Lifting and longevity: is 1 hour a week really the limit? Plus GLP1s and mood, training with ME/CFS, and Protein vs. Calories

0:00 [SPEAKER_01]: This month, we're tackling a study that went around claiming that the longevity benefit of lifting weights disappears once you train more than one hour per week. [SPEAKER_01]: It's a real paper, in a real journal, and the claim is wrong. [SPEAKER_01]: We'll walk through why. [SPEAKER_01]: We'll also get into whether a GLP-1 flat ends your mood and your motivation along with your appetite.

0:16 [SPEAKER_01]: Same calories, more weight loss argument that will not die, and what you can actually do in the gym when you have chronic fatigue syndrome. [SPEAKER_01]: I'm Dr. Jordan Faganbomb, and this is the Barbell Medicine podcast. [SPEAKER_01]: All right, well, let's get into this first one. [SPEAKER_01]: This is about lifting weights for more than one hour per week.

0:45 [SPEAKER_01]: The question is, the paper by Mama Edel says that the longevity benefit of lifting weights disappears once you get past about 60 minutes a week of training. [SPEAKER_01]: This seems unlikely to me. [SPEAKER_01]: I think we share your skepticism, but let's talk about why. [SPEAKER_01]: I think that the 60 minutes thing we need to walk through the whole study because it did become a headline for a while.

1:08 [SPEAKER_01]: This came out in 2022 by Pope is published in the British Journal of Sports Medicine by Mama and colleagues. [SPEAKER_01]: They took 16 prospective cohorts studies together and looked at whether lifting on its own is tied to living longer and how that changes with how much lifting you do.

1:24 [SPEAKER_01]: Let's start with some good news. [SPEAKER_01]: Any strength training versus none, unsurprisingly, improves things like mortality. [SPEAKER_01]: And this particular review was a 15% lower all-cosm mortality. [SPEAKER_01]: I think there was another one that showed like a 23% one from Dangkel.

1:39 [SPEAKER_01]: Basically, if you met the muscle strengthening guidelines, [SPEAKER_01]: Um, if you do lifting and cardio together, this particular review, uh, show that the reduction in all cause mortality, uh, dropped, uh, by about 40%, now the problem here is there's like a good dose response curve.

1:57 [SPEAKER_01]: where in this particular group of studies it showed that the more lifting that they did, the improvement or the reduction mortality, it sort of started to drift back towards neutral. [SPEAKER_01]: It never crossed the threshold shown it was harmful, but just the benefit wasn't proportional to the amount of exercise that they were doing.

2:17 [SPEAKER_01]: Now, some people might interpret that and say, well, look, if the improvement is reducing, [SPEAKER_01]: And then lifting more is bad. [SPEAKER_01]: Other people might view that in a way I kind of looked at it was like, well, how many people are actually doing a bunch of lifting? [SPEAKER_01]: And here, and when you look at the actual study, there's just not that many people that were doing a bunch of lifting and further, the sort of protective benefits never went back the other way showing harm.

2:44 [SPEAKER_01]: So with nobody in these cohorts in this study, really doing high lifting volumes, and further the way they collected this data was at the beginning of the study you just kind of self-reported, how much lifting that you were doing, and then they followed these people. [SPEAKER_01]: Now I'm not saying this is a terrible study design.

2:58 [SPEAKER_01]: It's just we've got to know the limitations of the study. [SPEAKER_01]: It's just messy here at high volumes. [SPEAKER_01]: The one thing that I kind of take away from this is that any lifting beats nothing. [SPEAKER_01]: I don't know though that's surprising to anyone, but the magnitude of benefit I think is surprising.

3:13 [SPEAKER_01]: If you talk to somebody who wasn't doing any lifting, and you said, look, just doing a little bit. [SPEAKER_01]: Has this potential to do a, have a big benefit? [SPEAKER_01]: I don't know that that motivates them to start lifting, but it certainly could be an interesting fodder for discussion.

3:27 [SPEAKER_01]: There's a newer, longer study that actually came out of Harvard this year by saying, followed about 147,000 people up to 30 years and re-measured their training as they went along rather than just asking a questionnaire at the beginning, the benefit actually went up to two hours. [SPEAKER_01]: Now, there was a continued sort of dose response relationship up to two hours.

3:47 [SPEAKER_01]: Now, again, that doesn't mean lifting from more than two hours per week is necessarily harmful. [SPEAKER_01]: There's just not that many people up there. [SPEAKER_01]: And further, you get a lot of confounders. [SPEAKER_01]: you know, as when we do this sort of sort of analysis. [SPEAKER_01]: But I think overall, our heuristic and Austin, you can correct me if I'm wrong or maybe overstating it.

4:05 [SPEAKER_01]: We still think there's this dose response relationship between exercise, generally speaking, and benefit. [SPEAKER_01]: where that shakes out for resistance training is probably lower. [SPEAKER_01]: Then most of what our listeners would want to hear, right? [SPEAKER_01]: Because they're like, do I just want to lift four times a week, five times a week?

4:20 [SPEAKER_01]: And we're like, for health benefits, it probably platos, you know, right around maybe double the current physical activity guidelines, for health benefit, maybe even a little lower. [SPEAKER_01]: But for conditioning, that benefit keeps kind of tracking on, you know, there's some benefit from continued more more increased volumes of exercise.

4:41 [SPEAKER_00]: Is that kind of square with what you're you think about like this sort of does response relationship sort of although there are things that even that claim leaves out here and that's part of why this type of study doesn't really get me terribly interested or excited or impact what I recommend to somebody it's just like I think you said that you weren't you weren't wanting to call this a terrible study design.

5:04 [SPEAKER_00]: I tend to not use inflammatory language like that in general, but I'm not pleased with the choice of metric here, in particular, like time of resistance training. [SPEAKER_00]: It's like if somebody tells me, I strength trained for 30 minutes or 60 minutes or two hours or four hours. [SPEAKER_00]: I still don't particularly know what you did, and I don't know whether it was appropriate for your level of adaptation.

5:28 [SPEAKER_00]: I don't know what your counting is resistance training. [SPEAKER_00]: I don't know any of the other variables to determine was this like a reasonable strength training program in general and was a reasonable match for you and your level of adaptation and your goals. [SPEAKER_00]: And so when you say that maybe it platos at double the guidelines, that still leaves out what is the actual outcome that the person is achieving?

5:50 [SPEAKER_00]: Because you've made this case before, is that, yeah, participating is beneficial. [SPEAKER_00]: But actually getting the adaptations is the thing that is best, you know, kind of correlated to the health impacts if you were doing a strength training program that is in fact making you stronger, right?

6:06 [SPEAKER_00]: And so then that brings into the equation. [SPEAKER_00]: Well, is the amount of training that you do? [SPEAKER_00]: How does that relate to the outcomes that you get? [SPEAKER_00]: And that is what is going to be different for everybody. [SPEAKER_00]: Some people need. [SPEAKER_00]: you know, to do more per week to get a, you know, incremental additional adaptation, whereas others, the freaks among us, the travary training sensitive, the closer to beginner territory, can make substantial progress on relatively little training.

6:34 [SPEAKER_00]: So there's multiple additional layers to this that make this study and any sort of claims that emerge from it in terms of, oh, if you, you know, train up to this many minutes per week, it's beneficial beyond that it's [SPEAKER_00]: not no longer beneficial. [SPEAKER_00]: I find that not only unconvincing, but actually pretty implausible.

6:54 [SPEAKER_00]: Now, if I'm translating this to like a clinical scenario where I'm sitting in front of a patient, doing some exercise counseling, you could frame this as if I was talking to them about whichever, whether they're strength training or they're cardiovascular, they're aerobic training. [SPEAKER_00]: And they're currently doing nothing.

7:09 [SPEAKER_00]: How strong of a case can I make for getting them from doing nothing to doing 30 minutes a week? [SPEAKER_00]: A very, very, very strong case. [SPEAKER_00]: from there how strong of a case can I make for getting them from doing say 30 or 60 minutes up to 60 to 90 minutes or you know two hours a week I can still make a pretty good case for that right.

7:29 [SPEAKER_00]: If they're already doing two hours a week of say strength training how much stronger of a case can I make for them pushing it to three hours to four hours I think it is fairly obvious to most people that purely from a health standpoint the strength of my case is going to diminish. [SPEAKER_00]: Yeah, four health outcomes.

7:46 [SPEAKER_00]: Now, if the person says, look, I have made a lot of progress so far, but my progress in strength adaptations in muscle gain is really starting to, you know, to taper off. [SPEAKER_00]: That's where I now suddenly have a stronger case of, yeah, we could probably be doing more, be doing things differently.

8:01 [SPEAKER_00]: But that's not really a conversation that's happening as much in the clinical realm. [SPEAKER_00]: That's more a conversation that's happening in like the coaching sort of realm for people who are highly motivated for those particular adaptive outcomes. [SPEAKER_00]: But for people who I'm working with who are either for a general health purposes, who have cardiovascular conditions that are just trying to get healthier, who are on GLP, one medicine is trying to maintain their strength and muscle.

8:21 [SPEAKER_00]: Again, that strongest case that I can make, yeah, is for the initial bit. [SPEAKER_00]: And that case weekends, the larger of volumes we're talking about, unless the person has very particular performance goals, or if they just want to. [SPEAKER_00]: But I'm not telling them if they say I want to that like, oh, don't go over this many minutes because you're gonna like, die sooner or compromise your longevity gains from this kind of thing.

8:44 [SPEAKER_00]: I just do not buy it. [SPEAKER_00]: And I would not use a study that looked at mainly time without, again, a sense of what is the actual program look like which is kind of hard to do in most of these types of studies because everybody's doing different stuff who knows what their programs are coming from.

9:02 [SPEAKER_00]: who knows what the actual level of intensity is that the person, it's just too messy, right? [SPEAKER_00]: And so this is fundamentally like useless for me in like clinical decision-making and like guidelines I would say. [SPEAKER_01]: Yeah, yeah. [SPEAKER_01]: What you would want from like a research approach for this is like some way to grade the exercise and to take heterogenous programs, different programs and then distill them down to a number that actually represents the training load on some level.

9:33 [SPEAKER_01]: Some kind of strength training stress index or something like that. [SPEAKER_01]: Yes, which I've been working on for a long time. [SPEAKER_01]: Yeah, and further the sort of metrics [SPEAKER_01]: The thing isn't just how much training the people are doing, it's really what is their response, because effectively what you would want to study like this to tell you clinically is that look by achieving X outcome.

9:52 [SPEAKER_01]: Here is the risk reduction, right? [SPEAKER_01]: So that whether that's strength, whether it's power, whether it's cardiovascular fitness, these are all things that can be tested. [SPEAKER_01]: And so you'd want to say, look by achieving this particular level of strength, power, cardiovascular fitness, you maximize your benefit, or right?

10:06 [SPEAKER_01]: And then after which, [SPEAKER_01]: with this study, maybe the headline was insinuating is that, well, once you go past the third amount, maybe not so good, which we have not seen. [SPEAKER_01]: We have not seen that for strength or says, look, the strongest quartile or turtile, or however you would split up, you know, various sort of, you know, strength categories.

10:27 [SPEAKER_01]: has like worse outcomes. [SPEAKER_01]: Never, never seen that. [SPEAKER_01]: So yeah, I would want an exercise program to generate the outcomes that we want and then measure those against, you know, if that's a performance outcome, how does that stack up against the health outcome? [SPEAKER_01]: And then we'd have a better answer.

10:44 [SPEAKER_01]: But overall, I think our general heuristic is that generally speaking, generally speaking. [SPEAKER_01]: more exercise, more better for health and certainly for fitness, where you sort of kind of get diminishing returns. [SPEAKER_01]: I think changes for each particular health are sort of fitness adaptation.

11:01 [SPEAKER_01]: Strength, power, cardiovascular fitness. [SPEAKER_01]: I think it's higher for cardiovascular fitness. [SPEAKER_01]: That's sealing. [SPEAKER_01]: Lower for strength and power, but I don't think I could convince somebody to do less strength training because I think it's harmful for them The only way that I could rationalize it being harmful is if it is likely to drive a injury and subsequent decrease in activity or Someone's doing so much resistance training that they're effectively unable to do any conditioning because they have no time Right, but I don't think that's really what these studies are pointing at [SPEAKER_00]: Yeah, I think that's a fair framing and this reminds me of I got a consult question from a patient recently who brought up the question of basically, are there any strategies to mitigate the downsides of, you know,

11:42 [SPEAKER_00]: strength training, for example, on the cardiovascular system, I'm like, what downsides. [SPEAKER_00]: And then they shared with me some resources that they had found. [SPEAKER_00]: They had used some some AI tools, some searching to to find some evidence. [SPEAKER_00]: But what was coming back was all of the evidence in something we talked about way back, 150 podcast episodes ago in the extreme exercise hypothesis on ultra-indurance sort of training and increased, or the association or increased risk of things like [SPEAKER_00]: And I was like, all of this is in ultra endurance, ultra high volume and high intensity aerobic, you know, sort of stuff not to demonize that or just say that that's necessarily bad for longevity.

12:19 [SPEAKER_00]: There are certainly tradeoffs, but that is like when you're getting at very, very, very high volumes and high intensities of ultra endurance sort of sort of activity, not applicable to strength training. [SPEAKER_00]: That is not a thing that is observed where, for example, if you do, you know, too many sets per week of deadlift or something that you're going to be at.

12:38 [SPEAKER_00]: markedly higher risk of developing a trophy relation or something like that. [SPEAKER_00]: That's not a thing that's ever been shown. [SPEAKER_00]: So good news, not something you need to worry about, and the vast overwhelming majority of people are not, in fact, meeting those kind of thresholds for what would be considered, you know, sufficiently ultra-indurance level volumes of activity that would be conferring some degree of risk, and the people who are are most often consciously choosing that because they [SPEAKER_01]: Yeah, yeah, I think the biggest risks from doing too much exercise it happens to be musculoskeletal injury.

13:08 [SPEAKER_01]: And then you know, you could go even further into your point, very consciously choosing to do a lot, a lot of conditioning exercise, sure increased risk of atrial fibrillation, which can be managed. [SPEAKER_01]: And ultimately those people aren't dying any sooner either, right? [SPEAKER_01]: It's just like, yeah, no biological free lunches here.

13:26 [SPEAKER_00]: Yeah. [SPEAKER_01]: All right, next question is on GLP ones. [SPEAKER_01]: Will we ever sufficiently talk about GLP ones such that all of the questions have been answered? [SPEAKER_01]: Me, thanks no. [SPEAKER_01]: So this question is, I'm probably going to try a GLP one. [SPEAKER_01]: My main concern is psychiatric.

13:41 [SPEAKER_01]: Does the quote, hedonic stuff that these act on only affect appetite? [SPEAKER_01]: I enjoy gaming with friends and other things that you'd call hedonic, including libido. [SPEAKER_01]: have you noticed GLP ones affecting people's motivation to do stuff, not counting eating, or their mood going down?

13:57 [SPEAKER_01]: So he knows the appetite effects cold, and he wants to know if the drug will dull his mood, his drive, his enjoyment of everything else. [SPEAKER_01]: To me there are three pieces to this, one is reassuring, one we genuinely don't know, and one he hasn't really asking about. [SPEAKER_01]: The first is reassuring to me it's the mood on average, holds or gets a little better.

14:18 [SPEAKER_01]: Now there was a some thought that maybe there was an increased risk of depression, maybe there was an increased risk of suicidal ideation. [SPEAKER_01]: For example, that was like some preliminary data coming out, but when those data has have been analyzed and taken to their conclusion, [SPEAKER_01]: The best controlled data coming out of the step trials in people without major psychiatric illness found depression scores a touch better on average with some aglytodd and placebo.

14:44 [SPEAKER_01]: Now, whether this is clinically meaningful or not, that's up for debate. [SPEAKER_01]: The authors said no, but it doesn't show like look prior increase risk of depression, even though there was maybe a thought that that could happen. [SPEAKER_01]: Sue's not all ideation is the same, it's the same story on that.

15:00 [SPEAKER_01]: There was a scare that has been locked back in early 2026 the FDA asked for the suicidal ideation wanting to be removed after reviewing 91 placebo controlled trials covering about 108,000 patients plus over 2 million real world users and the European regulatory body landed in the same place.

15:18 [SPEAKER_01]: So this ozampic makes you depressed sort of claim. [SPEAKER_01]: Yeah, we can kind of kind of dip that in the butt. [SPEAKER_01]: The second piece to me is less clear, and before I get into it, I want to tag you in, Austin, since you're the one actually prescribing these. [SPEAKER_01]: When a patient is on one of these, and you check in, do they ever describe anything past like the appetite change, something with their drive, mood, or wanting things called less across the board?

15:40 [SPEAKER_01]: What have you actually seen? [SPEAKER_00]: I will say a few things because this is a fairly common concern and conversation that I have with folks. [SPEAKER_00]: So, yes, I have seen some of these things. [SPEAKER_00]: No, it is not the most common response to these medicines. [SPEAKER_00]: So, some good news for this person is that it is not typical for patients who are starting these medicines, particularly when properly dosed and properly dosed means always starting at the lowest dose of the medicine for them to experience this.

16:12 [SPEAKER_00]: more often when I have seen more of this kind of suppression of mood, of interest, of motivation, it tends to arise at the highest doses and more often with Zepound than with, uh, we go via or, or semagletide. [SPEAKER_00]: There's some thought and conversation in this space of, is there some contribution of the GIP elements to that?

16:31 [SPEAKER_00]: I'm not going to get into the details of the neurobiology just yet. [SPEAKER_00]: But that's kind of part of the conversation. [SPEAKER_00]: The other things are that even that in that situation, it is frequently manageable. [SPEAKER_00]: So a lot of the time what I end up doing with these folks is lowering their dose.

16:47 [SPEAKER_00]: So say somebody's on 15 milligrams of trisepotiders upbound, which is the highest dose, which takes many months to get up to that dose just to be clear. [SPEAKER_00]: And you have a lot of opportunity and time along the way to notice how you're feeling, to not continue increasing, to go back down, to adjust your dosing strategy.

17:03 [SPEAKER_00]: But let's say you get up to 10 to 12 to 15 milligrams. [SPEAKER_00]: And you're experiencing something like this. [SPEAKER_00]: Then oftentimes, I'll drop them down. [SPEAKER_00]: Maybe by 5 milligrams or so from 15 say down to 10. [SPEAKER_00]: see how they do. [SPEAKER_00]: Sometimes we can augment their therapy, combine it with another tool like be appropriate on, which is a medicine that can have some kind of activating type effects, can improve some of this motivation, this energy, this drive, and I've had actually really quite good success in using this strategy with most of the patients that I have who have experienced this.

17:31 [SPEAKER_00]: But [SPEAKER_00]: Again, the big picture caveat that I want to kind of re-emphasize here and illustrate is that this is not a typical or a very, very common concern or effect that I'm observing in most patients using these medicines. [SPEAKER_00]: It affects a small minority. [SPEAKER_00]: And of that minority, it tends to be at the highest doses.

17:49 [SPEAKER_00]: The reason why that's good news for you is, well, [SPEAKER_00]: If it's affecting the minority, you are unlikely to be affected. [SPEAKER_00]: If you are nothing about starting these medicines is a permanent effect. [SPEAKER_00]: If you notice something that you don't like, talk with your prescribed in clinician, they should ideally know how to handle this.

18:05 [SPEAKER_00]: If not, I do. [SPEAKER_00]: We can get sometimes creative with dosing strategies and try other agents and other options. [SPEAKER_00]: And you can also stop at any time. [SPEAKER_00]: And that's not actually a problem either. [SPEAKER_00]: I have lots of patients who have existing psychiatric conditions.

18:19 [SPEAKER_00]: Some of them have actually quite severe psychiatric issues. [SPEAKER_00]: Things like bipolar disorder, things like that that are on actually fairly intensive psychiatric mental health medications, some with pro-history of very severe depression, with suicidality with hospitalizations who are actually doing fine on these medicines, again with monitoring and things like that over time.

18:42 [SPEAKER_00]: But this is not a concern that I want to kind of blow out of proportion in terms of what I'm observing in real life using this with lots and lots and lots of people. [SPEAKER_01]: Yeah, yeah, I think you know when the mechanism was kind of sust out a little bit. [SPEAKER_01]: Look, these drugs act on the brains reward pathway.

18:58 [SPEAKER_01]: This is sort of wiring the craze urge to want to do something with less payoff than you'd otherwise expect. [SPEAKER_01]: You know, then people are like, hmm. [SPEAKER_01]: could this be useful or researchers certainly were like could this be useful for substance abuse, right, which on the one hand was like a silver lining, and then other people took that to like to suggest, well, maybe I won't like anything.

19:16 [SPEAKER_01]: And there's been some effect, you know, people reporting like flag effect and stuff like that. [SPEAKER_01]: There's some interesting data here, you know, researchers have investigated what happens if you give people with alcohol, use disorder a GLP1 and see what happens. [SPEAKER_01]: Well, they they drink less, for example, [SPEAKER_01]: So there's a study came out last year in Jamas, psychiatry, 48 people with alcohol used disorder.

19:39 [SPEAKER_01]: They were on low dose, some agulotide, so it was epic, we gov, or placebo, and they were put in a bar lab, which... [SPEAKER_01]: Can I go? [SPEAKER_01]: Well, I guess it's a similar simulated drinking environment. [SPEAKER_01]: In any case, it cut how much they drank and they craved and they also cut their cigarette consumption as well.

19:57 [SPEAKER_01]: There's a second trial recently published in the Lancet which was bigger and longer and it showed the same thing. [SPEAKER_01]: Now, [SPEAKER_01]: This has never been studied for gaming, right? [SPEAKER_01]: It's never been studied socializing other hobbies or whatever. [SPEAKER_01]: So all of the brain imaging studies and the mechanisms hasn't really been applied here.

20:15 [SPEAKER_01]: We do think that if you wanna call them an anti-reward type effect, we do think that it reaches past food, but we don't know to what extent and the hobbies, in this case, are pretty much untested. [SPEAKER_01]: So that's an old question. [SPEAKER_01]: Yeah, sure, a few people, as you mentioned at my Nordie, can report feeling flat, but that's more anecdote than anything else.

20:36 [SPEAKER_01]: And I don't think there's a huge signal otherwise showing like a lot of people experience this, and it's a big problem. [SPEAKER_01]: I would be concerned if there was a big libido effect, but I suspect if anything, it would probably get better. [SPEAKER_01]: Mainly because the effect of the drug itself, like if someone's appropriately prescribed these medications they are carrying excess body fat, [SPEAKER_01]: And, you know, in men who are carrying extra body fat, that tends to reduce testosterone, particularly if they have a high amount of visceral adipose tissue, again, surrounding your internal organs.

21:08 [SPEAKER_01]: And because these drugs do such a good job at reducing that testosterone levels actually tend to go up. [SPEAKER_01]: Now, libido itself is more complex than just testosterone level, but we do think that this would likely improve. [SPEAKER_01]: I think you can see sort of a confounder though if people are not eating enough generally speaking and they're losing weight very quickly so that fatigue can sort of overwhelm any sort of home hormonal mediated improvement in libido, but that's like as kind of separate issue.

21:37 [SPEAKER_01]: But the third question and the one that I think needs to be asked whenever we discuss these sorts of things mainly due to the still fairly prohibitive cost, where are people getting these medications from? [SPEAKER_01]: So if somebody is sourcing a GLP-1 through like research chemical or gray, gray market, sort of peptide, I have concerns about that.

22:00 [SPEAKER_01]: Maybe not just related to like anodonia, right, or like reduced enjoyment of activities, but mostly just like safety, because you don't really know the dose that you're getting. [SPEAKER_01]: For example, you don't really know if what is marked labeled on the vials, what you're actually getting, plus if you're getting it through those sources, I do wonder about the monitoring.

22:19 [SPEAKER_01]: So all of that sort of kind of tilts the risk benefits scale firmly. [SPEAKER_01]: But to me, at least, towards the risk sort of situation, but I think overall the psychiatric risk is relatively low. [SPEAKER_01]: If anything likely to be beneficial, as long as somebody's not really taken an unregulated peptide from the grain market here.

22:36 [SPEAKER_01]: So, Austin, you've got patients on these medications. [SPEAKER_01]: Now, if this individual was your patient, [SPEAKER_01]: acknowledging this is not medical advice, this is for infotainment purposes only, and they're kind of express these concerns about antidonia, having a sort of flat effect, how would you counsel him on that?

22:54 [SPEAKER_01]: Would it be mostly like, hey, we're going to monitor this as we go along, we're starting low, this is minority, or anything unique in your sort of counseling year. [SPEAKER_00]: Yeah, I want to first be clear about what is the goal of therapy? [SPEAKER_00]: Because one of the things that wasn't listed in the question is like, what is the indication for using a gelp, one medicine in the situation?

23:09 [SPEAKER_00]: Is this somebody with obesity, with metabolic disease, with cardiovascular disease, with fatty liver disease, with chronic kidney disease, all of those things, or what, you know, any combination of them, really strengthens the case for benefit outweighing potential risk. [SPEAKER_00]: That's the first thing.

23:24 [SPEAKER_00]: Now, if on the other hand, he says, I'm [SPEAKER_00]: You know, as ELP won, whether prescription FDA approved or gray market read up, so I can prep for a bodybuilding show, I'm not saying he's saying this, but or she is saying this, but that obviously changes the potential benefit to potential risk sort of sort of calculation there, right?

23:45 [SPEAKER_00]: That's the first thing because we're always framing these therapeutic conversations around what are the potential benefits that we are looking for, what is the goal and what are the potential downsides that we should be aware of and to kind of take into account. [SPEAKER_00]: And then once accounting for those things, can we negotiate a mutually acceptable strategy to navigate that path together?

24:06 [SPEAKER_00]: And so if this person has clear clinical indications for their use, or that if they don't, they are willing to accept potential downsides, despite the lack of a clinical indication for its use, then yes, the plan would be, hey, we're going to start [SPEAKER_00]: We will monitor how you're doing, knowing that we have creative dosing strategies, options for combination therapies to address side effects if needed or we can always go back down and dose or we can stop and it is a reversible effect not something that is it tends to be permanent and again I would reiterate that the big picture of observation in practice is that this is infrequent.

24:43 [SPEAKER_00]: If it happens more often at the highest doses that take a while to get to, and it's something that we can mitigate by just going back down. [SPEAKER_00]: And so that flexibility is quite nice about these agents. [SPEAKER_01]: Yeah. [SPEAKER_01]: All right. [SPEAKER_01]: Well, that's about as new as medicine gets.

24:59 [SPEAKER_01]: Now, let's tackle one of the oldest questions in the field is a calorie really just a calorie. [SPEAKER_01]: So the question is, can you discuss the nuance around the studies showing weight loss when protein goes up even at the same or higher calories? [SPEAKER_01]: There's one you energetic, that just means at the same calorie level.

25:17 [SPEAKER_01]: There's one you energetic high protein trial in particular. [SPEAKER_01]: I've also heard people say keto [SPEAKER_01]: Yes, so on its face that these two scenarios look like they break physics, you know, you're eating more calories presumably and still losing weight. [SPEAKER_01]: But if you dig in, it's kind of a farce, okay?

25:37 [SPEAKER_01]: So let's start with the, we'll back up a little bit and start with the phrase that everyone kind of fights about. [SPEAKER_01]: Is a calorie really a calorie, just a calorie? [SPEAKER_01]: Yeah. [SPEAKER_01]: It is, 100% of the time, a calorie is just a calorie because it's a unit, just like a second or a meter or measures time or distance.

25:56 [SPEAKER_01]: A calorie is a unit of measure for energy. [SPEAKER_01]: That said, calories in calories are, is a calorie just a calorie. [SPEAKER_01]: I think what people are getting at when they're, I mean, trying to poke holes in that relationship is that, [SPEAKER_01]: on either side. [SPEAKER_01]: Calors in Calors out, both sides are dynamic and just stating the relationship is not terribly helpful advice for most folks.

26:18 [SPEAKER_01]: And I think that's fine. [SPEAKER_01]: Two things can be true. [SPEAKER_01]: A calorie can just be a calorie, but the advice to just eat less move more, or it's all just about energy balance may not be great advice. [SPEAKER_01]: And I think that's fine. [SPEAKER_01]: Now, with respect to protein, I think it's fair to say that protein pushes both the calories in and calories out.

26:37 [SPEAKER_01]: It affects them both in a way that favors weight loss. [SPEAKER_01]: I think it's fair to say that, but there's some nuance here. [SPEAKER_01]: Because effectively, the effects are modest. [SPEAKER_01]: So, when you increase dietary protein intake, a few things happen. [SPEAKER_01]: One, [SPEAKER_01]: it tends to displace other foods, you know Americans typically eat quite a lot of protein about 1.1 grams, a protein per kilogram bodyweight per day, but most of that protein is from ultra-processed or highly processed sources, tends to have a lot of fat and other things which increases energy intake and so when people make this [SPEAKER_01]: quote, conscious choice to eat more lean protein in particular, it can displace some of those higher calorie options and other options that don't have a lot of protein but otherwise do contain a lot of calories.

27:22 [SPEAKER_01]: So that could reduce energy intake, for example. [SPEAKER_01]: Increasing dietary protein intake also tends to increase the thermic effective food because protein costs more to digest than carbs or fat, but it's mostly a small effect, if any. [SPEAKER_01]: We know that, yeah, it does take more energy to break down protein, but how that affects total daily energy expenditure.

27:43 [SPEAKER_01]: We don't really know because everything kind of is dynamic. [SPEAKER_01]: When you increase one variable, the system isn't closed. [SPEAKER_01]: Everything else changes too. [SPEAKER_01]: So I don't know that increasing dietary protein actually increases calorie burn in a way that produces weight loss.

27:57 [SPEAKER_01]: I think the main factor here is it reduces intake overall. [SPEAKER_01]: So the study that was sent here is from 2020, a Hageat in British Journal of Nutrition is 12 weeks. [SPEAKER_01]: And basically they looked at the effect of a high protein diet versus a standard protein diet in women.

28:14 [SPEAKER_01]: Now the diets that were prescribed to these individuals were the same in calories. [SPEAKER_01]: That was for the prescription, which differs from how they were actually implemented because they actually a different levels of calories. [SPEAKER_01]: In the study in table one, the high protein group reported that they're intake fell over the trial while the standard protein groups actually held the same.

28:36 [SPEAKER_01]: So the average in the high protein group, they ate about 90 fewer calories per day, closer to 130 fewer calories by the end of the trial. [SPEAKER_01]: They also cut carbohydrates, which drags water and glycogen out. [SPEAKER_01]: they were eating less calories and what do you predict happens when when people do that?

28:54 [SPEAKER_01]: Well, they lose weight. [SPEAKER_01]: There was a improvement in body composition here showing increase in leg body mass decrease in fat mass unique to the high protein group, which isn't a surprising finding when it's combined with resistance training, but it was surprising in this study.

29:08 [SPEAKER_01]: So you have to look a little deeper and you look in the methodology and how did they assess body composition? [SPEAKER_01]: biological impedance, which is pretty poor, a bathroom grade device, if I'm being charitable. [SPEAKER_01]: Yeah, the authors themselves say, oh, this wasn't a gold standard in which vex the question, like, what, why did we use this for that?

29:28 [SPEAKER_01]: It just is not. [SPEAKER_01]: sensitive enough to discern relatively small changes in lean body mass and and you know in the defense of BIA by electrical impedance Dexa wouldn't be good either in this short period of time Mainly because you just need large changes in actual muscle tissue and fat mass for it to be picked up on either one of these test biological impedances just worse, right?

29:50 [SPEAKER_01]: So ultimately the people in the high protein diet at less say loss more weight [SPEAKER_01]: And the body composition changes in this relatively short study. [SPEAKER_01]: We're mostly a result of a measurement error. [SPEAKER_01]: Although again, I would expect a higher protein diet up to a certain level.

30:05 [SPEAKER_01]: Probably about 1.6, 1.8 grams of protein per kilogram body weight per day. [SPEAKER_01]: To improve lean mass, if people were resistance training, although if people weren't resistance training, I don't really think it's going to move much from muscle mass. [SPEAKER_01]: To me, the keto version dies the same death.

30:21 [SPEAKER_01]: When people say they want keto and they more and lost weight will really what happened is they felt like they were eating more, but actually their calorie intake went down. [SPEAKER_01]: This has been investigated. [SPEAKER_01]: People are said, hey, you can only eat these types of foods in this case, a ketogenic diet, and they tend to eat less some of the time.

30:38 [SPEAKER_01]: What's more interesting to me about the ketogenic diet data is that that is a relatively short-term effect when you look at six months, one year, the weight loss could advantage disappears relative to other types of diets. [SPEAKER_01]: Now, if somebody wanted to follow a ketogenic diet in perpetuity, the hate carbs, war on carbs.

30:56 [SPEAKER_01]: Okay. [SPEAKER_01]: There are ways to do that. [SPEAKER_01]: That's fine. [SPEAKER_01]: And that's ultimately fist of preferences, allows them to eat the correct amount of energy. [SPEAKER_01]: But the idea that ketogenic diet somehow breaks the law of physics where people can eat more calories and lose weight has never been shown.

31:11 [SPEAKER_01]: never been shown. [SPEAKER_01]: So Austin, how do you handle this? [SPEAKER_01]: When a patient swears, they're eating more and losing weight or they're losing on keto without counting their calories. [SPEAKER_01]: What does the conversation look like? [SPEAKER_01]: I'm really going to guess.

31:26 [SPEAKER_01]: You say, nice. [SPEAKER_00]: but I'm very curious how you address this. [SPEAKER_00]: Yeah, firstly, it would be. [SPEAKER_00]: Yeah, nice school. [SPEAKER_00]: Keep it up. [SPEAKER_00]: That's great. [SPEAKER_00]: I think that the other aspect of this conversation, though, is definitely wanting to be on the same team with the patient.

31:41 [SPEAKER_00]: And that means that if the ultimate goal of this is for their health, [SPEAKER_00]: Then yes, as long as they are making progress, losing in a way that they prefer, then yes, I'm on their team for that, but I also want to make sure that they are on my team in the sense of, hey, we want to make sure there's not detrimental effects happening from this diet and so the the reason I bring that up is.

31:59 [SPEAKER_00]: depending on the particular food choices, that the way that this keto diet is set up, there can be, even if you're losing weight, can be some other detrimental effects. [SPEAKER_00]: For example, if you are consuming very high amounts of animal derived saturated fats, as we've talked about many times before, that can have some detrimental effects on your bloodlipid profile, for example.

32:19 [SPEAKER_00]: there might be some other impacts that are adverse on your insulin sensitivity and things like that. [SPEAKER_00]: So I definitely want to make sure, hey, we'll want to make sure you're very sufficiently active. [SPEAKER_00]: And if I can get them to agree that we should aim to, you know, make the most progress we can while avoiding objectively detrimental effects, then we can say, hey, if we see that, like, say, your blood lipid panel goes, hey, wire, like your [SPEAKER_00]: LDL goes up, your triglycerides go up, your things like that, that would you be open to making some tweaks and modifications to this keto diet within the realm of your preferences as much as possible to mitigate that.

32:55 [SPEAKER_00]: And I think that there's likely to be a way to thread that needle maybe we swap out some of the dietary fat sources for more unsaturated sources from [SPEAKER_00]: from seafood sources, from plant-derived sources, things like that, and then aiming to get the dietary fiber and take up to our standard recommended targets for whichever population the patient falls in.

33:16 [SPEAKER_00]: So typically getting them up to, say, 30, 40 grams of fiber a day if they're willing to go that high or as high as they're willing to go within the confines of their diet, and then that might confer some beneficial effects on those otherwise detrimental effects. [SPEAKER_00]: getting the benefits we're looking for and mitigating the harms.

33:37 [SPEAKER_00]: If we can do those two things, and the person wants to stay, you know, like, we go for it. [SPEAKER_01]: Yeah. [SPEAKER_01]: Yeah, and further if somebody was like, I want to increase my dietary protein. [SPEAKER_01]: at, you know, what, what can I expect? [SPEAKER_01]: What to expect when you're expecting?

33:50 [SPEAKER_01]: It's like, well, it depends where you're starting out right now. [SPEAKER_01]: So for example, if a person can send me, you know, 0.6 to 0.8 grams of protein per kilogram body weight per day. [SPEAKER_01]: And they're like, I'm going to go up to 1.6. [SPEAKER_01]: And I'm like, okay, we'll provide it that your resistance training, right?

34:04 [SPEAKER_01]: I suspect you're going to have, uh, get, you know, a bigger benefit from your exercise. [SPEAKER_01]: I do suspect that that increase in protein is going to displace other higher calorie foods from your plate and so net I would expect some benefit. [SPEAKER_01]: Now going from like 1.6 to 2.2 or more I don't expect that benefit.

34:24 [SPEAKER_01]: On the other hand, it could further displace other foods from your plate. [SPEAKER_01]: And so some people may find that approach successful in the short term, but long term, that has not been born out either. [SPEAKER_01]: It's just like, no, just jack your protein up and you're going to lose more weight.

34:36 [SPEAKER_01]: It's like, well, at the end of the day, it all comes down to energy balance one way or another. [SPEAKER_01]: But I think overall, you and I are aligned. [SPEAKER_01]: We're not calling this person a liar and breaking out the physics for them and saying, look, the long point of that. [SPEAKER_01]: Yeah, there was no, just like telling people to you less and move more, that is not particularly useful advice.

34:53 [SPEAKER_01]: Telling people that it all comes down to energy balance is probably also not useful advice. [SPEAKER_01]: All right. [SPEAKER_01]: Our next question has to do with lifting and chronic fatigue syndrome. [SPEAKER_01]: The question is, what's the best weight lifting to do when you have chronic fatigue syndrome?

35:07 [SPEAKER_01]: I go weeks where I barely have the energy to shower. [SPEAKER_01]: I want to increase my lifting. [SPEAKER_01]: I sometimes lift weights and bed on my worst days. [SPEAKER_01]: But my boyfriend says that isn't doing anything. [SPEAKER_01]: What are some exercises that won't make me need to sleep for two days?

35:22 [SPEAKER_01]: Alright, so some people are going to say, look, chronic fatigue syndrome, this is made up, not a real illness. [SPEAKER_01]: But it is, and it's often referred to as myalgic and cephalomyelitis, or MECFS, and in 2015 there was a National Academy of Science panel that laid out formal criteria for diagnosing it.

35:41 [SPEAKER_01]: Now, the thing that separates it from just being called tired is what happens after somebody exerts themselves. [SPEAKER_01]: So in this particular instance, she does something, whether it's physical or mental, instead of being wiped out, that same day, or being tired that same day, there's a sort of extended sort of crash for multiple days, in some cases, even longer than that.

36:01 [SPEAKER_01]: And it's out of proportion to the effort that was done. [SPEAKER_01]: Now, her question says it plainly. [SPEAKER_01]: basically doing some light lifting and then I need to sleep for two days. [SPEAKER_01]: That sort of delayed crash is called post-exertional malaise and it's one of the key features of this particular condition.

36:17 [SPEAKER_01]: There's a really interesting case with the pair of identical twins where one has chronic fatigue syndrome and the other does it. [SPEAKER_01]: same genes, raised together, so you can't chalk it up to genetics or lifestyle. [SPEAKER_01]: Both did a hard exercise test two days in a row. [SPEAKER_01]: The healthy twin repeated the performance on day two just fine.

36:32 [SPEAKER_01]: The twin, though, with chronic fatigue syndrome, dropped about 13% at the anaerobic threshold test on the second day, basically the point where the effort tips from manageable to much harder. [SPEAKER_01]: and it's not just a twin curiosity, run the same two-day test on groups of these patients and the same pattern holds.

36:48 [SPEAKER_01]: They show a bigger drop-off on day two than healthy people do. [SPEAKER_01]: You can't really talk yourself out of that. [SPEAKER_01]: Unfortunately, there's no real proven program or exercise routine for this. [SPEAKER_01]: It hasn't been studied well. [SPEAKER_01]: But the one thing that everyone agrees on is basically staying under the sort of limit that sets off a crash.

37:07 [SPEAKER_01]: Now, this is a relatively new update because for a long time, the idea was, look, we just got to push these patients. [SPEAKER_01]: We just have to tell them just add a little bit more every week to sort of create it, to exercise. [SPEAKER_01]: Unfortunately, that's just like force progression and it turned out to be wrong.

37:22 [SPEAKER_01]: Now, it's also wrong in others. [SPEAKER_01]: Like people without this condition, but that seems to be a little bit more again disruptive in this population. [SPEAKER_01]: And there's just lower stakes. [SPEAKER_01]: If you kind of overdo it in a healthy person, they're like, man, I'm sore for longer.

37:38 [SPEAKER_01]: I'm tired for a lot of my performance has decreased, but they bounce back relatively quickly, usually. [SPEAKER_01]: these folks, these folks, these can be prolonged. [SPEAKER_01]: So the guidance is flipped and this happened in the last few years. [SPEAKER_01]: As far as her boyfriend goes, he's half right.

37:54 [SPEAKER_01]: Look, lifting weights in bed is probably not going to build as much muscle or strength as going to a gym and doing a cool real training session. [SPEAKER_01]: But that's not really the point. [SPEAKER_01]: It's better than doing nothing than one and two. [SPEAKER_01]: She's getting something out of it.

38:06 [SPEAKER_01]: For exercise to really accomplish nothing, it has to be so submaximal, so light, so easy that it does not challenge her or the person at any level, which is pretty hard to do. [SPEAKER_01]: You'd have to really fabricate something, you know, something unnatural for that to happen. [SPEAKER_01]: Ultimately, [SPEAKER_01]: to me this is like doing what you can when you can where you can and I think that's certainly better than nothing.

38:32 [SPEAKER_01]: So the way I would approach this from a practical perspective, I generally think that shorter bounce of exercise are likely a better place to start than longer ones and would do longer rest. [SPEAKER_01]: So instead of having like six exercises on the docket maybe only two right and instead of resting you know only two to four minutes maybe it's four to six minutes [SPEAKER_01]: I would also generally stick with lower RPE targets, you know, probably more at 5-6 compared to 6-7 or 8.

39:03 [SPEAKER_01]: I would also, instead of trying to force progression with the fixed rep range, for example, use double progression wherein you would have a rep range of like 6-10 reps, for example, in only ad-weight when you could max out all of the sets at 10 reps at a given load. [SPEAKER_01]: And so it's going to be a little bit more of a gradual progression delayed progression.

39:23 [SPEAKER_01]: that we're sort of constraining with that, that rep range. [SPEAKER_01]: I would also have a backup plan. [SPEAKER_01]: If, for example, someone is feeling like, I don't really have it today, you know, not just like, I feel sore. [SPEAKER_01]: I don't feel quite strong as normal. [SPEAKER_01]: In this case, like, my energy levels are really, really low.

39:37 [SPEAKER_01]: Maybe all they can do is I rise to metrics, you know, where you're creating force and not really moving dynamically. [SPEAKER_01]: maybe it's just much lighter. [SPEAKER_01]: And then the other thing that would add is kind of unique here. [SPEAKER_01]: We often talk about monitoring session RP, like how hard was the effort, you know, that was the whole training session, whereas a session RP 10 would be like that's maximal, so most things, most I've ever done.

39:56 [SPEAKER_01]: And SRP1 is like, that was rest. [SPEAKER_01]: I didn't do anything. [SPEAKER_01]: Yeah, we should measure that, but also I'd want to see what happens the next day and two days later and three days later because the disruption and for a long sort of decrease in energy level sometimes called an energy envelope happens days later.

40:16 [SPEAKER_01]: And so you would really want to have be kind of like monitoring this post hoc just to see like, is the program that we're on right now? [SPEAKER_01]: Is it adjustable enough? [SPEAKER_01]: And is it like actually like a meeting the person where they're at, you know, and I think that it's just harder to do when you have to sort of look at monitoring only directly after the session or during the session.

40:37 [SPEAKER_01]: So it needs to be a little bit longer than that. [SPEAKER_01]: So so awesome. [SPEAKER_01]: This is where you're better than any study. [SPEAKER_01]: If this were your patient, someone with chronic fatigue syndrome who actually wants to lift and is scared of the crash they've been experiencing, how would you go about counseling them?

40:51 [SPEAKER_01]: What is the sort of strategy look like day to day? [SPEAKER_01]: And how do you talk about it without sort of no seabowing them? [SPEAKER_01]: For example? [SPEAKER_00]: Yeah. [SPEAKER_00]: I will be totally up front that this is not an area of a great deal of expertise or experience for me.

41:05 [SPEAKER_00]: I think that this is a very challenging syndrome. [SPEAKER_00]: Number one, it is poorly understood. [SPEAKER_00]: It is multifactorial. [SPEAKER_00]: Different people experience it in very different ways. [SPEAKER_00]: And they likely have arrived at this kind of like final syndrome, probably in different ways as well.

41:21 [SPEAKER_00]: So that deviates a lot from kind of our more more traditional like medical diagnoses if you will, [SPEAKER_00]: patients tend to more often present with a kind of more prototypical pattern because so much of diagnosis involves things like pattern recognition and there might be a relatively common or shared underlying pathophysiology.

41:41 [SPEAKER_00]: Here it might be different pathophysologies that converge to manifest in a similar way in a diverse set of patients. [SPEAKER_00]: Ultimately, not super well understood, maybe some people have greater or lesser degrees of mitochondrial problems. [SPEAKER_00]: That's a total hypothesis, and again, I'm not an expert in this area.

41:58 [SPEAKER_00]: So, as a result, that's why I am both has reluctant to sign on to the idea that I'm better than any study here, but also be that I'm probably not the best person to be giving confident advice on this. [SPEAKER_00]: I think that a lot of what you proposed is probably reasonable. [SPEAKER_00]: Although I would also point out that even the best plan that you could propose within those kind of constraints may still fail for a person for reasons that we may understand and may not and so much more so I think the idea of individualization and again as I alluded to earlier being on the same team as the person is probably the most useful thing here, so trying to get a sense of like [SPEAKER_00]: How do you feel that I can help you best?

42:34 [SPEAKER_00]: Are you willing to work together, collaborate on this, iterate on this over time? [SPEAKER_00]: What are the goals you're trying to achieve? [SPEAKER_00]: Can we like mutually agree on an acceptable starting point with a plan to modify as we go? [SPEAKER_00]: Because you're right, that historically, the idea that, oh, these folks, they have the syndrome, but they still are capable of tolerating a stress and adapting to it, just like anyone else.

42:55 [SPEAKER_00]: It's like, [SPEAKER_00]: It might be a little bit of an exception to that rule because when they have been pushed, they tend to do worse. [SPEAKER_00]: And so there's some other path, some other strategy that's going to need to be worked out. [SPEAKER_00]: And again, it's going to need to be super individualized to the person and what they're willing to do.

43:09 [SPEAKER_00]: I think that both of us would hesitate to sign on to an idea of, well, [SPEAKER_00]: you're just not going to be able to exert yourself and just like, you know, bed rest is going to be the move for you. [SPEAKER_00]: That's not something you're likely to ever hear us say for somebody, but rather that prospectively without, you know, meeting with the person, working with them, got, you know, collaborating on this over time.

43:28 [SPEAKER_00]: It's going to be tough to propose something up front that is anything more than like a reasonable guess and that's kind of what you came up with there and with a if then sort of thing so that they have some confidence that hey we got a backup in mind and I like that you included some ideas for for backup strategies.

43:45 [SPEAKER_00]: But you need to be on the same team. [SPEAKER_00]: If there's an adversarial sort of relationship, if there's doubt in the relationship of, oh, well, I don't think that I can tolerate this, but they're making me do it or recommending that I do it. [SPEAKER_00]: Like you're already kind of on the wrong foot.

43:58 [SPEAKER_00]: So you need some rapport, you need some trust, you need some collaboration, you need some iteration, you need a lot of time. [SPEAKER_00]: If it were me, I would probably be like, hey, can we find somebody with way more expertise than me in this space who can guide you? [SPEAKER_00]: Because I've done that for other things that are not necessarily like, [SPEAKER_00]: will claim to know a lot about a lot of things, but certainly not everything, and this is one of those areas where, unfortunately, I do not have a great deal of that expertise, and a lot of that is an artifact or a consequence of my typical practice setting over the years.

44:27 [SPEAKER_00]: Working in hospital medicine for a lot of the time, and not having brick and mortar clinic where I'm seeing patients with these sorts of chronic debilitating illnesses, limits my degree of experience and working with them, and so then that limits my confidence [SPEAKER_01]: Yeah, well said, and I think, you know, if you're a coach working with somebody like this and you've never seen it before and never dealt with it before, I don't want to scare you off and say, and we don't want to scare you off and say, look, you can't touch this, you know, little empty hammer reference, but I would just generally be more conservative and more dynamic with your recommendations ready readiness to change what you're doing.

45:07 [SPEAKER_01]: And then further, if you get in a few weeks or few months and you feel like you really can't get purchased on like, [SPEAKER_01]: This is where the person should be starting, generally speaking, for the bones of a decent program. [SPEAKER_01]: You just can't find that entry point, then finding somebody with some more specialized expertise would be the move.

45:23 [SPEAKER_01]: And I think, you know, we see that all time in medicine. [SPEAKER_01]: It's like, look, this looks like something I feel like I can handle. [SPEAKER_01]: And then, you know, if that doesn't really shake out, okay, cool, we're gonna actually call, we're gonna get a consultant on board. [SPEAKER_01]: There's gonna help us, cause they have more expertise.

45:36 [SPEAKER_01]: That's a handful of the best questions from this month's direct line. [SPEAKER_01]: The full episode every question our members send in goes out to our Barrel Medicine Plus and Premium Members every month. [SPEAKER_01]: Now if you want the whole thing each month and you want your own questions to be answered on the show, head over to barvelmedicine.com and jump in.

45:52 [SPEAKER_01]: For everyone here at Barrel Medicine, I'm Dr. Jordan Faganbaum. [SPEAKER_01]: That's Dr. Austin Baraki. [SPEAKER_01]: We'll catch you next week and every week right here on the Barrel Medicine podcast.