Episode #391: VO2 Max vs. Cardiorespiratory Fitness, GLP-1 Costs, and the 10,000-Step Myth | Direct Line March 2026 (Free)

0:15 [SPEAKER_00]: Welcome back to the Barbell Medicine Direct line. [SPEAKER_00]: Our monthly ask us anything for our Barbell Medicine Plus subscribers. [SPEAKER_00]: I'm Dr. Jordan Flag and Mom. [SPEAKER_00]: We've got a stack set of questions today, and a lot of it comes down to one recurring theme. [SPEAKER_00]: The advice that was supposed to protect you might be doing the opposite.

0:30 [SPEAKER_00]: And to help me unpack all of this, we have the second most handsome Dr. North America. [SPEAKER_01]: Dr. Austin Baraki, what's going on, dude? [SPEAKER_01]: Hey, doing all right. [SPEAKER_01]: Looking forward to the breadth of topics that you've pulled together or that our audience is pulled together.

0:42 [SPEAKER_01]: I just wrapped up some training this morning and I'm comfortable ready to go. [SPEAKER_00]: All right, let's get into the first question. [SPEAKER_00]: This one's on VO2 Max versus cardiovascular fitness for longevity. [SPEAKER_00]: The question is. [SPEAKER_00]: Is Votumax the metric we should, or could reference for cardiovascular fitness when it comes to longevity?

0:59 [SPEAKER_00]: Dr. Eric Topel points out the data comes mostly from measures of cardiovascular fitness, not actual measures of Votumax, out of the square with Dr. Peter Ateas, recommendation for Votumax. [SPEAKER_00]: But to start, yeah, these aren't the same things, VO2 Max and Carter is pretty fitness or distinctly different.

1:16 [SPEAKER_00]: And most of the longevity studies that Dr. Atia has cited, they don't actually ever measure VO2 Max. [SPEAKER_00]: We can fully concede that. [SPEAKER_00]: VO2 Max, for those who are listening at home and maybe unfamiliar with what it actually is, it's a measurement of your maximum oxygen uptake.

1:29 [SPEAKER_00]: It usually requires a maximum effort test with a metabolic cart to get a real number. [SPEAKER_00]: Cardi respiratory fitness on the other hand is more broad than that. [SPEAKER_00]: In most large studies, it's an estimated treadmill test estimated exercise test sort of thing you take it to tolerance for people who either have signs if it's like a cardiac rehab sort of situation or just otherwise they feel some breathlessness they can't continue.

1:53 [SPEAKER_00]: And so it's a, you get a measurement of metabolic equivalents at peak effort. [SPEAKER_00]: You can also get a submaximal test. [SPEAKER_00]: There's also questionnaires. [SPEAKER_00]: There's a bunch of different ways to test it, but most of the time in the research, it's an exercise tolerance test, but a thing.

2:06 [SPEAKER_00]: So, Atia, despite this, gives specific view to max percentile targets by agent sex in his book, despite the underlying studies, not actually measuring that. [SPEAKER_00]: So, [SPEAKER_00]: He says, despite all this, that VO2 Max is the single most powerful marker for longevity. [SPEAKER_00]: He's been saying it on his podcast.

2:25 [SPEAKER_00]: It's all over his book Outlive. [SPEAKER_00]: And honestly, he's probably right directionally, but Dr. Topel and some other people on Twitter have recently been kind of like taking a task for this. [SPEAKER_00]: And particularly Dr. Topel's pointed fatigue, suggests there's like a meaningful scientific problem with that claim.

2:43 [SPEAKER_00]: I'll also [SPEAKER_01]: uh, I can do my best. [SPEAKER_01]: This is, this is an area where, you know, although the, the conversation is interesting, I see part of the issue being that folks like Dr. Tia, quote unquote, optimizers are very interested in, uh, discreet and concrete metrics that they can aim to optimize.

3:05 [SPEAKER_01]: And there's, I forget the, um, the eponymous, uh, law that once, uh, the measure becomes the outcome, it often like ceases to become a good measure, right? [SPEAKER_01]: And so, you're right that directionally, this is accurate in the sense of the O2 Max as a type of assessment for cardiovascular or aerobic fitness, but it is incomplete.

3:26 [SPEAKER_01]: And so, why aiming to just specifically target that outcome with your, you know, your training protocols. [SPEAKER_01]: just aiming at VO2 max optimization might be missing, missing some things. [SPEAKER_01]: And so some of the commonly cited studies in this realm, 1 in 2022 and Gemma Network, open very frequently cited that looked at exercise capacity.

3:51 [SPEAKER_01]: assessed by the Met's kind of measurement that we've talked about before from a stress test, not a direct VO2 Max measure, but rather the Met performance is then mapped onto your VO2 Max kind of percentiles. [SPEAKER_01]: And there are several others that also use, you know, performance-based metrics like another one in JAMA from 1989 that use the treadmill time.

4:13 [SPEAKER_01]: That's a performance-based test. [SPEAKER_01]: Dr. Atopal's point and many others who have made similar arguments is that we're kind of conflating or looking at various measures of cardiovascular respiratory fitness, which is a much more broad and kind of like an umbrella description of what we're talking about, and trying to collapse it down into this single metric of VO2 max, which is a very particular thing.

4:36 [SPEAKER_01]: That has very particular limiters, meaning that there are certain things that it will tell you more about. [SPEAKER_01]: So it might tell you a little bit more about like cardiac function. [SPEAKER_01]: For example, like central kind of adaptations and a little bit less about some of the more peripheral determinants of cardiovascular respiratory like performance.

4:53 [SPEAKER_01]: And so, you know, the relationship between cardiovascular respiratory fitness and longevity is pretty clear. [SPEAKER_01]: No one is really arguing that or debating it at this point, at least I hope not. [SPEAKER_01]: I think maybe some of our former colleagues still may under prioritize this in the strength training space, but people who are reasonable generally agree that being more fit from a cardiovascular standpoint is going to be both associated with and to some extent causally related to improvements in health and longevity.

5:21 [SPEAKER_01]: life span and health span and all of these good things that we're looking after, but rather that collapsing it down into just VO2 Max is short-sighted. [SPEAKER_01]: Given that most of the evidence that we're drawing, this off of looks at actual performance. [SPEAKER_01]: And so what kind of things can you draw from this?

5:37 [SPEAKER_01]: It might be like, hey, maybe why don't we just pay attention to performance? [SPEAKER_01]: And we don't need to use this very particular metric. [SPEAKER_01]: people who are very much into bio markers and bio hacking and optimizing very specific numbers on a lab test or or something that they can you know go out and do or calculate might not love that they might get a little uncomfortable with it, but at the same time, I don't know that you or I would have a problem with like picking a benchmark test and aiming to improve that over time and saying if that performance test that road test.

6:07 [SPEAKER_01]: That is relatively standardized over time is generally improving, then it is a reasonable take to say my cardiovascular fitness from central adaptations to peripheral adaptations to VO2 max, all of that is improving, likely improving a variety of other health outcomes and longevity as well.

6:21 [SPEAKER_01]: I don't know, what do you, what's your take there. [SPEAKER_00]: Yeah, I don't want to be like an Atea Apologist, you know, in some ways and reframe his actual discussion or his claims because honestly, I'm not super familiar with everything he's ever said about this. [SPEAKER_00]: It is surely possible that he's overstated on this, perhaps even even likely.

6:41 [SPEAKER_00]: But I think the pushback is mostly around, look, he gives these specific percentiles that people should be targeting and that's the benchmark. [SPEAKER_00]: And I can understand some criticism around that if they're not really based on the metric that he's telling people to chase. [SPEAKER_00]: But that seems fine, but it seems more like a semantic sort of thing to me, because I actually think it's useful to have a target like this.

7:04 [SPEAKER_00]: The analogous would be like a strengths, you know, a strengths standard, [SPEAKER_00]: You should get your strength up to this much on a particular exercise or this particular test. [SPEAKER_00]: And it's like, yeah, we'll not all encompassing. [SPEAKER_00]: It does give us what I view as a very important variable with respect to exercise prescription.

7:20 [SPEAKER_00]: It's the monitoring thing, because exercise works better when it actually works to make you fitter. [SPEAKER_00]: So it's not just like, [SPEAKER_00]: do the guidelines, double the guideline to like you have a do it in a way that makes you stronger that improves your carter respiratory fitness.

7:34 [SPEAKER_00]: And the view to max is a reasonable sort of test of your carter respiratory fitness. [SPEAKER_00]: There are other ways to test it too. [SPEAKER_00]: So he could have picked, you know, a 20 minute cycle time trial test and say look here, the here's the data we have on that or like a would or a power output sort of thing.

7:49 [SPEAKER_00]: You could have done any that. [SPEAKER_00]: We put in our barbell medicine vital five like look VO2 Max, here are some targets to get people to shoot for mainly because it's not enough in my opinion or our opinion to say, yeah, just exercise. [SPEAKER_00]: Do it in a way that's productive and also, by the way, exercise tolerance test has a really good correlation to actual measured VO2 Max.

8:09 [SPEAKER_00]: And so it's not like their worlds apart anyway. [SPEAKER_00]: There's just more stuff where different things that are being captured in that test. [SPEAKER_00]: So, [SPEAKER_00]: I don't think a Tia is wrong per se, it may be wrong about the precision, but right about the direction. [SPEAKER_00]: It's not really the same error, and I do think again, as you mentioned, nobody's arguing against like cardiovascular stiffness being useful.

8:28 [SPEAKER_00]: I just think, sure, if you want to say the specific percentile thresholds are not exactly as evidence-based as he's leading on. [SPEAKER_00]: Fine, you could just, you know, chastise them for not being a great science communicator in this particular respect, although what's the harm? [SPEAKER_01]: Well, think about it this way.

8:43 [SPEAKER_01]: Here's the pushback to your pushback on this, which we're kind of doing in real-time here. [SPEAKER_01]: If we're an agreement that Cardi-Resupport Fitness is the real thing that we care about, but we want a metric and we use VO2 Max. [SPEAKER_01]: then what happens and this is what we observe in that space a fair amount of the time is people looking for a very specific quote unquote protocols aimed at optimizing that one measure right to the potential exclusion or kind of deprioratization of other possible ways of training that would also improve cardiovascular [SPEAKER_01]: kind of quote unquote optimized towards VO2 Max.

9:20 [SPEAKER_01]: So this is where you'll hear them talk about. [SPEAKER_01]: This particular interval training protocol that was done in the study and was shown to improve VO2 Max. [SPEAKER_01]: And I would do that instead of this other form of aerobic training or cardiovascular training. [SPEAKER_01]: An analog that I might be able to draw here is like let's say that we look at the string training evidence.

9:38 [SPEAKER_01]: And it's like, yeah. [SPEAKER_01]: strength pretty clear, you know, predictive power, good correlation with health outcomes and things like that. [SPEAKER_01]: And so the metric or the outcome that I'm going to use is grip strength. [SPEAKER_01]: And so then all of my training protocols are going to be oriented around improving my grip strength.

9:52 [SPEAKER_01]: Is that going to make you healthier compared with not doing any strength training? [SPEAKER_01]: Sure, are there a lot of other ways that you could train to improve your strength that would also be useful even if you were not singularly focused on that one potential metric absolutely right you could pick any exercise maybe somebody else might say oh, it's your you know five Rm back squat it's like okay well then the only way that I'm going to aim to improve my strength for health and longevity is by back squatting and and everything's going to be orange on this like yeah there's a lot of ways that you could train for strength [SPEAKER_01]: that will improve your health outcomes and some that might even be worth including that you are deprioritizing because you're very focused on this one measure.

10:30 [SPEAKER_01]: So I think that's kind of like where there's a little bit of daylight between these different positions, these different takes, having metrics is great, but collapsing everything down into that one metric and making that the primary outcome of interest to potentially the exclusion of other valuable aspects might be where some people could improve [SPEAKER_00]: Yeah, just to wrap this up, you'll know in the Barwell Medicine Bible 5, it wasn't just a VO2 Max number, it was also some field tests that could be done across different modalities, and we kind of explicitly recommend that.

11:04 [SPEAKER_00]: So we don't hamstring people by saying, you just got to get your VO2 Max up and do anything else that doesn't directly raise your VO2 Max is useless. [SPEAKER_00]: We're just like, look. [SPEAKER_00]: We want to improve your cardiovascular fitness. [SPEAKER_00]: You're a various benchmarks you can chase or monitor your progress over time, because I think it does add a critical element that's missing from the current guidelines, which is not, it's do the exercise, but also make sure it works for you.

11:28 [SPEAKER_00]: Cool. [SPEAKER_00]: Next question, more on GLP ones. [SPEAKER_00]: Will this ever be sufficiently handled? [SPEAKER_00]: No, no, no, no, GLP one questions. [SPEAKER_00]: So the question is that GLP1 medications like OZAMPIC, we go V, MondioroZEPBound, they can be transformative for a lot of patients, but they're also very expensive, sometimes over $1,000 a month without insurance.

11:50 [SPEAKER_00]: Is there any real evidence that that's going to change that prices are going to come down? [SPEAKER_00]: And I want to be honest about the timeline here. [SPEAKER_00]: So the bottom line, [SPEAKER_00]: Without pretty strong insurance coverage, long-term use is difficult to access for many folks, unless they're willing to pay out a pocket.

12:05 [SPEAKER_00]: The question is, are generics coming soon? [SPEAKER_00]: And, you know, LaRaglutide was the became a generic, although there was some ever-greening type type situation that was going on with the manufacturer. [SPEAKER_00]: I think the main thing here with perspective generics is that GLP ones are either peptides or biologics.

12:24 [SPEAKER_00]: This is kind of arbitrary lying in the sand based on their structure peptides officially by the FDAV, like 40 amino acids long or less, and if it's above that, it's a protein drug or a biologic. [SPEAKER_00]: So because of this structure, they are more challenging to make. [SPEAKER_00]: And there are many different ways that manufacturers can maintain their patent on them.

12:45 [SPEAKER_00]: You know, so not just the formulation, but the pen, for example, and then other aspects of the drug. [SPEAKER_00]: So they can like kind of maintain or limit generic development. [SPEAKER_00]: Some thought that biosimilers could be a competing product. [SPEAKER_00]: These are highly similar to a approved reference protein drug or biologic, humira, there was some development here.

13:08 [SPEAKER_00]: And there are some biosimilers being developed in China and a few other countries, but none in the US right now. [SPEAKER_00]: So to me, I don't think there's an a generic ozampic or zepound coming soon, mainly because the key patents don't really expire [SPEAKER_00]: You've got to have a manufacturer who's willing to make these things and the pen, which I think requires a lot of funding.

13:31 [SPEAKER_00]: What do you think about that? [SPEAKER_01]: Uh, yeah, just a few kind of, um, I guess things from doing this day to day with patients is that while the list prices are certainly exorbitantly high in those ranges that you described, um, at this point in time in 2026, nobody is paying that amount in the US or should be.

13:52 [SPEAKER_01]: And that is because of the manufacturers direct access programs. [SPEAKER_01]: So with Eli Lilly, they [SPEAKER_01]: which I have no affiliation with to be clear and novo also has their own novo care kind of direct to manufacturer option. [SPEAKER_01]: And so if you are somebody who for some reason you know, maybe either with insurance or without it is still paying that amount, you should talk to your prescribers.

14:13 [SPEAKER_01]: So, you lie literally through the lead director's epitide, there is a bound is available in the range of 299 to 449 a month. [SPEAKER_01]: We go v through novo care, depending on the oral or the injection formulation ranging from [SPEAKER_01]: 349 a month. [SPEAKER_01]: And so these prices most recently dropped last fall, I believe, might have been sometime around October prior to that.

14:36 [SPEAKER_01]: Yes, you know, even people who wanted to go cash pay were paying these much, much higher and more exorbitant prices. [SPEAKER_01]: So prices are actively coming down. [SPEAKER_01]: These companies are competing against one another. [SPEAKER_01]: There's a lot of movement between the two companies, [SPEAKER_01]: other non-GLP-1 based therapies, so like amylen analogs and things like that.

14:58 [SPEAKER_01]: So ultimately what I'm seeing is... [SPEAKER_01]: drugs that are increasingly effective, increasingly safe, increasingly like long acting. [SPEAKER_01]: So Laragalutide was once a day and then these more recent ones are once a week. [SPEAKER_01]: There was one recently that was studied that's once a month, things like that.

15:14 [SPEAKER_01]: So more effective, safer, better tolerated, longer acting, and because all these players are competing with one another, yes, the prices are gradually coming down. [SPEAKER_01]: As I mentioned, the current pretcash prices that people are able to get range from like say 150 to 450 in general, direct from the manufacturer, at least in the US, and I have a substantial portion of patients who are using those options when their insurance is not covering it for whatever reason.

15:38 [SPEAKER_01]: But yes, I do expect that cost will continue to come down. [SPEAKER_01]: That is definitively what I expect to happen. [SPEAKER_01]: it might take longer than all of us would like, as it already has, but that is what I expect to happen. [SPEAKER_01]: As far as generics, yeah, that's a complicated question.

15:52 [SPEAKER_01]: Because these aren't just one drug, they all have some unique considerations to your point. [SPEAKER_01]: The idea of a generic manufacturer producing an auto-injector in pen form. [SPEAKER_01]: There's not too many examples of that that I can think of off the top of my head. [SPEAKER_01]: Whereas the oral options, as those become generics, those are far more likely [SPEAKER_01]: available in generic form once those patents expire, although there is still the caveat of the complexity of the manufacturing.

16:20 [SPEAKER_01]: So with oral semagaloo tied, for example, that is a peptide and the, you know, pretty advanced pharmaco engineering was needed to make that orally bioavailable. [SPEAKER_01]: The newer Lily oral product that we're expecting is going to be approved and available this year is called or for Glipper on and that is actually a small molecule glp1 so that is not a peptide in the same way as the injectable glp1s or oral legovie and therefore doesn't necessarily require that same degree of advanced bio engineering.

16:50 [SPEAKER_01]: So to the extent that we're able to get oral small molecules that would be like kind of a a grail to work towards and would be something that would make these much more easily accessible. [SPEAKER_01]: So yeah, if I fast forward a year does this base look like radically different, you know, it's evolving actually pretty quickly, but not, you know, on that rapid of a timeline do I expect like the whole space is going to be overhauled, but if I look maybe [SPEAKER_01]: You know, three, four, five years, it's going to be wild because if I rewind five years, you know, that was even pre-Zep-Bound pre-Trasepotide era all we had was a Zempic and we go if he was just kind of coming on the scene.

17:26 [SPEAKER_01]: Fast forward 10 years, who knows what this space is going to look like. [SPEAKER_01]: So, a lot of evolution, a lot more options. [SPEAKER_01]: Ultimately, like all good things, I think for people are coming, more options, more effective, safer, better tolerated, cheaper, [SPEAKER_01]: That's what, you know, for whatever you think about capitalism, that is what it is doing for us in this space.

17:43 [SPEAKER_01]: So reasons for optimism, at least on this front for people I think in the future. [SPEAKER_00]: Yeah. [SPEAKER_00]: Yeah. [SPEAKER_00]: The honest answer for patients right now is that the market pressures do seem to be working in their favor, whether it's due to compounding pharmacies, continuing to sell these things, that maybe shouldn't be happening.

17:58 [SPEAKER_00]: And subsequently, there's now a direct consumer programs from the manufacturers themselves. [SPEAKER_00]: So these assistance programs you should ask your doctor about that if you currently are paying four figures a month for these sort of things. [SPEAKER_00]: And then yeah, I suspect with continued R&D, we're going to have better agents available.

18:15 [SPEAKER_00]: Again, comparing LaRaglutide, once a day, not terribly effective to Orphaclipron or even, you know, retatratide. [SPEAKER_00]: It's like, okay, way more effective, less, you know, dosing frequency, less side effects generally speaking, [SPEAKER_00]: What a time to be alive, exactly. [SPEAKER_00]: All right, next question, something that we get asked quite frequently is walking enough for cardiovascular health.

18:43 [SPEAKER_00]: This individual asks, I often see evidence-based recommendations suggesting that two strength sessions per week plus 7,000 to 12,000 daily steps are sufficient to optimize health outcomes, optimize going a lot of heavy lifting in that sentence. [SPEAKER_00]: Does walking at that volume, meaningfully count towards physical activity guidelines for cardiovascular fitness and a personal training context should coaches still encourage additional conditioning so low intensity steady state or some high intensity interval training.

19:09 [SPEAKER_00]: If clients are already getting 7,220,000 steps per day and have limited time for training. [SPEAKER_00]: Austin, I'm going to leave with the fun fact, I don't know if you can do this. [SPEAKER_00]: Okay. [SPEAKER_00]: Did you lean Arto DaVinci, the Italian artist, who painted the last supper, he's credited with inventing the first step counter.

19:26 [SPEAKER_00]: It was mounted at the waist and had a long lever that was tied to the thigh. [SPEAKER_00]: And so when the thigh moved back and forth during walking, the gears rotated and the resulting steps were counted. [SPEAKER_00]: Genius. [SPEAKER_01]: Yeah, it's like a like the analog of like a mechanical watch kind of mechanism back in the day.

19:40 [SPEAKER_00]: Yeah, so I think this question boils down to enough for what, you know, optimal is different than like adequate and then adequate for what. [SPEAKER_00]: So it's enough to live longer. [SPEAKER_00]: That's not the same as enough to improve view to max or cardiovascular stiffness, which is not the same as enough to meet activity guideline, which is not the same as enough, you know, get to optimize longevity.

19:59 [SPEAKER_00]: These require kind of different answers. [SPEAKER_00]: I think the 10,000 steps thing has been mostly debunked, you know, most folks are aware that this is mostly a marketing thing, not necessarily a scientific thing, and if you're not aware, well, it came from the 1960s, there was a Japanese marketing campaign for a pedometer, where the name literally meant 10,000 step meter.

20:29 [SPEAKER_00]: quite genius. [SPEAKER_00]: Yet it still persists as some sort of health recommendation. [SPEAKER_00]: It's pretty reasonable to me. [SPEAKER_00]: I've done a little dive deep dive into this previously where in the United States, most adults with their habitual activity levels will walk [SPEAKER_00]: somewhere or take somewhere between 4,000 to 6,000 steps per day.

20:49 [SPEAKER_00]: Obviously, this varies based on occupational activity and obviously health condition, where some health condition is a walkbar less than that. [SPEAKER_00]: Some health conditions actually walk more. [SPEAKER_00]: But yeah, somewhere between 4,000 to 6,000 steps per day. [SPEAKER_00]: So, if you bumped this person's step count up to 10,000, [SPEAKER_00]: And it, on average, with the self-selected gate speed, which is around three miles an hour, more or less, it takes about 10 minutes to walk a thousand steps.

21:15 [SPEAKER_00]: So, if you're at the upper end of that range, 6,000 steps per day, and you bump into 10,000 steps per day, that's 40 minutes of additional walking or additional exercise. [SPEAKER_00]: And so yeah, there's some decent evidence showing that when people increase their step count from around, you know, 4,000 to 6,000 steps per day up to 7,500 steps per day is associated with significantly lower mortality and various populations.

21:40 [SPEAKER_00]: And that's kind of where that evidence settles out, right? [SPEAKER_00]: And that's 7,000 to 8,000 steps per day. [SPEAKER_00]: Above that, it's not to say there's no additional benefit, but I think this kind of gets at the crux of the question, is this enough to sort of generate improvements in cardiovascular restory fitness that are analogous to other forms of cardio?

22:00 [SPEAKER_00]: In other words, could you just recommend walking relative or instead of a place of formal conditioning on a elliptical on an exercise bike on the stairs? [SPEAKER_00]: Austin, what do you think about that is walking intense enough to sort of meet criteria for true exercise or is it more of like, it's activity, but not necessarily exercise?

22:22 [SPEAKER_01]: Yeah, I think that this question is unanswerable as stated and the reason as you stated to be clear. [SPEAKER_01]: And the reason why is just is walking intense enough because it's like saying is squatting intense enough and it's like, well, well, how much are you doing? [SPEAKER_01]: And so there's always going to be the trade off of intensity and overall volume.

22:43 [SPEAKER_01]: And so one of the interesting kind of rabbit holes. [SPEAKER_01]: I can't say that I've done an ultra comprehensive deep dive into it. [SPEAKER_01]: But something that I found interesting recently was this concept of the physical activity level, abbreviated as PLL, which kind of describes the ratio of the persons.

22:58 [SPEAKER_01]: total energy expenditure compared with their basal metabolic rate. [SPEAKER_01]: And that, as a proxy for various sorts of health outcomes and things like that. [SPEAKER_01]: And so, you know, you can have a physical activity level at PAL of like 1.5 or 2.5, again, as a multiplier of how many times your basal metabolic rate are you expanding?

23:17 [SPEAKER_01]: per day. [SPEAKER_01]: And so there are a lot of different ways that you can achieve that type of higher, like overall physical activity level, overall energy expenditure. [SPEAKER_01]: We've talked about this a little bit in other context where it seems that just like overall flux through the system, meaning like, you know, say you're like consuming calories, the calorie flux through the system the way it's consumed, metabolized, and expanded, [SPEAKER_01]: rather than the lipids like stagnating in your blood for long pairs of time if they are moving through getting cleared quickly like people tend to do better and so there's some evidence in this space looking at [SPEAKER_01]: various hunter-gatherer populations and things like that who have very, very high physical activity levels, this PAL kind of metric, and who have fantastic health outcomes when you are looking at the types of things that kill us in modern society, right?

24:11 [SPEAKER_01]: These non-communicable lifestyle-related metabolic diseases, things like that. [SPEAKER_01]: And so if you ask the question like is walking intense enough, again, that's only a partial answer or a partially completed question in my mind. [SPEAKER_01]: And what I'm getting at to stop beating around the bush is, I think it is actually fine for this purpose if you do enough of it.

24:31 [SPEAKER_01]: Now, [SPEAKER_01]: If the, since the original question askerhead said to optimize health outcomes, if the context is seven to 12,000 steps a day, I'd say, no, I would say you need probably substantially more than that to get a PLN high enough to like really, really optimize those health outcomes.

24:48 [SPEAKER_01]: So if somebody said, I only want to walk for my cardiovascular respiratory fitness and I'd be like, are you willing to walk? [SPEAKER_01]: I don't know 15, 20,000 steps a day, something like that. [SPEAKER_01]: I think that that would probably be fine. [SPEAKER_01]: I think you could do that.

25:00 [SPEAKER_01]: Get to do that. [SPEAKER_01]: Do some strength training twice a week. [SPEAKER_01]: I think that'd be like a reasonable thing if you were willing and able to do that. [SPEAKER_01]: I struggle to see, for example, somebody who's willing to walk 20,000 steps a day, who's like, oh, they're going to have some...

25:14 [SPEAKER_01]: preventable health consequence unless they add it in some like high intensity interval training on top of that. [SPEAKER_01]: Could they have some like potential fitness gains? [SPEAKER_01]: Sure, they potentially could, but I think that if you're going to use a fundamentally like low intensity activity for this outcome, [SPEAKER_01]: I think if you do a massive amount of it, you will probably be pretty in pretty good shape.

25:36 [SPEAKER_01]: And so yeah, I don't think that just 7 or 12,000, again, for the purposes of this person asking specifically, I want to optimize my health outcomes because what I'm anticipating is I say this, and then we're going to get questions in the group of people saying, well, I thought 10,000 steps a day was enough.

25:49 [SPEAKER_01]: I can't do it. [SPEAKER_01]: And it's like, [SPEAKER_01]: Yeah, people are busy, they got jobs, they got kids, they got families and there are trade offs with that. [SPEAKER_01]: Like we talked about this recently and the context of another post for somebody was like, it's not realistic to expect that everybody is going to do this much exercise.

26:01 [SPEAKER_01]: And it's like, yeah, building elite levels of fitness takes time and you might not have that time. [SPEAKER_01]: That's why you don't have elite levels of fitness. [SPEAKER_01]: I'm sorry to say. [SPEAKER_00]: Yeah, point out a few things. [SPEAKER_00]: One, missed opportunity to say, are you willing to walk 500 miles?

26:15 [SPEAKER_00]: It's like that would have been a nice little, we'll say it. [SPEAKER_00]: And then too, yeah, when you brought up PAL, a triggered this memory of mine, working on another project, there's this classic study of jute mill workers where they actually measured their PAL. [SPEAKER_00]: And so like the workers who were, you know, [SPEAKER_00]: in the fields, and then back in the factory, whatever, their PLL was through the roof, right, and that there's a mortality risk there's relatively low.

26:39 [SPEAKER_00]: But the office worker's same environment, far lower PLL, there's a risk there. [SPEAKER_00]: And so it's all about energy throughput. [SPEAKER_00]: And I think it sets up a nice continuum, the lower the intensity of the activity, the more of it you're going to have to do to get the same energy throughput, as time becomes more more limited, more and more intensities needed.

26:57 [SPEAKER_00]: And so you think about a person who is willing [SPEAKER_00]: But 20,000 steps a day. [SPEAKER_00]: That's over two hours of walking per day at a self-selected pace, even if you're kind of hustling around. [SPEAKER_00]: Most people don't have that on top of the other responsibilities that they generally have.

27:14 [SPEAKER_00]: And so as your time availability becomes less and less, you're going to need more and more intense exercise. [SPEAKER_00]: So you know, I got into a little Twitter spat with an individual. [SPEAKER_00]: They're like, [SPEAKER_00]: Why are you recommending high-intensity training or high-intensity training?

27:28 [SPEAKER_00]: You know, it's not optimal for VO2 mag zone 2 is king and I'm like, what if you only have an hour a week? [SPEAKER_00]: Yeah. [SPEAKER_00]: At that point, the intensity is going to make up for, at least on some level, the amount of time that you have. [SPEAKER_00]: And so that's the relationship that we see.

27:42 [SPEAKER_00]: If you have all the time in the world and you want to walk, that's fine. [SPEAKER_00]: I think the more interesting question here that is unanswerable is that if somebody were to be walking 20,000 steps per day, and let's just say that they did not budge their cardiovascular respiratory fitness from where it was, but their energy throughput is high.

27:58 [SPEAKER_00]: Does their longevity look similar to somebody who actually did increase their view to a max or their cardiovascular fitness through a, you know, maybe more optimal training methods? [SPEAKER_00]: And that is a question that remains unanswered. [SPEAKER_01]: Yeah, I agree. [SPEAKER_01]: No, no clear answer to that question.

28:13 [SPEAKER_01]: The problem are like the wrinkle in your case that you make and this is implicit, you, you already know this, but just to make it clear is that if to the extent you're time limited and you're having to make up for that gap with more intensity, there is an earlier and a firmer ceiling to how intense you can realistically go.

28:30 [SPEAKER_01]: In other words, like you cannot necessarily fully make up for the same amount of like PAL that overall energy expenditure purely through [SPEAKER_01]: if you, because you can only go so intense and then like survive, like recover from it, right? [SPEAKER_01]: Kind of like when we talk about with lifting weights, like the intensity, you can only go up to 100% of your one rep mix.

28:49 [SPEAKER_01]: You can't slash arguably shouldn't go try to go heavier than that on a regular basis, whereas the overall training volume that you can expose yourself to, provided it is like dosed and progressed reasonably. [SPEAKER_01]: People can get up to exceptionally high overall activity volumes.

29:03 [SPEAKER_01]: Again, the practicality of that may or may not be feasible for people. [SPEAKER_01]: In my own life, you know, now I'm doing a lot more hybrid, I'm doing some hospital work, I'm doing more telemedicine work than I have in the past. [SPEAKER_01]: And I realized that with the amount of telemedicine work I was doing, I did not want to be seated at a desk doing virtual appointments for most of the day.

29:21 [SPEAKER_01]: So I acquired a walking pad that I've posted about. [SPEAKER_01]: And so on a routine, if I do have like a full day of virtual, you know, consults and visits and calls and things like that. [SPEAKER_01]: It's actually not difficult or unusual for me to range between 15 to 25,000 steps. [SPEAKER_01]: Just kind of casually going and that's even at a very low slow pace at like a one mile per hour Type pace because I don't want to be like hustling bouncing around on the screen It's like enough that I can like stabilize my torso and like look reasonable on on on on on video And I feel fine and I'm recovering fine and my strength is fine and and I'm still I'm still doing other activity Including some running and some lifting and stuff like that because I enjoy it and I feel better when I'm generally more active But that's like some of the steps that I've taken to to get there.

30:04 [SPEAKER_01]: So yeah, the lower intensity you have to do more [SPEAKER_01]: If you're times compromised, you're going to have to pull the lever of intensity a bit, but that lever will only be able to get you so far. [SPEAKER_01]: And unfortunately, not everyone is going to be able to reach elite levels of fitness without spending a lot of time doing the activity.

30:19 [SPEAKER_01]: That's just the reality. [SPEAKER_00]: And that time may not be available. [SPEAKER_00]: Yeah. [SPEAKER_00]: Yeah. [SPEAKER_00]: Point.