WEBVTT 00:00.031 --> 00:02.294 [SPEAKER_01]: Welcome back to the Barbell Medicine podcast. 00:02.314 --> 00:05.057 [SPEAKER_01]: I'm Dr. Jordan Faganbaum and this is the direct line. 00:05.257 --> 00:09.101 [SPEAKER_01]: Are monthly ask us anything for our Barbell Medicine plus subscribers? 00:09.482 --> 00:11.544 [SPEAKER_01]: What you're hearing right now is the free preview. 00:11.804 --> 00:13.647 [SPEAKER_01]: Three questions from this month's episode. 00:14.187 --> 00:19.393 [SPEAKER_01]: First up, a mid-30s woman with bilateral shin pain wants to know if her creatine is causing it. 00:19.774 --> 00:28.924 [SPEAKER_01]: We walk through the compartment syndrome literature, the case reports that's getting passed around online and mostly missed interpreted, and what we would actually do if we saw this person in clinic. 00:28.904 --> 00:41.555 [SPEAKER_01]: Then we cover whether splitting your resistance training sessions across the day changes anything for strength and hypertrophy outcomes, and we close with endometriosis for the lifter, including what the evidence says about exercise, nutrition, and the anti-inflammatory diet claims. 00:42.156 --> 00:52.846 [SPEAKER_01]: The full episode covers a lot more at it lives on barbell medicine plus, which also gets you ad-free listening on every episode, early access to every episode, bonus podcasts, and discounts on all of our products. 00:53.526 --> 00:58.911 [SPEAKER_01]: It's 995 a month, and you can get a 30-day 01:10.923 --> 01:12.226 [SPEAKER_01]: And it helped us work through it all. 01:12.286 --> 01:13.930 [SPEAKER_01]: It's the second most handsome doctor in North America. 01:14.070 --> 01:16.256 [SPEAKER_01]: Dr. Austin Baraki, what's going on, dude? 01:16.276 --> 01:17.980 [SPEAKER_00]: That was quite a preamble. 01:18.000 --> 01:18.802 [SPEAKER_00]: A lot of set up there. 01:19.583 --> 01:20.927 [SPEAKER_00]: A lot of set up, a lot of alliteration. 01:20.947 --> 01:21.548 [SPEAKER_00]: That's for everyone. 01:22.270 --> 01:24.435 [SPEAKER_01]: Something, yeah, something the whole family can enjoy. 01:24.475 --> 01:25.537 [SPEAKER_01]: That's what we do here on the public. 01:25.558 --> 01:26.620 [SPEAKER_01]: That's in podcast. 01:27.207 --> 01:36.021 [SPEAKER_01]: All right, let's start off with this creatine question, some more elaboration there, and we're going to talk about compartments syndrome. 01:36.041 --> 01:39.907 [SPEAKER_01]: So I should have said creatine question, compartment syndrome, and maybe just get it all in there. 01:40.308 --> 01:52.227 [SPEAKER_01]: So this question asks, I started taking five grams of creatine about a month ago, and recently when I run, within the first 10 to 15 minutes, I'm getting terrible calf and shin pain and pressure in one or both legs. 01:52.347 --> 01:54.210 [SPEAKER_01]: Sometimes my foot will even go numb. 01:54.190 --> 01:57.236 [SPEAKER_01]: I've been lifting weights and running regularly prior to this. 01:57.596 --> 01:59.380 [SPEAKER_01]: I'm mid-30s woman if that matters. 01:59.820 --> 02:05.411 [SPEAKER_01]: I've read that this has been reported with creatine supplementation due to increased water retention inside the muscles. 02:05.832 --> 02:10.360 [SPEAKER_01]: Do I have to totally stop taking creatine or would it be worth trying a lower dose? 02:10.829 --> 02:27.100 [SPEAKER_01]: So this is something we actually talked about yesterday in another episode that would be released shortly, but there is a published case report linking creatine to a clinical diagnosis of the condition this woman probably has, which is called chronic exertional compartment syndrome. 02:27.080 --> 02:31.165 [SPEAKER_01]: I want to try to diagnose anybody here over the air, but it does sound like that. 02:31.445 --> 02:32.406 [SPEAKER_01]: It's this condition. 02:32.466 --> 02:38.913 [SPEAKER_01]: The way it works is that running sort of pressurizes the muscular compartments in the lower leg. 02:39.174 --> 02:50.486 [SPEAKER_01]: The sleeves of connective tissue that hold each muscle group in place, basically a tight and as pressure inside those sleeves goes up, it compresses the nerves and the small blood vessels running through them. 02:50.666 --> 02:56.513 [SPEAKER_01]: So you experience pain, and in this case the foot can go numb, 02:56.493 --> 03:00.164 [SPEAKER_01]: It makes the symptoms resolve, and the pain and numbness go away. 03:00.405 --> 03:01.729 [SPEAKER_01]: Then it comes back the next time you run. 03:01.970 --> 03:10.215 [SPEAKER_01]: I have this, not in my legs, but in my arms when I race motorcycles, particularly if I spend a bunch of time off. 03:10.448 --> 03:15.961 [SPEAKER_01]: hand will go numb, which is problematic when you're trying to operate a motor vehicle at speed. 03:17.385 --> 03:21.555 [SPEAKER_01]: Interestingly, she also fits the demographic that this happens in most often. 03:22.277 --> 03:28.592 [SPEAKER_01]: A study from 2013 by Waterman looked at 8.3 million US active duty military, 03:28.572 --> 03:29.635 [SPEAKER_01]: person years. 03:29.675 --> 03:31.059 [SPEAKER_01]: That's the fancy way of saying live. 03:31.079 --> 03:37.377 [SPEAKER_01]: A bunch of people in the military over a long period of time and found 41 hundred chronic exertional compartments in rooms. 03:38.039 --> 03:38.380 [SPEAKER_01]: Cases. 03:38.901 --> 03:44.016 [SPEAKER_01]: Female sex was an independent risk factor and so was being between the ages of 17 and 40. 03:43.996 --> 03:45.679 [SPEAKER_01]: So she does fit the demographic. 03:45.779 --> 03:47.722 [SPEAKER_01]: It does kind of sound like that. 03:48.443 --> 03:54.812 [SPEAKER_01]: And I think what we want to walk through here is what creatine actually does to like water in the body. 03:54.913 --> 04:02.584 [SPEAKER_01]: Mainly, not to say, look, creatine has no possible influence here, but just that that's not probably where I'd start, where we would start. 04:02.624 --> 04:04.147 [SPEAKER_01]: I mean, you may feel differently, Dr. Brocky. 04:04.207 --> 04:05.008 [SPEAKER_01]: We'll see. 04:05.208 --> 04:16.740 [SPEAKER_01]: So when we look at the data on what creatine does to body water, a lot of this comes from loading phases where people are taking like 20 grams of creatine per day for usually a week. 04:16.780 --> 04:22.927 [SPEAKER_01]: And the idea is that you would load creatine such that it saturates your cells faster. 04:23.348 --> 04:34.860 [SPEAKER_01]: So for example, if you just started taking three to five grams of creatine per day, versus doing a loading phase for one week first, the loading phase gets you saturated 04:34.840 --> 04:40.345 [SPEAKER_01]: by a significant period of time, in this case, significant period of a couple weeks. 04:41.000 --> 04:51.491 [SPEAKER_01]: Now, what happens during the loading phase is told a body water goes up, but the ratio of the water that's inside the cells compared to the water that's outside the cells does not change. 04:52.291 --> 04:54.694 [SPEAKER_01]: The author's own conclusion from this one is landmark papers. 04:54.994 --> 05:01.681 [SPEAKER_01]: There's no evidence that creature shifts fluid in a way that would cause problems, which we can maybe end this question here and just move on. 05:02.482 --> 05:10.990 [SPEAKER_01]: But this has been repeated in a number of positions stands by the International Society for Sports Nutrition 05:10.970 --> 05:18.447 [SPEAKER_01]: It doesn't really increase total body water, it doesn't really shift the fluid significantly and doesn't really cause dehydration or cramping. 05:20.511 --> 05:28.810 [SPEAKER_01]: There have been studies on compartment pressures where we actually measure what's going on inside the different muscular compartments. 05:28.992 --> 05:44.419 [SPEAKER_01]: For studies here, three in healthy men on loading doses again or higher, the compartment pressures tend to go up some subjects reported tightness and burning with activity, but none met diagnostic criteria for this chronic exertional compartments syndrome. 05:44.399 --> 05:48.326 [SPEAKER_01]: The Ford Studying, this is the one that's getting the most aeroplane, probably because it's the newest, is from 2025. 05:48.426 --> 05:55.179 [SPEAKER_01]: It's a case report on a runner who started creating and developed chronic exertional compartments syndrome about a month later. 05:55.419 --> 05:57.323 [SPEAKER_01]: It required surgery, which is a fast theotomy. 05:57.603 --> 05:59.427 [SPEAKER_01]: We basically take the fascia that covers the muscle. 05:59.727 --> 06:05.057 [SPEAKER_01]: You cut a hole in it or long relief in it so that muscle has room to expand. 06:05.122 --> 06:12.289 [SPEAKER_01]: The case report, the authors, they are called it an association, not a causation, but the internet usually doesn't have access to these papers for whatever reason. 06:12.529 --> 06:20.337 [SPEAKER_01]: When I see a case report behind a paywall, I also get a little myth because I'm like, guys, if anything should be free in academic literature, it should be case reports. 06:20.417 --> 06:30.927 [SPEAKER_01]: But in any case, they also didn't disclose her exact dose, the pressures of the lower limb if they were measured or training history, just one case, but yeah, people have taken this and kind of run with it. 06:30.907 --> 06:37.616 [SPEAKER_01]: And the mechanistic story does sound reasonable to me if creatine causes some sort of water retention, liquid loading. 06:38.677 --> 06:45.546 [SPEAKER_01]: And water can raise pressures, perhaps pressures in the compartments that could cause chronic exertional compartments syndrome. 06:45.566 --> 06:51.554 [SPEAKER_01]: But again, there's a lot of logical leaps in there like that ultimately don't plant a pan out. 06:52.215 --> 06:55.699 [SPEAKER_01]: Creatine doesn't really increase total body water outside of maybe a loading phase. 06:55.679 --> 07:04.113 [SPEAKER_01]: the compartment pressures are very significantly amongst individuals and none of them have met chronic exertional compartments syndrome sort of criteria. 07:04.173 --> 07:07.859 [SPEAKER_01]: So like kind of just a big red X at every every leap there. 07:08.761 --> 07:13.408 [SPEAKER_01]: So to me, I don't know that stopping creatine is the move here. 07:14.150 --> 07:22.243 [SPEAKER_01]: If this is something that happens every time you run, I think actually getting a work up by an actual sports medicine physician is a good idea, you know. 07:22.662 --> 07:26.007 [SPEAKER_01]: I wouldn't want to change anything prior just to sort of diagnose this accurately. 07:26.207 --> 07:33.358 [SPEAKER_01]: If that makes sense, it could be a typical stress fracture, something like that, or it could actually be chronic exertional compartments in Rome. 07:33.378 --> 07:35.962 [SPEAKER_01]: In which case, you'd want to measure those sort of things. 07:37.224 --> 07:40.329 [SPEAKER_01]: I don't know that DIY in this has a big risk, though, either. 07:40.709 --> 07:43.894 [SPEAKER_01]: Like, if you just stop taking a creatine that goes away, like, okay. 07:43.874 --> 07:49.022 [SPEAKER_01]: I don't know that I would blame the creatine, although again, assessing that out would require some additional diagnostic steps. 07:50.003 --> 08:08.470 [SPEAKER_01]: I don't think that dropping the dose is necessarily the greatest idea, but that's more of a mechanistic sort of hedge because we think that creatine typically has a general washout period of about a week, but the creatine saturation can stay elevated for up to four weeks, so you would need some time for that to resolve. 08:09.171 --> 08:10.894 [SPEAKER_01]: So Austin and a person like this, 08:11.768 --> 08:17.021 [SPEAKER_01]: you know, buy that or shin pain four weeks into taking creatine and get the sort of foot numbness 10 to 15 minutes in. 08:17.903 --> 08:21.913 [SPEAKER_01]: Would you say a just stop the creatine and move on with your life or would you go further with that? 08:21.978 --> 08:24.500 [SPEAKER_00]: Yeah, the context matters here quite a bit. 08:24.961 --> 08:29.945 [SPEAKER_00]: Here we have a person who is pretty young does not disclose any other associated medical history. 08:29.985 --> 08:35.850 [SPEAKER_00]: And I'd really want to characterize very specifically both the nature of the symptoms and the timing of the symptoms. 08:36.331 --> 08:45.179 [SPEAKER_00]: And so if the symptoms are really localized to the shin, that is different than if the symptoms are a little bit more localized to the calf, which is different than if they're localized to just foot numbness. 08:45.219 --> 08:47.381 [SPEAKER_00]: Like all of those things send me in very different directions. 08:47.581 --> 08:51.985 [SPEAKER_00]: Also, the fact that it is bilateral 08:51.965 --> 09:02.983 [SPEAKER_00]: And both sides onset at the same time, you know, like overall in her training course, not just like at the same time with activity, that also changes the way I think about this compared to if it was unilateral, right? 09:03.003 --> 09:14.682 [SPEAKER_00]: So like to your point about a stress fracture, like what is what's the likelihood of a bilateral symmetric, you know, temporarily, you know, simultaneous stress fractures becoming symptomatic on both sides, that lowers that probability quite a bit. 09:15.202 --> 09:19.367 [SPEAKER_00]: If it's more in the shins, then I'm more questioning like, what's the running history like? 09:19.408 --> 09:20.389 [SPEAKER_00]: How do we ramp up to this? 09:20.429 --> 09:22.832 [SPEAKER_00]: This is just like run of the bill, Shins Blint, type scenario. 09:22.852 --> 09:25.676 [SPEAKER_00]: She said her question that she's been lifting and running for a long time. 09:25.756 --> 09:32.164 [SPEAKER_00]: So assuming that there have been no dramatic changes in training load, which would be one of the questions I would get at, have we, you know, changed something? 09:32.184 --> 09:37.952 [SPEAKER_00]: Have we started doing something more, introducing sprints, much more distance, change in footwear, all sorts of other things that can be like, 09:37.932 --> 09:48.307 [SPEAKER_00]: shorter term variables that could impact this, and if the symptoms are much more, you know, calf specific and like this kind of foot numbness, that tends to raise more concerns about, well, could there be a vascular phenomenon? 09:48.807 --> 10:01.425 [SPEAKER_00]: So any kind of like exertional symptom, the no misdiagnosis is going to be something vascular, and then the neurological symptom seemingly is more of like a consequence of what else the other aspect here, which could be maybe something compressive, like a 10:01.405 --> 10:06.833 [SPEAKER_00]: you know transient exertional compressive neuropathy of some kind which could fit with the diagnosis of chronic exertional compartments syndrome. 10:06.853 --> 10:23.616 [SPEAKER_00]: So it's possible, but I'd want some more background history about like, hey, other medical history, any vascular risk factors, and then when it comes to the the history of that creatine, I agree with you like the the idea that this is like a do not pass go go directly to a physician and get a diagnosis. 10:23.596 --> 10:38.635 [SPEAKER_00]: I'm not sensing this is like an ultra immediate short term red flag if it's something that we don't seemingly are not able to to get better than that would be a reason to definitely get checked out on a shorter time frame, but you're right that DIY is at the riskiest thing either and what I mean by that is a like 10:38.615 --> 10:57.156 [SPEAKER_00]: discontinuation and re-challenge is a pretty reasonable way that even somebody who leans skeptical, which I think that like both of us just like upfront don't typically associate creatine with this sort of a manifestation, we might tend skeptical on that, but if somebody says, look, I was running and lifting, doing everything fine, I kept doing the same thing, I introduced creatine, this came on. 10:57.477 --> 10:58.058 [SPEAKER_00]: We're like, ah, 10:58.038 --> 11:03.007 [SPEAKER_00]: Okay, tough to say for sure than like then I stopped it in it went away Then I took started taking in and the same thing came back. 11:03.087 --> 11:19.135 [SPEAKER_00]: It's like, okay, I relent I don't have a full explanation for why some of these things are plausible even though there's not like this super compelling like so much more You know intracidular or extracidular fluid accumulation, you know specific to creating but you've given me enough of a reason and it's like 11:19.115 --> 11:25.708 [SPEAKER_00]: Ultimately, do I care more about your ability to do the conditioning that you like to do running or being on a couple grams of creatine a day? 11:25.929 --> 11:29.636 [SPEAKER_00]: The benefits of creatine are modest to arguably trivial for most. 11:30.157 --> 11:36.089 [SPEAKER_00]: The benefits of even running a couple, you know, a little bit, probably already outweigh the benefits you're getting from creatine. 11:36.109 --> 11:38.895 [SPEAKER_00]: So I'd rather you be able to run and I would just like lean in that direction. 11:39.095 --> 11:57.355 [SPEAKER_01]: Yeah, yeah, I mean, I think about if somebody is vulnerable to a like a compartment syndrome type experience, right, perhaps a subtle shift in fluid maybe does that or other changes that co-occur when somebody takes creatine, perhaps dietary pattern changes, they're training loads. 11:57.635 --> 12:03.882 [SPEAKER_01]: There's obviously a lot of variables here, but ultimately like if someone's like, I'm just gonna quit the creatine and see what happens, I'd be like, fine, that's fine. 12:04.343 --> 12:08.427 [SPEAKER_01]: But when somebody tells me the story and I start thinking about, well, what could it be? 12:08.407 --> 12:18.430 [SPEAKER_01]: Okay, it kind of smells like sounds like compartments in room, but what if there's an orthopedic issue or what if there's a vascular issue or neurological issue and I'm like, well, I don't wouldn't want to miss those. 12:18.771 --> 12:26.027 [SPEAKER_01]: And so to the extent delaying the diagnosis versus with the like a withdrawal and re-challenge thing, I'm like, I don't know, I don't know, I don't 12:26.260 --> 12:33.859 [SPEAKER_01]: that outside of the vascular thing is like the no miss and then I don't really want to say that on air because it does seem like really risky. 12:33.879 --> 12:39.974 [SPEAKER_00]: Yeah, so much of that thought process in response was based on the context that we know about this person. 12:40.395 --> 12:43.442 [SPEAKER_00]: Otherwise, 12:43.422 --> 12:52.396 [SPEAKER_00]: If you turn this into like a 60 year old, whether they smoked or not, I'm like, not, we need to get you checked out because this could be like a qualification manifestation, you need a more thorough vascular email or something like that. 12:52.456 --> 12:59.907 [SPEAKER_00]: It's not to say that younger people can't have some kind of like vascular disease that can manifest with qualification or like neurogenic pseudo-clodication or something like that. 12:59.927 --> 13:01.870 [SPEAKER_00]: Like any of those are possible, just not very likely. 13:02.271 --> 13:08.400 [SPEAKER_00]: And so I would first probably trial, discontinuation see what happens and if it persists, then it's like, okay, that wasn't it. 13:08.440 --> 13:09.501 [SPEAKER_00]: Now we can date a little deeper. 13:09.602 --> 13:10.543 [SPEAKER_00]: That's a, I think, a, 13:10.523 --> 13:16.216 [SPEAKER_00]: from what I'm sensing here probably a reasonable way to go, but if somebody said I want to get checked out sooner, also fine. 13:16.236 --> 13:17.820 [SPEAKER_01]: This is for Infotainment purposes only. 13:17.860 --> 13:18.802 [SPEAKER_01]: There are your doctors. 13:18.882 --> 13:20.346 [SPEAKER_01]: We are doctors, but yeah. 13:20.646 --> 13:21.428 [SPEAKER_01]: Yeah. 13:21.982 --> 13:25.565 [SPEAKER_01]: All right, next question is about splitting up resistance training sessions. 13:25.826 --> 13:34.033 [SPEAKER_01]: So the question is, if I have three resistance training movements planned for the day, but due to certain logistical issues, I split them up hours apart sometimes. 13:34.493 --> 13:36.876 [SPEAKER_01]: Does that affect strength and high-purchary over the long run? 13:37.376 --> 13:49.407 [SPEAKER_01]: I would assume maybe you are getting less fatigue resistance adaptations, but if I'm doing the three sets from my bench press, I would assume that doing the leg press two hours later is not impacting strength and size for either of them. 13:49.977 --> 13:50.698 [SPEAKER_01]: Yeah, that's fine. 13:50.718 --> 13:53.160 [SPEAKER_01]: So just move on to the next question. 13:53.180 --> 14:19.427 [SPEAKER_01]: But I actually think though, we don't need to do a deep dive on this per se, but I do think some insight into my general heuristic, our general heuristics about training, maybe useful, just to answer these sorts of questions, going forward, I think you would agree that our role as coaches or our program, like our templates, like what they're designed to do, 14:19.407 --> 14:24.361 [SPEAKER_01]: We want people to do as much physical activity as possible, and including formal exercise. 14:24.622 --> 14:34.108 [SPEAKER_01]: And the idea is because there's a dose response relationship between the amount of exercise that people do, and the benefits from it not only health benefits, but also performance benefits, obviously. 14:34.291 --> 14:39.178 [SPEAKER_01]: In this case, frequency is a tool to distribute that training load. 14:40.080 --> 14:42.463 [SPEAKER_01]: So you could jam a given amount of training. 14:42.543 --> 14:51.496 [SPEAKER_01]: Again, if you just have this list of 20 exercises needed to do, you could put it on one day, two days, three days, four days, five days, seven days, split it up, however you want. 14:51.657 --> 14:56.704 [SPEAKER_01]: We think frequencies are tool to distribute that based on your preferences, logistical constraints, etc. 14:57.393 --> 15:07.944 [SPEAKER_01]: When you look at the evidence on frequency, as its own, like sort of independent variable here, it almost disappears entirely when you look at training adaptations that we care about. 15:08.224 --> 15:11.668 [SPEAKER_01]: Strength, hypertrophy, power, cardiovascular fitness. 15:12.089 --> 15:18.355 [SPEAKER_01]: In fact, the majority of the time when it does show up as an individual variable, it's because they have not corrected for volume. 15:18.716 --> 15:21.038 [SPEAKER_01]: Total amount of training that gets done. 15:21.018 --> 15:28.316 [SPEAKER_01]: And so, you know, the prime example of this is one of Shownfeld's initial meta analyses on this from 2016 to 10 studies. 15:29.098 --> 15:37.158 [SPEAKER_01]: And they said that the weekly volume was equated in the higher frequency groups grew about 3% more and 3% more on average. 15:37.178 --> 15:38.622 [SPEAKER_01]: Now, as it turns out, 15:38.939 --> 15:40.521 [SPEAKER_01]: the volume was not actually equated. 15:40.561 --> 15:48.488 [SPEAKER_01]: And when they updated them that analysis in 2019, this time with 25 studies, the volume was better equated and everything disappeared. 15:48.528 --> 15:49.870 [SPEAKER_01]: The high-purchary difference disappeared. 15:50.130 --> 15:54.294 [SPEAKER_01]: See the same thing, Edgar Jix, 22, 22 study on strength. 15:55.796 --> 15:59.579 [SPEAKER_01]: Mainly, there was a signal when people went from one time per week of doing strength training. 15:59.739 --> 16:00.780 [SPEAKER_01]: Some multiple times per week. 16:00.801 --> 16:03.103 [SPEAKER_01]: Their strength has seemed improved, because they were doing more training. 16:04.144 --> 16:05.385 [SPEAKER_01]: I do think, though, 16:05.365 --> 16:15.258 [SPEAKER_01]: This is maybe where I go against the evidence and I recall back to like a 2018 seminar that we did when that someone was like what opinion do you hold or believe that you hold is like not evidence based. 16:15.499 --> 16:22.388 [SPEAKER_01]: Yeah, I actually do think there's something maybe to an increased frequency because not just from adherence. 16:22.528 --> 16:30.799 [SPEAKER_01]: I do think that's probably the number one use case is like look if I could split it up seven days a week and that's better for me adherence that's number one maximizes training load fits with the heuristic. 16:31.910 --> 16:36.777 [SPEAKER_01]: But imagine a scenario where I took all of your deadlift volume. 16:36.797 --> 16:38.880 [SPEAKER_01]: I don't know how many sets per week you're deadlifting right now. 16:39.220 --> 16:40.121 [SPEAKER_01]: Let's just say it's 10. 16:40.422 --> 16:41.483 [SPEAKER_01]: Nice, nice and neat. 16:41.503 --> 16:42.745 [SPEAKER_01]: And I put that all on one day. 16:43.546 --> 16:45.829 [SPEAKER_01]: Verse, I split that up over two days or three days. 16:46.690 --> 16:49.795 [SPEAKER_01]: I suspect that your actual training load is going to be higher. 16:49.855 --> 16:53.580 [SPEAKER_01]: The more I split that up, do to intro work out fatigue. 16:53.560 --> 16:54.041 [SPEAKER_01]: Right? 16:54.361 --> 16:58.306 [SPEAKER_01]: You're going to be able to lift a little more weight a little more reps that are given RPE if I split it up. 16:58.687 --> 17:11.223 [SPEAKER_01]: And so the training load, yeah, on a one week basis is not that much different, but it's a little different two weeks, you know, total if we summed it together, a little bit more different, eight weeks, 16 weeks, that sort of difference grows, right? 17:11.284 --> 17:17.712 [SPEAKER_01]: And so the training load that you're able to accumulate over a year of, for example, is 17:17.692 --> 17:18.614 [SPEAKER_01]: potentially much greater. 17:19.295 --> 17:25.946 [SPEAKER_01]: And also to the extent that you're training these things in a more fresh state might allow for some additional skilled development. 17:25.966 --> 17:27.629 [SPEAKER_01]: I feel like it's not an evidence-based take. 17:27.669 --> 17:32.577 [SPEAKER_01]: I mean, I can herring the data and try to come up with a rationalization, but I don't know. 17:32.597 --> 17:33.659 [SPEAKER_01]: Let's where I kind of go off the rails. 17:33.719 --> 17:34.941 [SPEAKER_01]: What do you think about that? 17:35.090 --> 17:36.852 [SPEAKER_00]: Yeah, I think we've kind of shared that opinion. 17:37.113 --> 17:43.521 [SPEAKER_00]: More so for what we've deemed movements that are a little bit more sensitive to skill components, potentially being won on that aspect. 17:43.561 --> 17:49.629 [SPEAKER_00]: Like, I think what both of us have either are selves trained more for example, for overhead pressing or coached people. 17:50.170 --> 17:54.215 [SPEAKER_00]: I mean, I remember coaching Alan through all for a while when he was preparing for that sort of thing. 17:54.235 --> 17:58.621 [SPEAKER_00]: And I think I had impressing overhead somewhere between five to seven days a week. 17:59.362 --> 18:04.168 [SPEAKER_00]: And sometimes it was as much as just like set a eight minute timer and work up to a single, just to get a little, 18:04.148 --> 18:10.177 [SPEAKER_00]: practice exposure, making sure that you're, you know, very skilled and adept with the movement pattern and all that kind of thing. 18:10.197 --> 18:13.822 [SPEAKER_00]: And it's a relatively low fatigue thing overall, so you can get that frequency of exposure. 18:14.323 --> 18:18.850 [SPEAKER_00]: And then the other aspect, the kind of the quote unquote bigger heavier lifts distributing things. 18:19.351 --> 18:28.625 [SPEAKER_00]: Yeah, if you're splitting up those sets, it's a much more daunting task to look at if I don't ever do something like this, but to do like 10, you know, working sets of deadlift in a session versus pulling twice a week. 18:28.645 --> 18:33.632 [SPEAKER_00]: We've done for years and chemilatively ended 18:33.612 --> 18:46.648 [SPEAKER_00]: Even if it's the similar load, but you're able to put a bit more effort or maintain a bit higher volitional bar velocity or something, there's maybe something to the idea that you can get a little bit more out of it even if it's just from the neurological kind of aspect of the strength adaptation. 18:46.668 --> 18:55.418 [SPEAKER_00]: So I think that's kind of what we feel in our gut about this even if it has not yet been born out in the research and admittedly it might be a little difficult to study because of 18:55.398 --> 18:57.560 [SPEAKER_00]: there's you know it's just a messy landscape. 18:57.580 --> 18:58.981 [SPEAKER_00]: There's a lot of granularity here. 18:59.082 --> 19:00.963 [SPEAKER_00]: There's differences in individual responsiveness. 19:01.063 --> 19:11.994 [SPEAKER_00]: You need to be able to have enough power to tease apart small differences between groups or you need to run the trial long enough to accrue big enough differences that you can detect if you're sent you know if your size is relatively small. 19:12.014 --> 19:21.363 [SPEAKER_00]: So tough to study, tough to prove, born out in our experience to some extent, but we ourselves discount our own experience in a lot of ways just because we know that how good humans aren't fooling themselves. 19:21.423 --> 19:23.785 [SPEAKER_00]: So that's that's about as far as I would take it. 19:23.967 --> 19:43.360 [SPEAKER_01]: Yeah, I think the only other wrinkle here is that where I kind of go off the reservation with respect to the evidence is that when it's with respect to cardiovascular fitness, the same sort of relationship shows up where like the frequency doesn't seem to matter and in fact when you look at the guidelines over time, you know, originally there was a sort of 10 minute cat. 19:43.340 --> 19:52.174 [SPEAKER_01]: where you had to accumulate exercise in at least 10 minute bouts, and then it was five minute bouts, and now that re-restriction that cap has been completely removed. 19:52.194 --> 19:55.800 [SPEAKER_01]: It's like, look, even a one minute, bout of exercise counts, right? 19:56.141 --> 20:10.444 [SPEAKER_01]: And I'm like, okay, while true, I do believe that these exercise snacks, if you want to call them that, many episodes of exercise certainly contribute to total exercise load and certainly can be useful for improving health and fitness. 20:10.711 --> 20:39.069 [SPEAKER_01]: But if I was trying to maximize somebody's cardiovascular fitness, I lean towards, look, you're going to need some longer sessions in there and I don't think that you could do like a two minute bout every hour on the hour every day to and get the same net effect than if you concentrated that mainly, I mean you can cardiac drift in the middle of a session, the rate limiting demands, you know, our steps for the metabolic demands that you're imposing on a person go up as the session gets a little longer things just change. 20:39.089 --> 20:39.570 [SPEAKER_01]: And so, 20:41.086 --> 20:42.548 [SPEAKER_01]: there's something there. 20:42.568 --> 20:43.329 [SPEAKER_01]: But I can't prove it. 20:43.729 --> 20:45.731 [SPEAKER_01]: And so, you know, watch this space, I guess. 20:47.313 --> 20:47.573 [SPEAKER_01]: I don't know. 20:47.593 --> 20:47.694 [SPEAKER_01]: Yeah. 20:47.714 --> 20:47.934 [SPEAKER_01]: All right. 20:48.154 --> 20:51.057 [SPEAKER_01]: Next question is about endometriosis for the lifter. 20:51.638 --> 20:57.205 [SPEAKER_01]: Question is, would you consider doing a dedicated episode on endometriosis, and nutrition, and fitness? 20:57.745 --> 21:02.371 [SPEAKER_01]: I love the one regarding PCOS, now PMOS, and learned a lot. 21:02.391 --> 21:10.620 [SPEAKER_01]: But as an endometriosis, endometriosis suffer and also high level competitive power lifter, I would love a 21:11.140 --> 21:12.005 [SPEAKER_01]: Fine, you know what? 21:12.548 --> 21:13.634 [SPEAKER_01]: You've badgered us into doing it. 21:13.654 --> 21:16.510 [SPEAKER_01]: This was actually on our radar, but now, you know. 21:16.709 --> 21:18.231 [SPEAKER_01]: Maybe a little bit more timely. 21:18.251 --> 21:23.158 [SPEAKER_01]: We're doing a menopause series right now and can commit to doing one on endometriosis as well. 21:23.498 --> 21:24.640 [SPEAKER_01]: I didn't want to briefly talk about Exxon. 21:24.660 --> 21:27.364 [SPEAKER_01]: I don't think we've discussed this in any detail. 21:27.404 --> 21:32.130 [SPEAKER_01]: So we'll do a little primer here and then save the rest for our full episode. 21:32.991 --> 21:40.882 [SPEAKER_01]: One thing, you know, I did a little bit of a research review probably about a year ago thinking about doing this and somehow primed to do it again. 21:40.982 --> 21:41.603 [SPEAKER_01]: But, 21:42.089 --> 21:43.631 [SPEAKER_01]: one crazy statistic here. 21:44.312 --> 21:52.402 [SPEAKER_01]: Andometriosis takes almost seven years on average to diagnose symptoms can get normalized or dismissed at bad periods. 21:52.823 --> 21:54.926 [SPEAKER_01]: Primary care often misses this unfortunately. 21:55.546 --> 21:57.829 [SPEAKER_01]: And so you're right about the problem. 21:57.889 --> 22:00.192 [SPEAKER_01]: Like it is a significant issue. 22:00.473 --> 22:04.057 [SPEAKER_01]: And the fact that it takes so long to get diagnosed, that's problematic. 22:04.177 --> 22:11.607 [SPEAKER_01]: So yeah, we'll do a full episode, probably this summer specific to the liftor. 22:11.587 --> 22:15.955 [SPEAKER_01]: Well, this is tissue that is similar to the uterine lining growing outside of the uterus. 22:16.496 --> 22:17.218 [SPEAKER_01]: It's chronic. 22:17.418 --> 22:20.023 [SPEAKER_01]: It's estrogen responsive and it's inflammatory. 22:20.324 --> 22:30.523 [SPEAKER_01]: Roughly, one in 10 reproductive age women have it up to half of women with infertility, have it, and up to 90% of women with chronic pelvic pain have it. 22:30.503 --> 22:39.119 [SPEAKER_01]: The 2022 European guideline made a change that a lot of clinicians have not caught up to that laparoscopy is no longer required to diagnose it. 22:39.219 --> 22:41.202 [SPEAKER_01]: You can do with skilled ultrasound or MRI. 22:42.325 --> 22:46.993 [SPEAKER_01]: Those are sufficient to start medical treatment when imaging matches the clinical picture. 22:47.092 --> 22:50.137 [SPEAKER_01]: Now, that's one of the bigger changes that's happened in the last few years. 22:50.658 --> 22:54.686 [SPEAKER_01]: Now, no study has shown that heavy resistance training worsens endometriosis. 22:55.367 --> 23:00.997 [SPEAKER_01]: Recent reviews show what we call low certainty evidence that exercise reduces pain. 23:01.377 --> 23:03.862 [SPEAKER_01]: So, we could oversell that here on the Barrel Medicine podcast. 23:03.902 --> 23:09.572 [SPEAKER_01]: Look, just exercise and you won't have endometriosis pain, but that wouldn't really be in keeping with what the literature says. 23:09.552 --> 23:18.527 [SPEAKER_01]: Similarly, on cycle, menstrual cycle and performance, the literature is consistent, the average effect of cycle phase on performance is trivial. 23:19.008 --> 23:20.310 [SPEAKER_01]: Basically, it's individual variation. 23:20.350 --> 23:24.056 [SPEAKER_01]: Some people are going to have their own unique lived experience and it is what it is. 23:24.457 --> 23:30.447 [SPEAKER_01]: But on average, most people will not see a performance benefit or decrement based on where they're at in the menstrual cycle. 23:30.562 --> 23:43.599 [SPEAKER_01]: We'll save any of the hormonal management stuff for our full episode, but the rest of our question sheet sheet pointed out a few interesting things with respect to like these nutrition narratives that get kind of promoted around enemy triosis. 23:44.039 --> 23:48.665 [SPEAKER_01]: There are no dietary interventions that have high quality evidence for modifying endometriosis. 23:48.946 --> 23:54.493 [SPEAKER_01]: So things like a gluten-free diet, uh, you most of those have no control groups and are unblinded. 23:54.473 --> 24:07.428 [SPEAKER_01]: And so, in this case, any benefit, we would say, the person might have a silly act or sort of a gluten, you know, non-silly act, gluten in sensitivity, but we need better data to show gluten free actually does something. 24:08.790 --> 24:17.380 [SPEAKER_01]: People may often have IBS where like a low-fod map diet could be useful, and I can overlet people can have two things. 24:17.620 --> 24:23.147 [SPEAKER_01]: For example, but it's not really a dietary pattern for enemy triosis. 24:23.296 --> 24:43.397 [SPEAKER_01]: When I think about unique nutrition sort of recommendations here, I really comes back to iron one of your pet earpets or topic here with Anemia, mainly because heavy bleeding is common with this condition and so and also the issue around ferritin, monitoring people are doing that and like, oh well you're with the normal range, your ferritin is 20 and you're like, 24:43.816 --> 24:46.447 [SPEAKER_01]: That doesn't, yeah, not, not normal. 24:46.849 --> 24:51.268 [SPEAKER_01]: Yeah, so, you know, the protein recommendations are the same as we've been saying for a long time. 24:51.368 --> 24:53.758 [SPEAKER_01]: Somewhere around 1.6 grams per kilo per day. 24:54.127 --> 25:08.849 [SPEAKER_01]: low carbohydrate diets don't tend to do better and particularly if you're an athlete, low carbohydrate diets would generally be ill-advised and then ultimately making sure that the person's getting enough energy to not only support a healthy body composition, but also what they're asking their body to do. 25:09.691 --> 25:20.607 [SPEAKER_01]: I don't see any evidence that low energy availability is more common in individuals with endometriosis compared to not, but again, just generally speaking female athletes that 25:20.587 --> 25:33.826 [SPEAKER_01]: As far as how this should affect training, you know, one of the benefits of having an auto-regulated program is that it's pretty much a useful tool for almost any condition and that includes certainly enemy triosis. 25:34.066 --> 25:47.184 [SPEAKER_01]: People with symptomatic days, you know, your performance might be down due to what you're experiencing and ultimately having a dynamically adjusting program is going to be better than something that is fixed rigid on paper. 25:47.565 --> 25:50.509 [SPEAKER_01]: But again, that's not unique 25:50.489 --> 25:52.292 [SPEAKER_01]: the human experience generally speaking. 25:52.692 --> 26:04.769 [SPEAKER_01]: I do think that as people have either medical conditions or things that otherwise affect their performance more with more volatility, so whether it's bad sleep, more stress, et cetera. 26:04.789 --> 26:10.337 [SPEAKER_01]: That just means there's more importance placed on that dynamically, so adjusting program. 26:10.317 --> 26:14.263 [SPEAKER_01]: One interesting note here is like post-op. 26:14.283 --> 26:22.134 [SPEAKER_01]: Like if people do have a laparoscopy, for example, for diagnosis, the return to activity is based on vibes. 26:23.155 --> 26:24.357 [SPEAKER_01]: Just an expert opinion at this point. 26:24.877 --> 26:27.541 [SPEAKER_01]: So they're suggesting walking within 24 to 48 hours. 26:28.102 --> 26:30.806 [SPEAKER_01]: Start lifting some light weights within the first two weeks. 26:31.186 --> 26:33.810 [SPEAKER_01]: They say no vowel salvo, which is silly because 26:34.769 --> 26:36.552 [SPEAKER_01]: good luck avoiding that. 26:37.434 --> 26:40.419 [SPEAKER_01]: And then, you know, compoundless, you know, weeks two to four. 26:41.441 --> 26:49.234 [SPEAKER_01]: I don't know how I feel about that, but I also am not pushing back strongly against a lot of these post-op sort of things because it's such a short period in somebody's training life. 26:49.254 --> 26:53.842 [SPEAKER_01]: I'm like, look, if it's not going to matter in a year or two years, five years, I don't really care. 26:55.765 --> 26:59.612 [SPEAKER_01]: The other thing, I won't get you take on this for ask you a clinical, clinical question. 27:00.082 --> 27:07.099 [SPEAKER_01]: So imagine a person with endometriosis they are competitive, lifter, but they're not on any sort of continuous medical management. 27:07.500 --> 27:14.537 [SPEAKER_01]: And they've got to meet coming up and they're like, look, I think this is gonna time up with my heaviest bleeding days. 27:14.577 --> 27:17.584 [SPEAKER_01]: My typically experienced a lot of symptoms here. 27:18.155 --> 27:20.079 [SPEAKER_01]: Can I take something for that? 27:20.440 --> 27:34.932 [SPEAKER_01]: And so there's some thought that, like, short-term medical management a few days before expected the menstrual cycle delays the menstrual cycle through the meat, like an off-label used, do you feel like that's a terrible idea or viable option? 27:34.912 --> 27:35.593 [SPEAKER_00]: Totally viable. 27:35.873 --> 27:36.053 [SPEAKER_00]: Yeah. 27:36.574 --> 27:41.900 [SPEAKER_00]: I mean, I'm thinking about as I usually do with interventions does the potential benefits outweigh the potential risks. 27:42.140 --> 27:46.766 [SPEAKER_00]: And, you know, those types of treatments are often used for a long-term management of this anyway. 27:46.946 --> 27:55.997 [SPEAKER_00]: And so if there's not been on something like that and they're wanting to temporarily use it for better control going into like a high stakes to them event, totally fair, reasonable. 27:56.197 --> 27:56.718 [SPEAKER_00]: Yeah. 27:56.738 --> 27:57.619 [SPEAKER_00]: Yeah. 27:57.639 --> 27:57.919 [SPEAKER_00]: All right. 27:57.999 --> 27:59.721 [SPEAKER_01]: So here's a clinical question. 27:59.836 --> 28:03.184 [SPEAKER_01]: patient walks in, Dr. Barackie, biopsy confirmed enemy triosis. 28:03.204 --> 28:03.925 [SPEAKER_01]: They're a power lifter. 28:03.945 --> 28:07.413 [SPEAKER_01]: There's six months into hormonal treatment, pain's doing better. 28:08.295 --> 28:12.545 [SPEAKER_01]: But a menopause style influencer has around a supplement stack and an anti-inflammatory diet. 28:12.926 --> 28:14.630 [SPEAKER_01]: She wants to know whether to keep following that advice. 28:15.231 --> 28:16.073 [SPEAKER_01]: Where do you go from there? 28:16.829 --> 28:20.915 [SPEAKER_00]: Yeah, this certainly something else that I encounter somewhat regularly. 28:20.995 --> 28:41.908 [SPEAKER_00]: Endometriosis is a very common underdiagnose can be first, you know, varying severity in different patients for some very debilitating for others less so it is also just straight up one of the absolute weirdest conditions that exists in medicine, you know, so difficult to like explain like why on earth. 28:41.888 --> 29:04.032 [SPEAKER_00]: or do we find like, you know, one of the, one of the, some of the weirder examples of like uterine tissue that's ended up in the plural lining around the lungs, there's a, you know, uncommon condition that called cataminial pneumothorax, for example, where, you know, every month when the woman menstruates, it leads to a collapsed lung, for example, because of the endometriosis tissue in the plural space or. 29:04.012 --> 29:11.246 [SPEAKER_00]: I heard another case of cyclical bleeding out of this woman's belly button because she had an endometrioma implant right there. 29:11.407 --> 29:13.551 [SPEAKER_00]: And so it's like blood every month in that spot. 29:13.591 --> 29:16.296 [SPEAKER_00]: Like very, very weird types of things that can emerge. 29:16.396 --> 29:19.242 [SPEAKER_00]: And so they're all the point I'm making is that they're all unique. 29:19.362 --> 29:21.767 [SPEAKER_00]: And so every woman's experience with this, 29:21.747 --> 29:37.789 [SPEAKER_00]: is likely to be unique upon where are these endometrial implants, and what is the cyclic nature, like what are the symptoms that are manifesting, that you can get ridiculous quote unquote sciatica pain from an endometrial implant on your sciatica nerve, essentially, and they'd be like cyclical, or ridiculous pain, for example. 29:37.809 --> 29:43.717 [SPEAKER_00]: So it's just fundamentally weird, and that's why it needs to be so individualized, and dealt with by somebody who's experienced in managing it. 29:44.538 --> 29:47.883 [SPEAKER_00]: Whether medically or surgically, or both, there's a lot of treatment options. 29:48.043 --> 29:51.568 [SPEAKER_00]: They're improving as time goes on, 29:51.548 --> 30:11.413 [SPEAKER_00]: Unsurprisingly, we'll continue to sound like chills to some extent, but have seen at least in a fraction of these patients some improvements when I've been using GLP1 agonists, of course, that's to treat concomitant weight management challenges, but does seem like there might be some anti-inflammatory effects of those medicines to whatever extent it's from the medicine or from the weight loss that happens, et cetera. 30:11.393 --> 30:16.760 [SPEAKER_00]: But to get to the main crux of this question, the supplement stack, I would just have to go through supplement by supplement and see again. 30:16.860 --> 30:17.902 [SPEAKER_00]: What is the theory? 30:17.922 --> 30:18.663 [SPEAKER_00]: What is the idea? 30:18.763 --> 30:21.206 [SPEAKER_00]: Is it potential offering any potential benefit? 30:21.286 --> 30:22.308 [SPEAKER_00]: What's the potential downside? 30:22.328 --> 30:23.409 [SPEAKER_00]: Does it seem safe? 30:23.429 --> 30:26.013 [SPEAKER_00]: Is it a battle worth fighting that day in the bigger picture? 30:26.093 --> 30:29.277 [SPEAKER_00]: And maybe so, maybe not, depending on what kind of rapport I have with this person. 30:30.479 --> 30:35.545 [SPEAKER_00]: But the anti-inflammatory diet, I actually don't get terribly fired up over this unless it's just something totally wacky. 30:36.066 --> 30:41.333 [SPEAKER_00]: I'd like to get a sense of, well, what is this actual diet? 30:41.313 --> 30:47.844 [SPEAKER_00]: The general pattern is that following general health improving behaviors tends to improve chronic health conditions. 30:47.984 --> 30:53.593 [SPEAKER_00]: And so if this quote unquote anti-inflammatory diet, if I look at it and I'm like, yeah, that looks like a pretty healthy diet. 30:53.893 --> 30:56.197 [SPEAKER_00]: And you want to slap a label on it and call it anti-inflammatory. 30:56.398 --> 30:57.319 [SPEAKER_00]: That's totally fine. 30:57.820 --> 31:05.012 [SPEAKER_00]: But that's also not fundamentally different than maybe the generally healthy dietary pattern that I'd recommend to anyone, regardless of whether they had endometriosis or not. 31:05.152 --> 31:08.417 [SPEAKER_00]: I think where we kind of take an issue with this a little bit is like, oh, 31:08.397 --> 31:19.463 [SPEAKER_00]: there's a specific endometriosis diet that you need, similar to like there's a specific endometriosis program, which hopefully based on what I just described earlier, like every phenotype of endometriosis is different from the next. 31:19.563 --> 31:25.798 [SPEAKER_00]: There can't be a single endometriosis exercise program because their symptoms and manifestations are going to vary. 31:25.778 --> 31:34.227 [SPEAKER_00]: But if the idea is like, hey, we should eat a generally health-promoting dietary pattern, which is to be clear, anti-inflammatory, compared with unhealthy dietary patterns. 31:35.008 --> 31:40.254 [SPEAKER_00]: We should get regular exercise based on the person's preferences and goals and tolerance and capacity and things like that. 31:40.294 --> 31:41.135 [SPEAKER_00]: We should get good sleep. 31:41.175 --> 31:48.883 [SPEAKER_00]: We should use medications when clinically appropriate, for example, for weight management, for other metabolic health aspects, things like that that can... 31:48.863 --> 31:54.129 [SPEAKER_00]: all feed into improving the general healthy milieu to use your one of your preferred terms. 31:54.669 --> 31:57.412 [SPEAKER_00]: That is likely to improve all sorts of chronic painstates. 31:57.472 --> 32:01.277 [SPEAKER_00]: Now, will it dramatically improve every case of persistent pain from this? 32:01.477 --> 32:01.677 [SPEAKER_00]: No. 32:02.158 --> 32:05.121 [SPEAKER_00]: Will it take pain from a score of nine or 10 to a score of zero? 32:05.201 --> 32:07.944 [SPEAKER_00]: No, but it is a step along the way towards improvement. 32:08.044 --> 32:12.609 [SPEAKER_00]: While the other more targeted treatments might have an opportunity to offer benefit. 32:12.649 --> 32:13.470 [SPEAKER_00]: That might be 32:13.450 --> 32:16.095 [SPEAKER_00]: something as simple as a combined oral contraceptive. 32:16.135 --> 32:19.080 [SPEAKER_00]: It might be a GNRH, Agnist or Antagonist. 32:19.100 --> 32:21.043 [SPEAKER_00]: It might be certain other kind of targeted therapies. 32:21.103 --> 32:23.668 [SPEAKER_00]: It might be surgical excision of endometrial implants. 32:24.168 --> 32:39.154 [SPEAKER_00]: And then as we move along in time, you know, there's more and more attention being given to this and certainly again as one of the more pervasive, more challenging and certainly one of the exceptionally weird medical conditions that exist hopefully some even better treatments kind of come forth over time. 32:39.455 --> 32:47.208 [SPEAKER_01]: Yeah, yeah, I think that that little that line about, you know, you're not pushing back on the anti-inflammatory diet most of the time, you don't get too fired up about it. 32:47.989 --> 32:52.877 [SPEAKER_01]: I am similar in that and same thing with like a supplement stack as long as it's not BS. 32:53.398 --> 32:56.704 [SPEAKER_01]: You know, I'm saying, so like, if someone's like, I'm on a anti-inflammatory diet, I'm like, oh, what does that mean? 32:56.924 --> 32:59.488 [SPEAKER_01]: And they're like, well, I don't need any carbs because carbs are inflammatory. 32:59.508 --> 33:00.450 [SPEAKER_01]: I'm like, 33:00.430 --> 33:02.393 [SPEAKER_01]: Okay, well, now I'm going to take nomad to issue, right? 33:02.693 --> 33:05.497 [SPEAKER_01]: It's almost like on a supplement second and I'm like, okay, like, what is it? 33:05.517 --> 33:07.559 [SPEAKER_01]: An endometriosis specific supplement stack. 33:07.579 --> 33:09.141 [SPEAKER_01]: And they're like, sure, it's protein and creatine. 33:09.161 --> 33:12.105 [SPEAKER_01]: I'm like, oh, okay, yeah, like, can you carry on? 33:12.325 --> 33:22.759 [SPEAKER_01]: You know, man, but like the further it, you know, diverges from what we have good evidence on, or potentially the more harm it could cause, whether it's through a restricted eating pattern, in the case of the diet. 33:22.739 --> 33:44.342 [SPEAKER_01]: a low energy availability in case the diet or like, you know, supplement contamination or otherwise, then I'm like, you know, okay, now I've got to say something, but otherwise, I prefer not to say anything if they feel empowered, you know, if we can market an endometriosis specific diet and it was just like the general meeting, like we might not feel good about advertising it that way, but like if people did it, more uptake, yeah, fair.