or they sore all the time,
[SPEAKER_00]: And so you kind of got to weave your way through this a little bit of the art of programming.
[SPEAKER_00]: And it's an educated guess based on that sort of information.
[SPEAKER_00]: And so if you think the person is doing well with the training, they're ready most of their sessions.
[SPEAKER_00]: You know, session RP45 something low.
[SPEAKER_00]: They're not really sore, they're sleeping well, they're highly motivated to train no real injuries to speak of.
[SPEAKER_00]: Their environment is resource rich, they're ready to go.
[SPEAKER_00]: They probably could use more training load.
[SPEAKER_00]: Envolume is one way to increase that.
[SPEAKER_00]: If on the other hand, they're super sore, very fatigued, tired, not motivated, burnout, whatever.
[SPEAKER_00]: Maybe the training load was actually too high and we got to dial it down.
[SPEAKER_00]: So that is how I would, you know, you can use volume to adjust that.
[SPEAKER_00]: That's one parameter of many, right, including intensity proximity to failure exercise selection.
[SPEAKER_00]: There's a lot of different changes here.
[SPEAKER_00]: And so in the new low fatigue template, the second generation, I got a few pages on kind of how I think about this.
[SPEAKER_00]: That was maybe what a few minutes, but yeah, but there's more in that ebook that accompanies those programs and you can see how that actually shakes out any real program.
[SPEAKER_00]: So I would reference that if you have more questions on this.
[SPEAKER_00]: All right, the the the votes are in the stash works.
[SPEAKER_00]: We're going to keep it through November.
[SPEAKER_00]: It is no shave November.
[SPEAKER_00]: So, you know, we'll see how on really this thing gets.
[SPEAKER_00]: If you're just joining us, just quick little plug.
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[SPEAKER_00]: Gustavo underscore son is Pilates a valuable thing to add to training for a normal, healthy person who weight trains.
[SPEAKER_00]: Yeah, this is a great question.
[SPEAKER_00]: We have a podcast that I did on Pilates Review and the evidence on it and it's history and whatever.
[SPEAKER_00]: It is not good for virtually anything that people do exercise for.
[SPEAKER_00]: And what I mean by that, if you think about resistance training, what is the purpose of resistance training?
[SPEAKER_00]: Well, we want improved muscle quality, muscle function, increases muscle mass, so strength, hypertrophy, power, bone mineral density, right?
[SPEAKER_00]: So all of these sort of, we're applying resistance training to the human body to get all of these outcomes.
[SPEAKER_00]: Plotty is not good for that.
[SPEAKER_00]: Um, it's not good for strength, not good for hypertrophy, not good for bone mineral density, because it doesn't load the skeleton enough, um, it's not good for that.
[SPEAKER_00]: It's not good for generating cardiovascular, cardio respiratory fitness, either, and so I view it as an accoutrement.
[SPEAKER_00]: If somebody is meeting or exceeding, ideally exceeding the current physical activity guidelines, and they want to do Pilates on top of that, that's fine.
[SPEAKER_00]: It's mostly like something that they enjoy doing.
[SPEAKER_00]: It's kind of like any other recreational activity.
[SPEAKER_00]: That's how I view Pilates.
[SPEAKER_00]: It's not a training modality.
[SPEAKER_00]: It's like recreation, which is fine.
[SPEAKER_00]: If somebody's asking me, look, if I did Pilates, instead of doing more training, which is likely to get me better results, and by results, they mean muscle mass, muscle strength, bone mineral density, muscle power, balance coordination, whatever related to producing force in a coordinated manner, well, it's not very good.
[SPEAKER_00]: It's not, doesn't mean Pilates is bad.
[SPEAKER_00]: It's just, it's good at getting better at Pilates.
[SPEAKER_00]: That's it.
[SPEAKER_00]: And it's great physical activity, just like everything else.
[SPEAKER_00]: So yeah, I view it as an accoutrement, but I don't recommend it to replace real exercise.
[SPEAKER_00]: And that's maybe the most shade I'll throw at Pilates.
[SPEAKER_00]: I don't, I think it's fine.
[SPEAKER_00]: I've done Pilates before.
[SPEAKER_00]: Yes, it can be hard.
[SPEAKER_00]: There are a lot of hard things that people can do that don't really contribute to fitness.
[SPEAKER_00]: Pilates is one of them at this time.
[SPEAKER_00]: But yeah, it's certainly better than no activity, just not enough to qualify as strength training, not enough to improve muscle mass, not enough to improve cardiovascular fitness.
[SPEAKER_00]: Yeah, just recreation.
[SPEAKER_00]: Daniel Sarp is zone two cardio, really that amazing for cardiovascular fitness and health.
[SPEAKER_00]: Um, simple answer, no, a longer answer, it could be, the thing is this, if someone is advertising zone two is like this panacea that you should only do your cardio zone two because it has the most robust effect on health.
[SPEAKER_00]: We would need some better evidence to show that to be the case.
[SPEAKER_00]: And in fact, a recent study came out showing that higher intensity than zone two is more efficient at improving health than moderate intensity.
[SPEAKER_00]: So they found the vigorous physical activity, you know, depending on the health condition or written.
[SPEAKER_00]: medical condition that you're assessing risk on, vigorous intensity physical activity was four times, five times, nine times as effective as moderate intensity, physical activity would zone two would fall into.
[SPEAKER_00]: Doesn't mean that zone two's bad, zone two can be very good, and so it can be useful when people are doing high volumes of conditioning.
[SPEAKER_00]: And what I mean by that is like they're doing way more than the current physical activity guidelines, which is at least 150 minutes per week of moderate to vigorous physical activity.
[SPEAKER_00]: And so if somebody's not doing, you know, a couple of, you know, three hours, four hours, five hours of cardio per week endurance training per week, then I don't think it matters if they're doing a bunch of zone two stuff.
[SPEAKER_00]: I think it can be useful to work up the training load, the training volume, because it's not very fatiguing.
[SPEAKER_00]: So you can do more of it, but I still would expose people generally to some higher intensity work.
[SPEAKER_00]: You know, 80-20 is the traditional rule, 80% should be low and slow.
[SPEAKER_00]: Modern intensity, 20% would be higher intensity, but that's only for people that are doing a lot of cardio work.
[SPEAKER_00]: If someone's only doing 60 minutes, 90 minutes, 2 hours, 120 minutes per week.
[SPEAKER_00]: I don't think it matters.
[SPEAKER_00]: This is, I mean, I would do only sprints, but I think more vigorous activity.
[SPEAKER_00]: So it's own three, he's on four.
[SPEAKER_00]: Yeah, it's all fine.
[SPEAKER_00]: But if somebody, if we're directly comparing three hours for a week of zone two, there's three hours of zone three, I don't think there's a difference at outcomes.
[SPEAKER_00]: Three hours of zone two, there's three hours of zone four.
[SPEAKER_00]: I don't think there's a difference.
[SPEAKER_00]: That's probably too much of the higher intensity work for some folks just to tolerate.
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